Intraoperative testosterone assay for virilizing ovarian tumor topographic assessment: report of a Leydig cell tumor of the ovary in a premenopausal woman with an adrenal incidentaloma.

Ovarian virilizing tumors are rare and can lead to assessment difficulties because of their small size. A 41-yr-old female was referred for evaluation of hirsutism that had increased within the previous 3 yr. Menstrual cycle length was normal. Plasma testosterone was 3.9 ng/ml (normal range, 0.2-0.8 ng/ml), was not suppressible by 2 mg dexamethasone (4.3 ng/ml), and was increased (6.3 ng/ml) after three daily injections of hCG (5000 IU). Abdominal computed tomography scan showed an adrenal nodule (13 x 6 mm) that remained unchanged after 3 months. Ultrasound examination of the pelvis was normal. Ovarian and adrenal venous catheterization did not yield additional information. Topographic assessment was made by intraoperative measurement of testosterone in the samples taken from each ovarian vein (competitive chemiluminescent immunoassay ADVIA Centaur; right ovarian vein, 105 ng/ml; left ovarian vein, 5 ng/ml; peripheral blood, 7 ng/ml). Right annexectomy resulted in normalization of testosterone levels (0.22 ng/ml). Histopathological examination found a Leydig cell tumor of hilar type (1.5 cm). This observation illustrates the usefulness of intraoperative measurement of testosterone by a rapid automated technique for topographic assessment of ovarian virilizing tumor in premenopausal women.

Randomized trial of three luteinizing hormone-releasing hormone analogues used for ovarian stimulation in an in vitro fertilization program.

OBJECTIVE: To determine if biochemical differences in luteinizing hormone-releasing hormone analogues (LH-RH-a) have a clinical influence, we studied three of these molecules: buserelin acetate (group B), triptorelin (group T), and leuprorelin (group L). DESIGN: Clinical trial. SETTING: In Vitro Fertilization (IVF) Center. PATIENTS: Two hundred forty-six patients, undergoing their first IVF attempt, were randomly allocated to one group. The analogues were used in a long protocol for ovarian stimulation in an IVF program. RESULTS: After 15 days of LH-RH-a therapy, the follicle-stimulating hormone level was lower in group B (2.9 +/- 1, 4.3 +/- 1.7, 4.8 +/- 2.1 UI/L for B, T, and L groups, respectively; P less than 0.001), although no difference was found in LH and estradiol (E2) levels. After follicular growth stimulation by human menopausal gonadotropins (hMG), E2 level was significantly lower in B group (1,799 +/- 1,101, 2,440 +/- 1,298, 2,137 +/- 1,044 pg/mL for B, T, and L groups, respectively; P less than 0.01), as well as the E2 level per hMG ampule (67 +/- 51, 97 +/- 61, 82 +/- 49 for B, T, and L groups respectively; P less than 0.01). The pregnancy per stimulated cycle rate was not significantly different among the groups. CONCLUSIONS: These results suggest that LH-RH-a could act not only on the pituitary but also on the ovaries. Moreover, these data suggest that buserelin acetate could be preferentially used for high responders and triptorelin for poor responders.

Influence of ovarian cysts on the results of in vitro fertilization.

OBJECTIVE: To determine if ovarian cysts are associated with a particular basal endocrine profile and impair follicular growth. DESIGN: Retrospective study. SETTING: In Vitro Fertilization (IVF) Center. PATIENTS: Nine hundred fourteen stimulation cycles stimulated with a combination of luteinizing hormone-releasing hormone analogues (LH-RH-a) and human menopausal gonadotropins (hMG) in a long protocol in an IVF program. RESULTS: After 15 days of LH-RH-a therapy, ovarian cysts (> or = 20 mm) were observed in 8% of cases. These cysts were not related to a particular basal endocrine profile and did not impair follicular growth and IVF results. However, puncturing these cysts enhanced the quality of subsequent follicular growth. On the contrary, cysts appearing during hMG treatment (> or = 25 mm) were related with a lower LH:follicle-stimulating hormone ratio (0.79 +/- 0.52 versus 0.92 +/- 0.74 in absence of cyst) and to a lower ovarian response as assessed by the maximal estradiol level to the total number of hMG ampules ratio (51.6 +/- 36.5 versus 65.9 +/- 47.9 in absence of cyst). However, this difference had no influence on the pregnancy per stimulation rate (18% versus 16% in absence of cyst; not significant). CONCLUSIONS: Results show that the pathogens of ovarian cysts appearing during the blockage phase and during the stimulation phase are different. However, they do not impair the results of IVF, and thus it is not necessary to cancel the attempt in case of ovarian cyst.

Randomized trial of two media used for in vitro fertilization.

Culture media are important components of IVF. Their selection must meet the need for efficiency, and also economic and practical requirements. From these standpoints, we compared two widely used media: Ham's F10 supplemented with cord serum and Menezo B2 used without serum. The test followed a randomized protocol using two series of 159 and 162 oocytes. Since no difference was seen in efficiency assessed from cleavage rate, the discussion focuses on cost and ease of use.

Respective consequences of abdominal, vaginal, and laparoscopic hysterectomies on women's sexuality.

OBJECTIVE: To determine the relative effects of abdominal, vaginal or laparoscopic approaches for hysterectomy on female sexuality. STUDY DESIGN: One hundred and seventy women who underwent abdominal (n=68), vaginal (n=67), and laparoscopic (n=35) hysterectomy for benign disease were studied. Pre- and postoperative sexuality was assessed by questionnaire. RESULTS: Overall, sexuality after hysterectomy remained unchanged in 60.4% of cases, and improved or deteriorated in 21.3 and 18.3%, respectively. Postoperative delay in resuming sexual activity was shorter after vaginal (45.2+/-6.7 days) hysterectomy than after abdominal hysterectomy (62.4+/-9.3 days). Deterioration of sexual function occurred more frequently after abdominal hysterectomy (24%) than after vaginal (13.5%) or laparoscopic (8.5%) hysterectomy. CONCLUSION: These results indicate that the impact of vaginal and laparoscopic hysterectomy on women's sexuality may be milder than that of abdominal hysterectomy.

Choice of an ovarian stimulation protocol according to the follicular puncture method in an in vitro fertilization programme.

In order to ascertain the adequacy of ovarian stimulation protocols with a type of follicular puncture, 126 women undergoing in vitro fertilization received either combination clomiphene/hMG or hMG alone according to a randomized test protocol. Within both groups patients for whom a pelvic examination was required had laparoscopies, while others had transvaginal ultrasonically guided punctures as far as possible. Clomiphene/hMG was more efficient than hMG alone as assessed from the cleavage rate (68% vs. 54%; p less than 0.01) and the pregnancy per attempt rate (16% vs. 5%; p less than 0.05). Laparoscopic punctures were more efficient than ultrasonically guided punctures (mean number of recovered oocytes: 4.8 +/- 2.6 vs. 3 +/- 2.5; p less than 0.001), but slightly better results were achieved by this latter method in ongoing pregnancy per puncture rate (18% vs. 8%; NS). With ultrasonically guided punctures, stimulation by clomiphene/hMG allowed better oocyte recoveries (3.8 +/- 2.5 vs. 2.3 +/- 1.9, p less than 0.05). Such results constitute an argument for preferential use of the clomiphene/hMG stimulation protocol with ultrasonically guided punctures.

Paradoxical ovarian stimulations in the use of LHRH analogs.

In the case of in vitro fertilization, LHRH analogs are used to induce an hypophysary blockage, before the phase of stimulation, via administration of exogenous gonadotropin. During in vitro fertilization attempts using LHRH analogs, the blockage is controlled after 14 days of treatment through measurement of the plasmatic estradiol and pelvic ultra-sonography. In this retrospective study, which concerned 1075 in vitro fertilization cycles, a paradoxical ovarian stimulation with LHRH analogs was observed in 93 cases (8.7%), with high estradiol levels and follicular growth (detected by ultra-sonography), in spite of low FSH and LH levels. In 4 cases, a follicular puncture was performed, which allowed to collect oocytes from which embryos were obtained, thus confirming the observed follicular growth and maturation. The most probable hypothesis explaining this phenomenon seems to be a direct ovarian stimulation, effectuated in vivo by LHRH analogs. This stimulation is only observed in certain patients, and apparently more frequently, with certain LHRH analogs, probably through a variation in the expression of ovarian LHRH receptors.

Paradoxical ovarian stimulations in the use of LHRH analogs.

In the case of in vitro fertilization, LHRH analogs are used to induce a hypophysial blockage before the phase of stimulation, via administration of exogenous gonadotropin. During in vitro fertilization attempts using LHRH analogs, the blockage is controlled after 14 days of treatment by measuring plasmatic estradiol and by pelvic ultrasonography. In this retrospective study, which concerned 1075 in vitro fertilization cycles, a paradoxical ovarian stimulation with LHRH analogs was observed in 93 cases (8.7%) with high estradiol levels and follicular growth (detected by ultrasonography), in spite of low FSH and LH levels. In 4 cases, a follicular puncture was performed, which made it possible to collect oocytes from which embryos were obtained, thus confirming the observed follicular growth and maturation. The most probable hypothesis explaining this phenomenon seems to be direct ovarian stimulation effectuated in vivo by LHRH analogs. This stimulation is only observed in certain patients, and, more frequently it seems, with certain LHRH analogs, which is probably due to a variation in the expression of ovarian LHRH receptors.

[Desmoid tumors of the anterior abdominal wall. Apropos of a case]. / Tumeurs desmoïdes de la paroi abdominale antérieure. A propos d'une observation.

The authors describe a case of a desmoid tumor of the anterior abdominal wall. From a review of the world literature, the main characteristics of these tumors are detailed, and the various pathophysiological hypotheses, demonstrating the necessity of exclusively surgical treatment, are presented.

[Vaginal hysterectomy in fibroma. Apropos of 453 cases. Retrospective comparison with 509 cases of abdominal hysterectomy]. / Hystérectomie vaginale pour fibrome. A propos de 453 cas. Comparaison rétrospective à 509 hystérectomies abdominales.

The authors present a series of 962 hysterectomies for fibroma carried out between January 1981 and December 1995 in the Department of Gynecology and Obstetrics of CHU Toulouse-La Grave. They carried out 453 vaginal hysterectomies and 509 abdominal hysterectomies. They compared the largest series reported in the literature, between vaginal and abdominal technique. The vaginal route has the obvious advantages of speed of operation, less operative trauma, lower risk of thrombo-embolic disease and the hospital stay is shorter. Laparoscopic assistance allows to extend indications of vaginal route.

[Triploidy]. / La triploïdie.

Using their own experience which they described in 1984 and reviewing as well the literature of the condition since that time has led the authors to suggest that triploidy should be considered as a pathological entity with three clinical forms: early abortion, mid-trimester termination and the birth of triploidy fetuses either alive or dead. They discuss the clinical features, the ultrasound appearances, the pathological and anatomical details and the cytogenetics of triploidy. They differentiate this condition from trophoblast disease and from the central hydropic conditions which occur with normal caryotypes. They emphasize that there is a difference in the way classical molar pregnancy evolves and repeat again that the term "embryonic mole" should be avoided.

[Idiopathic thrombopenic purpura and pregnancy]. / Purpura thrombopénique idiopathique et grossesse.

The association of IPT (idiopathic thrombocytopenic purpura) and pregnancy happens rarely, but when it does it gives rise to two problems, the maternal and the neonatal. On the maternal level the risk is haemorrhage. Furthermore, the role of splenectomy in pregnancy still needs to be discussed; whereas all authors agree that treatment with corticoids and perhaps even with platelet transfusion may be necessary. As far as the newborn are concerned, it is common to find a low level of platelets which means that the newborn has particular risks of blood vessel rupture and intra-cranial haemorrhage (our observation). The attitude that the authors propose as far as the obstetric management of these cases is concerned is to carry out routine Caesarean section at term before labour starts. They analyse the other methods of dealing with these cases from the point of view of the maternal platelets and also from the fetal platelets estimated from scalp blood during labour.

[A summary of the results of microsurgical exploration and treatment. 40 cases of male sterility (author's transl)]. / La microchirurgie dans la stérilité masculine. Résultats du bilan et du traitement chez 40 patients.

The authors report their statistical results of 40 subjects that were explored and where double epididymo-deferens anastomoses were achieved. They found that there were associated conditions which worsened the prognosis, namely: stenosis of the genital tracts and broncho-pulmonary infections. On the other hand stenosis of the genital tracts associated with varicocoele gave a better prognosis. Permeability was achieved in 40 p. 100 of cases. Six pregnancies occured from 33 patients who were followed up with post-operative spermograms. The following treatments are useful if added to the surgical treatment: gonadotrophins, corticoids and antibiotics. They point out that surgical cure is much more likely when varicocoele is associated.

[Home care by hospital midwives in the prevention of premature labor]. / La surveillance à domicile par les sages-femmes hospitalières dans la prévention de l'accouchement prématuré.

The authors analyse the results of 4 years home supervision of high-risk pregnancies by hospital midwives. The inquiry concerns 813 women out of a total of 12,643 deliveries in the same period of time (1978-1981). This supervision deals with the people who were selected by patient consultation or after hospitalisation. It is particularly concerned with patients with threatened premature labour. The role of the midwife is at once medical in that she undertakes a constant review of the state of the pregnancy, and social and psychological. Domiciliary visiting can often take the place of admission to hospital. Even though has not been a great decrease in the number of premature labours it does seen certain that patients who have been followed in this way have had pregnancies that have lasted longer. Over the 4 years when the experience has been gained the number of deliveries occurring before the 34th week has dropped from 2.8 to 1%. Finally, it is an extremely efficient way of lowering hospital expenses.

[Experimental study of the patency of rabbit fallopian tubes after section of the isthmus and microsurgical anastomosis]. / Etude expérimentale de la perméabilité des trompes de lapines après section de l'isthme et anastomose microchirurgicale.

The authors carried out 45 microsurgical plastic operations in rabbits to study tubal patency. They found patency in 42%. They compared the microscopical appearances that were found later in relationship to the type of suture material (Vicryl absorbable or Prolene non-absorbable). The difference seems to be significant because of the inflammatory action that occurs. This was shown in 17% of cases where absorbable material was used and in 36% where non-absorbable was used.

[Evaluation of the economic burden in the respective indications of in vitro fertilization and tubal microsurgery at a regional hospital center]. / Evaluation du poids économique dans les indications respectives de la fécondation in vitro et de la microchirurgie tubaire dans un Centre Hospitalier Régional.

The authors have calculated the cost of obtaining and maintaining an intrauterine pregnancy to term by IVF and by tubal surgery according to the four classical indications. They have worked this out from local experience. The indications are: reversal of sterilization, surgery on proximal lesions, surgery on distal lesions and multifocal lesions. IVF is superior to surgery where the lesions are multifocal and possibly also in proximal blocks. But surgery is indicated in a large number of distal blocks and particularly in reversal of sterilization. The authors point out how difficult it is to extrapolate from national or international statistics. The choice must depend particularly on the experience of the local teams.

[HIV seropositivity and pregnancy. Apropos of 48 cases (how should they be managed at the present time?)]. / Séropositivité HIV et grossesse. A propos de 48 observations (quelle conduite à tenir pratique adopter aujourd'hui?)

We describe the gynaecological and obstetrical management of 48 HIV seropositive, pregnant women and review the literature. We did not find that pregnancy aggravated the development of the condition from the asymptomatic anti-HIV related complex (ARC) and AIDS. It seemed that fetal malformations, especially of the face, occurred most frequently in babies born to HIV seropositive mothers. Materno-fetal transmission of HIV was found in the uterus in 50% of our cases. In conclusion, we recommend safe contraception to prevent pregnancies in anti HIV seropositive women. If that fails, induced first trimester abortion is medically indicated and should be carried out if possible, as should strict medical control post-partum of both mother and child if the pregnancy is carried to term.

[Fetal blood sampling under ultrasonic control]. / Prélèvement de sang du cordon foetal sous contrôle échographique.

Withdrawing foetal blood from the umbilical cord under ultrasonic control requires close co-ordination between obstetricians and echographists. The most important indications for this procedure are infections and foetal karyotype determination.

[Evaluation of systemic antibiotic preventive treatment in colorectal surgery]. / Appréciation de l'antibio-prophylaxie systémique en chirurgie colo-rectale.

A comparison was made of two methods of prophylactic antibiotic therapy against the septic complications of colonic and rectal surgery: --preoperative oral antibiotics associated with peroperative systemic antibiotics; --peroperative systemic antibiotics only, continued for 24 hours after surgery. Both types of antibiotic therapy were of short duration and were designed to cover aerobic and anaerobic organisms. Two groups of 30 patients were selected at random. They were homogeneous. The septic complication rate was 10% in the oral plus systemic and 24% in the systemic group. It is felt that the combination of oral and systemic antibiotics remains preferable, in particular bearing in mind the efficacy of oral metronidazole.

[Ureteral and vesicular endometriosis: case report]. / Endométriose urétérale et vésicale: à propos d'une observation.

The authors report a case of both vesical and ureteral endometriosis diagnosed after recurrent acute pyelonephitis. A Gonadotrophin-Releasing Hormone (GnRH) agonist therapy and a conservative endoscopic management is started allowing an almost complete regression of the lesions. A review of the literature is presented about this unexceptional localisation of endometriosis (1 to 2% of all endometriosis).