Nonpuerperal Uterine Inversion: What the Gynaecologists Need to Know?

INTRODUCTION: Nonpuerperal uterine inversion (NPUI) is a rare clinical problem with diagnostic and surgical challenges. The objective of our study was to review the literature on NPUI and describe causative pathologies, diagnosis, and different surgical options available for treatment. MATERIALS AND METHODS: A comprehensive literature review was carried out on MEDLINE and Google Scholar databases to look for NPUI using the term "non-puerperal uterine inversion," and further went through the cross-references of the published articles. Data are published case reports from 1911 to September 2018. Of the 153 published cases, 133 reports had adequate details of surgery for analysis. These reports were analyzed, concerning the clinical presentation, methods of diagnosis, and surgical treatment. RESULTS: Mean age of the women was 46.3 years (standard deviation: 18, N = 153). Leiomyoma remained the commonest (56.2%) aetiology. While malignancies contributed to 32.02% of cases, 9.2% were idiopathic. High degree of clinical suspicion and identification of unique features on ultrasonography and magnetic resonance imaging enable prompt diagnosis. In cases of uncertainty, laparoscopy or biopsy of the mass was used to confirm the diagnosis. Hysterectomy or repositioning and repair of the uterus are the only treatment options available. The surgical methods implemented were analyzed in three aspects: route of surgical access, method of repositioning, and final surgical procedure undertaken. The majority (48.8%) had only abdominal access, while 27.1% had both abdominal and vaginal access. Haultain procedure was the most useful procedure for reposition (18.0%) of the uterus. The majority (39.7%) required abdominal hysterectomy with or without debulking of the tumour abdominally, while 15.0% had uterine repair after repositioning. We reviewed the different surgical techniques and described and proposed a treatment algorithm. CONCLUSIONS: Fibroids were the commonest cause for NPUI. Malignancies accounted for one-third of cases. A combined abdominal and vaginal approach, followed by hysterectomy or repair after repositioning, seems to be better for nonmalignant cases.

Differentiation of human male germ cells from Wharton's jelly-derived mesenchymal stem cells.

OBJECTIVE: Recapitulation of the spermatogenesis process in vitro is a tool for studying the biology of germ cells, and may lead to promising therapeutic strategies in the future. In this study, we attempted to transdifferentiate Wharton's jelly-derived mesenchymal stem cells (WJ-MSCs) into male germ cells using all-trans retinoic acid and Sertoli cell-conditioned medium. METHODS: Human WJ-MSCs were propagated by the explant culture method, and cells at the second passage were induced with differentiation medium containing all-trans retinoic acid for 2 weeks. Putative germ cells were cultured with Sertoli cell-conditioned medium at 36℃ for 3 more weeks. RESULTS: The gene expression profile was consistent with the stage-specific development of germ cells. The expression of Oct4 and Plzf (early germ cell markers) was diminished, while Stra8 (a premeiotic marker), Scp3 (a meiotic marker), and Acr and Prm1 (postmeiotic markers) were upregulated during the induction period. In morphological studies, approximately 5% of the cells were secondary spermatocytes that had completed two stages of acrosome formation (the Golgi phase and the cap phase). A few spermatid-like cells that had undergone the initial stage of tail formation were also noted. CONCLUSION: Human WJ-MSCs can be transdifferentiated into more advanced stages of germ cells by a simple two-step induction protocol using retinoic acid and Sertoli cell-conditioned medium.

A comparison of endometrial thickness following augmentation of ovulation with clomifene citrate or letrozole in women with ovulatory infertility.

OBJECTIVES: To compare endometrial thickness following augmentation of ovulation with clomifene (CC) and letrozole and to assess the rate of multi-follicle development and the FSH fluctuations during the stimulated cycles. METHODS: A comparative study was carried out at the infertility clinic of Faculty of Medicine, University of Kelaniya, Sri Lanka. Each arm included 25 participants. They received either 100 mg of CC or 2.5 mg of letrozole per day for 5 days starting from 2nd day of the cycle. The fluctuation of FSH in the follicular phase of the cycle, the endometrial thickness and the number of pre-ovulatory follicles on the day of detecting a mature follicle, were measured. RESULTS: Treatment with letrozole resulted in a smaller rise in the follicular phase FSH, which was shorter in duration than with CC. Also it resulted in a higher mean endometrial thickness at the time of detecting a mature follicle [9.89 (SD=2.02) mm vs. 8.58 (SD=1.32) mm; p=0.021]. Augmentation of ovulation with CC showed a trend towards multi-follicle development compared to letrozole. CONCLUSIONS: This study suggests that letrozole is superior to CC in augmentation of ovulation in terms of endometrial growth and mono-follicle development. However more studies are needed to assess how these differences affect the treatment outcome before it is recommended for clinical use.

Antibiotics supplemented culture media can eliminate non-specific bacteria from human semen during sperm preparation for intra uterine insemination.

RATIONALE: Bacterial flora can be isolated from many semen samples of subfertile males. Bacteriospermia can compromise the outcome of intra uterine insemination (IUI) by contaminating the post-processed sperm sample. OBJECTIVES: The objective of the present study is to determine the efficacy of penicillin and streptomycin in eliminating the bacteria from semen samples in the sperm processing procedure, and to assess the effects of antibiotics on sperm motility, survivability, and pregnancy rates. DESIGN AND SETTINGS: A prospectively controlled study was carried out using couples undergoing IUI with their informed consent. INTERVENTION: Sperm processing using the swim-up technique in penicillin and streptomycin supplemented culture medium. SUBJECTS AND METHODS: Couples were consecutively allocated in two groups for sperm processing (a) Group AB+ (antibiotics supplemented culture medium, n = 33) and (b) Group AB- (antibiotic free culture medium, n = 33). Semen culture was performed before and after sperm processing. Sperm motility was assessed immediately after processing and after 24 h of incubation. RESULTS: Bacterial isolates were found in 20 (60.6%) and 22 (66.1%) of samples before processing in Groups AB+ and AB- respectively. Addition of antibiotics resulted in completely eliminating non-specific bacteria from semen samples without affecting sperm motility. In vitro survival rate of sperm enhanced in AB+ group compared with AB- group (motile sperm after 24 h), 62.21% (standard deviation [SD]: 37.27) versus 41.36% (SD: 30.78), P = 0.012. Pregnancy rate, was comparable between two groups (9% in Group AB+ vs. 6% in Group AB-, P = 0.45). CONCLUSION: Penicillin streptomycin combination could completely eliminate non-specific bacteria from semen samples during sperm processing in this population. The types of antibiotics and dosage used did not seem to have any harmful effects on human sperm.

Aetiology of infertility among females seeking treatment at a tertiary care hospital in Sri Lanka.

OBJECTIVES: Aim of this study was to describe the proportion of contributory factors of female infertility in a population that sought fertility treatment. Furthermore, the clinical findings and underlying pathologies associated with ovulatory dysfunction were also sought. METHODS: A cross-sectional study was carried out at the infertility clinic of the North Colombo Teaching Hospital. New clinic attendees were recruited and both partners had a detailed clinical interview. The women underwent a baseline pelvic ultrasound scan, assessment of ovulation and a hormone profile. Tests for tubal patency were carried out when clinically indicated. RESULTS: Ovulatory dysfunction was noted in 53% (n=218). Clinical and investigatory findings associated with ovulatory dysfunction included irregular menstrual cycles, acanthosis nigricans, hirsutism, polycystic ovary syndrome, a LH:FSH ratio of >1, and increased TSH or testosterone levels. Unilateral tubal occlusion was seen in 9.1 % (n=18) while it was bilateral in 1% (n=2). Abnormalities in sexual function were noted in 10.8% (n=56). CONCLUSIONS: Abnormalities in ovulation were common. Clinical findings that could be used to recognise women at risk of ovulatory dysfunction were identified. Abnormalities in sexual function, which are often overlooked in the clinical management of infertility, were seen in over 10% of patients. Tubal factor infertility is rare.

A qualitative study on patients' perceptions of expectant management of first trimester incomplete miscarriage.

INTRODUCTION: Efficacy and safety of expectant management of first trimester miscarriage are well known, though the patients' perceptions and attitudes are less clear. This study was designed to understand the women's perception of symptoms, acceptability, fertility wishes and care received. METHODS: A qualitative study among 25 women who were allocated to the expectant management arm of a randomised control trial, which compared expectant versus surgical management of incomplete miscarriage, was carried out. Interviews were recorded at the end of two weeks from the initial diagnosis based on five themes, which were transcribed and analysed. RESULTS: Out of the 25 interviewed, two had to undergo surgical evacuation due to failed expectant management. Excessive bleeding was the main concern especially for employed women. Ideas and beliefs of family members influenced the women's experience. Majority preferred expectant management in a possible future event. Many expected to conceive again but preferred to delay a pregnancy even in the absence of any contraindications. Inadequate knowledge of expectant management led to dissatisfaction regarding the care received. CONCLUSIONS: Better understanding on the natural course of events in spontaneous miscarriage will help not only the patient but also the relatives in accepting expectant management of first trimester miscarriage and influence their ideas, beliefs and feelings. Improved health education, counselling, and symptomatic relief are important aspects in improving the overall quality of care.

A trial of expectant management in incomplete miscarriage.

INTRODUCTION: Incomplete miscarriage is often treated with surgical evacuation in Sri Lanka. Expectant management, which is an alternative treatment, was assessed for efficacy and safety in a local setting. METHODS: Randomised clinical trial of two treatment groups of expectant and surgical management with 71 and 69 participants, respectively, was done at the University Gynaecology Unit of the Colombo North Teaching Hospital, Ragama, from December 2007 to July 2009. Women with incomplete miscarriage at a period of amenorrhoea of < 14 weeks and retained products of conception of < 50mm were included. Expectant management involved in-ward treatment till resolution of heavy bleeding and pain and follow up for two weeks. In surgical treatment, evacuation was undertaken and the patient sent home from hospital after bleeding settled with follow up. The maximum anteroposterior diameter of the endometrial cavity was measured with transvaginal ultrasonography and a diameter < 15mm was considered as complete miscarriage. RESULTS: Expectant management had a treatment success of 90.1% at one week and 94.4% at two weeks. For surgical treatment this was 95.7%. Infection was noted in one subject from the surgical group and none in the expectant group. Fall in the haemoglobin concentration in the two groups was clinically not significant. The expectantly managed group had a shorter hospital stay than the surgically managed group (1.58 vs 2.57 days, p = 0.008). CONCLUSIONS: Expectant management is an effective and safe alternative to surgical evacuation in management of incomplete miscarriage in the local setting. It relieves the burden on the healthcare provider by shortening the hospital stay and avoiding the need for evacuation of retained products of conception under anaesthesia.

Effects of zinc supplementation on sexual behavior of male rats.

CONTEXT: Effects of zinc on male sexual competence are poorly understood. AIM: To study the effects of different doses of zinc on the sexual competence of males using a rat model. MATERIALS AND METHODS: Three subsets (eight in each subset) of sexually experienced adult male rats were supplemented with three different oral doses of zinc sulphate (a daily dose of 1 mg, 5 mg and 10 mg respectively) for two weeks. A subset of eight animals without zinc supplementation was used as the control group Sexual behavior was observed by placing them individually in cages with receptive females. Statistical Analysis : Data analysis was done using SPSS v10 for windows computer software. RESULTS: Supplementation of 5 mg of zinc/day for two weeks led to a prolongation of ejaculatory latency; 711.6 sec. (SEM 85.47) vs. 489.50 sec. (SEM 67.66), P < 0.05 and an increase in number of penile thrusting; 52.80 (SEM 11.28) vs. 26.50 (SEM 6.17), P < 0.05, compared to controls. The same group had elevated prolactin (PRL) and testosterone (T) levels compared to controls at the end of treatment period; PRL- 7.22 ng/dl (SEM 3.68) vs. 2.90 ng/dl (SEM 0.34) and T- 8.21 ng/ml (SEM 6.09) vs. 2.39 ng/ml (SEM 1.79), P < 0.05. In contrast, reduction of libido was evident in the same group, but this effect was not statistically significant ( P > 0.05). However, partner preference index was positive and 5 mg zinc supplementation did not exert a significant adverse effect on the muscle strength and co-ordination. The subset of rats supplemented with 1 mg/day did not show a difference from the control group while supplementation with 10 mg/day led to a reduction of the libido index, number of mounts and intromissions. Conclusions : Zinc therapy improves sexual competence of male rats; the effect is dose dependent. Increase in the T levels is beneficial in this regard. However, increase in PRL is responsible for the reduced libido index. Further studies on pigs and monkeys are needed to evaluate the therapeutic use of zinc in sexual dysfunction.

Endosonographic characteristics of the anal sphincter complex in primigravid Sri Lankan women.

OBJECTIVE: To determine the endosonographic anatomy of the anal sphincter complex in primigravid Sri Lankan women. METHOD: This is an observational study of 95 primigravid women admitted to an antenatal ward. They were examined using anal endosonography and data from subjects without sphincter injury were analyzed to describe anal sphincter morphology. Individual anal canal components were measured at defined levels, and the relationship of individual measurements with age and body mass index was calculated. RESULTS: Ninety-three of 95 women had no anal sphincter damage. The puborectalis sling (mean 5.5 mm, S.D. 0.77) forms the upper most border of the sphincter complex. The mean width of the deep external sphincter was 4.3 mm (S.D. 0.61); that of the superficial external sphincter was 4.5 mm (S.D. 0.56); and that of the internal anal sphincter at the mid anal canal was 2.1 mm (S.D. 0.21). The intersphincteric space (mean 2.1 mm, S.D. 0.26) could be distinguished sonographically in all subjects. The mean width of the anterior ring of the subcutaneous component was 3.8 mm (S.D. 1.01). The perineal body was sonographically identified in 60%. CONCLUSION: A set of normal values for the anal sphincter components in Sri Lankan primigravid women was established.

Spontaneous hepatic rupture in pregnancy.

Spontaneous hepatic rupture in pregnancy is rare and associated with significant maternal morbidity and mortality. It has been reported in association with severe pregnancy-induced hypertension and HELLP (haemolysis elevated liver enzymes low platelets) syndrome. New imaging techniques enable early diagnosis, and in those with subcapsular haematomas, conservative management. Surgical intervention is necessary in capsular rupture with haemodynamic instability. We here report three fatal cases and discuss the diagnosis and management.