生殖医学杂志最新文献

Background: Cesarean section is the most frequently performed obstetrics operation. It can be associated with short- and long-term risks, one of which is uterine scar dehiscence. Women with uterine scar dehiscence often fear pregnancy because they are advised it may increase the risk of uterine rupture. It is generally recommended that women undergo transvaginal or laparoscopic repair of the uterine dehiscence before any future pregnancies.

Case: A 32-year-old woman with a previous transverse lower-segment cesarean section complicated by severe uterine dehiscence, diagnosed by MRI before pregnancy, was treated with expectant management during a subsequent pregnancy. She was asymptomatic during pregnancy until term delivery with expectant management.

Conclusion: We recommend that patients with severe uterine dehiscence undergo transvaginal or laparoscopic repair before attempting another pregnancy. However, if they become pregnant without repair of the dehiscence, they can be managed conservatively with routine surveillance and intermittent monitoring by ultrasound to term unless there is an emergency.

Objective: To compare the uterine transverse diameter (UTD) in women with normal uteri and women with uterine canalization defects as well as to assess its performance for ruling out such defects.

Study design: Retrospective analysis of prospectively collected data in a series of selected women with primary or secondary infertility. Measurement of UTD and 3D volume acquisition for subsequent off-line analysis was performed in order to identify possible canalization defects. UTD of the normal uterus, measured by 2D ultrasound, was compared to that of arcuate, subseptate, and septate uteri. ROC curve was plotted to determine the best UTD cutoff for differentiating normal from abnormal uteri.

Results: A total of 421 women were ultimately evaluated. UTD was significantly larger in women with arcuate (53.3 mm, SD 6.3, p<0.05), subseptate (55.0 mm, SD 6.7, p<0.05), and septate (56.0 mm, SD 4.8, p<0.05) uterus as compared with the normal uterus (45.9 mm, SD 7.1). ROC curve showed that the best UTD cutoff for ruling out the presence of a uterine canalization defect was 45 mm (AUC 0.809, 95% CI 0.768–0.849).

Conclusion: Measurement of UTD may be a simple and practical method for ruling out a uterine canalization defect in infertile women.

Objective: To evaluate the effects of estradiol on endometrial regeneration and stromal fibrosis after endometrial curettage.

Study design: This is an experimental, prospective study. Combining ovariectomized rabbits and different doses of estrogen replacement, we divided 33 female rabbits into 4 groups: control, low estrogen, moderate estrogen, and high estrogen. Hematoxylin-eosin staining and Masson’s trichrome staining were used to assess the regeneration of endometrial glands and the degree of stromal fibrosis.

Results: Before curettage, estradiol at high serum level could stimulate endometrial gland regeneration as assessed by the number of endometrial glands in paraffin sections stained with hematoxylin and eosin. However, after curettage, both high and low doses of estradiol impaired glandular regeneration while enhancing stro-ma fibrosis, which was calculated as the ratio of stromal fibrosis area to endometrial area in paraffin sections stained with Masson’s trichrome, as compared with the control group. In addition, estradiol is favorable to endometrial repair at the physiological level.

Conclusion: Estradiol compromises glandular regeneration and promotes stromal fibrosis at both low and high serum levels but is favorable to endometrial repair at the physiological level. This study may provide new insight for the role of estrogen therapy after hysteroscopic division of intrauterine adhesion.

Background: Fetoscopic laser coagulation of the placental anastomoses is the standard treatment for twin-to-twin transfusion syndrome (TTTS). Despite certain improvements in fetoscopic technique, every fourth fetoscopic procedure is still complicated by preterm premature rupture of membranes, leading to ascending infection, fetal demise, and/or preterm delivery. re-TTTS occurs after fetoscopy in 2–14% of cases, impairing the outcome.

Case: A 26-year-old woman underwent laser coagulation of placental anastomoses because of stage III TTTS at 21/6 weeks of gestation. A microinvasive fetoscopic technique with 1-mm optic was used. Three weeks later, during a second fetoscopy because of re-TTTS, a defect of the chorioamniotic membranes of about 3 mm2 in area was visualized. This was without any signs of wound healing. We decided to perform laser coagulation with Nd:YAG laser of 10–30 W energy, moving from the wound’s edge to the center until complete closure of the defect could be achieved. The patient gave birth at 34/0 weeks to 2 healthy female infants weighing 2,013 g and 1,712 g. Microscopic evaluation of chorioamniotic membranes found dystrophic calcification within the treated membranes; this had been covered by amniotic epithelium.

Conclusion: Small iatrogenic amniotic membrane defects could be successfully treated by laser technique.

Background: Sarcoidosis is a multisystem inflammatory disease of unknown etiology. It is uncommon, with an incidence of approximately 16.5 per 100,000 men.1 It is characterized by noncaseating epithelioid granulomata that typically affect the chest, skin, eyes, and, much less commonly, the genital system (<0.2% of cases). Sarcoidosis can affect any of the scrotal structures, although due to its rarity, investigation of solid masses of the testes are largely targeted towards excluding either a malignant or infective etiology.²

Case: We report a rare case of a 27-year-old male who presented with bilateral testicular and neck swellings. He underwent orchidectomy, and histopathology demonstrated sarcoidosis. He subsequently developed both pituitary and testicular sarcoidosis resulting in azoospermia. Through the administration of gonadotropins and surgical sperm retrieval we were able to retrieve sperm suitable for assisted reproductive technologies.

Conclusion: This case illustrates the difficulties faced in managing the fertility of men who develop systemic sarcoidosis. It also highlights the diagnostic and therapeutic challenges faced by physicians when presented with a case of systemic sarcoidosis.

Objective: Serendipitous Signs, Symptoms, Laboratory Parameters, and Instrumental Patterns of Amniotic Fluid Embolism: Lessons from an Analysis of Case Reports.

Study design: Wide analysis of the case reports on AFE published from 1990 to 2014. A scoring system for quantifying the relevance was attributed to each sign, symptom, laboratory parameter, and instrumental abnormal pattern in AFE cases. Principal component rotated factor analysis was used to reduce data. The residual signs, symptoms, and laboratory and instrumental parameters were introduced in a multivariable logistic regression model (dependent variable: survival).

Results: AFE, clinically, has at least 2 serendipitous symptoms (restlessness and confusion, at rates between 10–15%) and a serendipitous laboratory parameter (rise in C-reactive protein blood levels, between 2–3%). Fatal AFE cases relate mostly to the severity of cardiac and pulmonary impairment, rather than with restlessness, confusion, and rise in C-reactive protein.

Conclusion: The hypothesis that AFE has atypical behavior should be retained; the extent to which serendipitous findings of AFE relate to AFE outcomes is uncertain.

Objective: To assess the efficacy and safety of combined hysteroscopic morcellation/endometrial ablation for treating abnormal uterine bleeding (AUB).

Study design: Prospective case series from 5 U.S. gynecology clinics. Women with intrauterine polyps and/or type-0 myomas and transformed Uterine Fibroid Symptom and Health-Related Quality-of-Life (UFS-HRQoL) symptom severity score ≥47 points (100 possible) underwent hysteroscopic morcellation (MyoSure) of intrauterine pathologies before endometrial radiofrequency ablation (NovaSure). Outcome measures were amenorrhea rate, UFS-HRQoL scoring, AUB retreatment/reintervention, bleeding days, and perioperative adverse events, through 12 months.

Results: Of 26 enrolled women, 24 were available through study completion. Lesions were 27% myomas and 73% polyps. Procedure room time was 19±13 minutes. Complete lesion eradication occurred in 96% of women. At 12 months, amenorrhea prevalence was 46% (p<0.0001 vs. baseline), and 87% of women reported either no bleeding or normalized bleeding. Bleeding/spotting days decreased from 15.7±7.4 to 3.1±4.2 days/month (p<0.0001), symptom severity decreased from 75±13 to 12±18 points (p<0.0001), and QoL scores increased from 29±18 to 88±23 points (p<0.0001). Three women required additional AUB intervention. Perioperative adverse events were minor nausea (n=1) and abdominopelvic cramping (n=2) without sequelae.

Conclusion: Sequential hysteroscopic morcellation and endometrial radiofrequency ablation of intrauterine lesions in women with AUB increases amenorrhea rate, alleviates bleeding symptoms, and improves quality of life, with an acceptable safety profile.

Objective: To examine the cost benefit of performing hysteroscopic polypectomy (HP) in infertile women with endometrial polyp(s) before controlled ovarian hyperstimulation with intrauterine insemination (COH/IUI).

Study design: Decision analytic model comparing costs and clinical outcomes.

Results: HP and COH/IUI costs ranged from $537–$12,530 and $800–$7,600, respectively. Performing an HP before COH/IUI lowered fertility cost by $7,652 per clinical pregnancy. When COH/IUI costs remained constant, HP was most cost beneficial when the cost of HP was below a threshold value of $9,452. When HP costs remained constant, the threshold value at which HP was no longer cost beneficial was at COH/IUI costs below $704. The cost benefit was greatest when an office-based HP is performed.

Conclusion: HP before COH/IUI is more cost beneficial than fertility treatment alone, particularly when office-based hysteroscopy is performed.

Background: In modern gynecology an intrauterine device (IUD) with levonorgestrel is often used as a method of contraception. The levonorgestrel-releasing intrauterine system is small and T-shaped. In Slovenia, only a gynecologist may insert it. CASES: We present 2 clinical cases in which, despite strong evidence that no perforation had occurred during insertion, the IUD was found outside the uterus. If the IUD threads are not visible or the IUD cannot be located in the uterine cavity, an X-ray of the abdomen must be performed. If the IUD is found in the abdominal cavity outside the uterus, removal by laparoscopy is carried out.

Conclusion: Given the large number of inserted IUDs, the complications associated with the levonorgestrel-releasing intrauterine system are quite rare, and therefore it remains one of the most widely used contraceptive methods.