Hysteroscopic metroplasty in patients with a uterine septum and otherwise unexplained infertility

Objective

To evaluate the reproductive outcomes of patients with a uterine septum and otherwise unexplained infertility who underwent hysteroscopic metroplasty, and to compare them with those of patients with the same diagnosis who did not have hysteroscopic metroplasty.

Methods

The present retrospective study included 127 patients with diagnosis of a uterine septum and otherwise unexplained infertility. The reproductive outcomes of 102 patients who underwent hysteroscopic metroplasty (group 1) and 25 patients who rejected the operation (group 2) were compared.

Results

Of the 102 patients who underwent hysteroscopic metroplasty, 44 (43.1%) were able to achieve pregnancy, as compared with 5 (20%) of the 25 patients who did not undergo the operation (P = 0.03). The abortion rate was 11.4% (5/44) in group 1, compared with 60% (3/5) in group 2 (P = 0.02). The live birth rate was 35.3% (36/102) in group 1, as compared with 8% (2/25) in group 2 (P = 0.008).

Conclusions

The results indicate that hysteroscopic metroplasty improves reproductive outcome for patients with a uterine septum and otherwise unexplained infertility.     

Determinants of fertility and reproductive success after hysteroscopic septoplasty for women with unexplained primary infertility: a prospective analysis of 88 cases

Objective

To evaluate prospectively the effect of hysteroscopic septoplasty as therapy for unexplained primary infertility in women with uterine septum as a sole cause for reproductive failure and to define the factors influencing reproductive success.

Study design

In a prospective comparative study, we enrolled 103 infertile women with uterine septum as a sole cause for reproductive failure. They had had unexplained primary infertility >2 years and a follow-up >12 months. Uterine anomalies were diagnosed by means of hysterosalpingography (HSG) and 2D-transvaginal sonography (TVS) with intrauterine saline infusion. Hysteroscopic septoplasty was performed in the early follicular phase. Pregnancy rates (PR) according to patient and septum characteristics (septum size) were the main outcome measures.

Results

Follow-up was complete for 88 patients. The mean (±SD) age of the patients was 36.1 ± 2.1 years. Forty-two patients became pregnant (40.7%). The mean (±SD) delay in conception was 7.5 ± 2.6 months. Nearly 80% of the pregnant women conceived spontaneously. Of 44 pregnancies in 42 women, 36 live newborns were delivered. The PR was significantly higher in women <35 years of age or with <3 years of unexplained primary infertility. Moreover, in women with a septum size larger than one-half of their uterine length the PR was significantly higher than those with septum size <1/2 of their uterus (P = .12).

Conclusion

Fertility and pregnancy after hysteroscopic septoplasty in women with unexplained primary infertility and uterine septum as a sole cause for reproductive failure seems to depend on patient age, duration of infertility before septoplasty, and septum size. Women with a septum size larger than one-half of their uterine length have a higher chance of successful pregnancy after hysteroscopic septoplasty.     

Intrauterine device or estrogen treatment after hysteroscopic uterine septum resection

Objective

To investigate the effects on adhesion formation and pregnancy maintenance of an intrauterine device (IUD) and/or estrogen treatment after hysteroscopic septum resection.

Methods

After septum resection 100 women received either no treatment, or estrogens, or an IUD, or an IUD plus estrogens (n = 25 per group). Most were later checked hysteroscopically for uterine cavity adhesions. All pregnancies occurring during the study period were recorded.

Results

Adhesions developed in 1 of 19 (5.3%) of the untreated women, 3 of 25 (12%) of the women treated with an IUD plus estrogens, 2 of 19 (10.5%) of the women treated with an IUD only, and none of the women treated with estrogens only. None of the differences, however, were significant. Regarding pregnancy, the differences between groups were also not significant.

Conclusion

Neither IUD placement, nor estrogen treatment, nor both were found to prevent intrauterine adhesions or facilitate pregnancy after hysteroscopic uterine septum resection.     

Midtrimester abortion using vaginal misoprostol for women with three or more prior cesarean deliveries

Objective

To evaluate the safety and efficacy of vaginal misoprostol for second-trimester abortion in women with 3 or more prior cesarean deliveries.

Methods

This study was conducted with 138 women who needed pregnancy termination between 13 and 26 gestational weeks, 31 with 3 or more previous cesarean deliveries and 107 with no uterine scars (the controls). Misoprostol was inserted in the vagina every 6 hours until regular contractions or products of conception appeared, a 200-µg tablet for the first 24 hours and 2 tablets thereafter. The outcomes assessed were successful vaginal abortion, hemorrhage requiring blood transfusion, incomplete abortion, and uterine rupture.

Results

A vaginal abortion occurred in 28 women (90.3%) in the study group and 107 (100%) in the control group (P = 0.01). There were no significant differences in the prevalence of the other assessed outcomes.

Conclusion

Vaginal misoprostol appears to be safe and acceptably effective for second-trimester pregnancy termination in women with 3 or more previous cesarean deliveries.     

Peripartum cardiomyopathy

Objective

To determine the clinical and echocardiographic profiles of women with peripartum cardiomyopathy and ascertain the natural course of the disease.

Methods

Fifty-six women with peripartum cardiomyopathy were followed up for a mean period of 6.1 years and their clinical and echocardiographic profiles were studied as well as their outcomes.

Results

The mean ± SD age at presentation was 31 ± 5 years and mean parity was 2.6 ± 1. Of the 56 patients, 18 (32.1%) had NYHA Class II, 24 (42.9%) had NYHA Class III, and 14 (25%) had NYHA Class IV symptoms, and 21 (37.5%) and 35 (62.5%), respectively, presented with features of heart failure during pregnancy and the postpartum. During follow-up, the left ventricular ejection fraction improved from 31% ± 7.2% to 43% ± 8% (P ≤ 0.05). Nine patients (16.1%) became pregnant, with a mortality of 55.5% during pregnancy and 23.2% during follow-up.

Conclusion

Women with peripartum cardiomyopathy present with severe left ventricular dysfunction late in the pregnancy or early in the puerperium. A considerable number of women still die from this condition despite the use of angiotensin-converting enzyme inhibitors and β-blockers. A subsequent pregnancy carries a very high risk of mortality.     

The significance of surgical staging in intermediate-risk endometrial cancer

Objective

The objective was to evaluate rates of nodal disease in endometrial cancer within risk groups based on uterine factors, and to estimate the rate of potential undertreatment and impact on survival if nodal status was unknown.

Methods

This was a population-based retrospective cohort study of endometrioid-type endometrial cancer in British Columbia from 2005 to 2009. All women with a preoperative grade 2/3 cancer underwent hysterectomy, bilateral salpingo-oophorectomy (HBSO) and lymphadenectomy, and those with intermediate- or high-risk disease based on uterine factors after HBSO alone underwent secondary lymphadenectomy. We compared rates of node-positivity and potential undertreatment in each group if nodal status had been unknown (chi-square test), and estimated the survival benefit from lymphadenectomy.

Results

There were 222 women who underwent primary or secondary lymphadenectomy. Median age was 65 (range 38-86) and median number of lymph nodes was 10 (range 2-39). Of the 66 women with intermediate-risk disease (grade 1 or 2 tumor, deep myometrial invasion), 6 had nodal disease (9.1%) and received adjuvant chemotherapy. They remain disease-free after 24 months (range 8-55). They would not have qualified for chemotherapy based on uterine factors alone, and would have been undertreated compared to other risk groups (chi-square p = 0.071). A 1% survival benefit was estimated from lymphadenectomy.

Conclusion

Women with a grade 1 or 2 tumor and deep myometrial invasion have a 9% risk of nodal disease. Lymphadenectomy is significant for this subgroup as they would have been undertreated based on uterine risk factors alone, although the survival benefit is limited.     

Improved quality of life is partly explained by fewer symptoms after treatment of fibroids with mifepristone

Objective

To examine mediators of mifepristone treatment on improvements in health-related quality of life (HRQOL) among women with symptomatic fibroids.

Methods

The study sample included women with symptomatic uterine fibroids who were treated with 5 mg or 2.5 mg of mifepristone or placebo. Assessments of uterine size (ultrasound), pain (McGill pain questionnaire), bleeding (diary), anemia (gm/dL), and HRQOL measured using the uterine fibroid symptom quality of life scale were done at baseline, 3 months, and 6 months. The improvements in HRQOL that could be explained by changes in these clinical factors were assessed.

Results

The final sample included 62 women. Treatment with mifepristone was associated with significant improvement in HRQOL, which was explained in part by reduction in pain (28%, P < 0.001) and bleeding (18%, P < 0.001). Reduction in uterine volume was of marginal significance (P = 0.05) and was associated with a decrease in HRQOL (7%). Much of the impact of treatment on HRQOL (61%) remained unexplained in this model.

Conclusions

Improvements in HRQOL after treatment with mifepristone are partly explained by improvements in pain and bleeding, but not uterine size. However, most of the improvement in HRQOL is not explained by improvements in these clinical parameters.     

Uterine cavity shape and the best site for embryo transfer

Objective

To determine the best site for embryo placement in uterine cavities of varying shapes.

Method

In this prospective investigation, 638 embryo transfers were allocated to two groups: for group 1 (n = 558) embryos were transferred into uterine cavities of normal shape; for group 2 (n = 80) embryos were transferred into uterine cavities of abnormal shape. The uterine cavity was divided into 3 equal regions: upper, middle, and lower. Pregnancy outcomes for placements in each region were compared within and between the 2 groups.

Results

No significant differences were found in rates of pregnancy or implantation among the 3 regions in group 1. In contrast, the implantation rate in group 2 was highest when embryos were placed in the middle region of the uterine cavity: 28.8% compared with 6.8% and 8.3% for the upper and lower regions, respectively (P < 0.05).

Conclusion

For the normal uterine cavity, pregnancy outcomes do not depend on embryo placement. However, for uterine anomalies, embryo placement in the middle region of the uterine cavity gave the best outcome.     

Fetal myocardial morphological and functional changes associated with well-controlled gestational diabetes

Objective

To make a global evaluation of the fetal myocardial changes in a well-controlled gestational diabetic population.

Study design

Twenty-four pregnant well-controlled diabetic patients were selected. Sixteen normal pregnancies were randomly collected as a control group. Measurements of morphological and functional myocardial parameters were performed. Data from the left ventricular outflow tract and peripheral Doppler data were obtained.

Result

The thickness of the interventricular septum was increased in diabetic pregnancies (p < 0.001). Tricuspid E/A index was the only functional parameter showing a significant variation, with lower values in diabetic pregnancies. Doppler parameters from the left ventricular outflow tract and peripheral Doppler waveforms were similar between groups.

Conclusion

A tendency towards interventricular septum hypertrophy was observed even in well-controlled diabetic pregnancies. Mild hypertrophic cardiac changes were not associated with abnormal cardiac function or signs of left ventricular outflow obstruction, although minor changes in right ventricular diastolic function were recorded.     

Fertility outcome following transvaginal cervicoisthmic cerclage using a polypropylene sling

Objective

To report fertility and pregnancy outcomes following transvaginal cervicoisthmic cerclage with a polypropylene sling during a previous pregnancy.

Methods

A continuous series of 57 women who underwent prophylactic cervicoisthmic cerclage during a previous (reference) pregnancy were enrolled. Telephone interviews were carried out to evaluate each patient's subsequent fertility.

Results

Among the 57 women interviewed, 8 had an inadequate follow-up, 13 women were lost to follow-up, 1 woman required a hemostatic hysterectomy, and 2 women required removal of the sling. Nineteen women did not desire a subsequent pregnancy. Of the 14 women who did desire a subsequent pregnancy, 1 woman had previously known tubal infertility. Of the 13 remaining women, 7 subsequently became pregnant. One woman had a spontaneous abortion (11 weeks of pregnancy); 1 woman delivered at 22 weeks of pregnancy, after a spontaneous premature membrane rupture; 1 woman had a cesarean delivery at 25 weeks of pregnancy; and 4 patients had a cesarean delivery after 37 weeks of pregnancy. Median duration of the 4 subsequent pregnancies at delivery was 37 weeks (interquartile range [IQR], 37-38 weeks). Median birth weight was 3040 g (IQR, 2500-3250 g).

Conclusion

Subsequent pregnancy is possible after transvaginal cervicoisthmic cerclage using a synthetic sling.     

Do patients manage to achieve pregnancy after a major complication of deeply infiltrating endometriosis resection?

Objective

To evaluate the fertility status in women suffering from major postoperative complications following deep endometriosis surgery.

Study design

A retrospective study in teaching and research hospitals (tertiary centers) including 23 women submitted to the surgical treatment for deep endometriosis and presenting a major postoperative complication. Postoperatively, women desiring pregnancy who conceived were compared to those who did not conceive using Mann-Whitney test and Fisher's exact test. Main outcome measure included the pregnancy rate among these women.

Results

The overall intrauterine pregnancy rate was 47.8% and the live birth rate was 30.4%. There were 10 spontaneous conceptions and 3 IVF conceptions among 11 patients. Women who did not conceive were older than those who conceived (33.9 vs. 29.3 years; p = 0.02). The pregnancy rate after intestinal complications was lower than after urinary complications (33.3% vs. 83.3%; p = 0.04).

Conclusion

Fertility remains preserved among women experiencing a major complication after removal of deep endometriosis with a live birth rate of 30.4%. Women experiencing bowel complications have a reduced probability of conception compared with those who experience a urologic complication.     

Effect of cervical mucus aspiration before intrauterine insemination

Objective

To determine whether cervical mucus aspiration before intrauterine insemination (IUI) has any effect on clinical pregnancy rates.

Method

The outcomes of 186 IUI cycles in 95 consecutive patients in whom mucus was aspired prior to IUI were compared retrospectively with those of 1057 IUI cycles in 505 women.

Results

The pregnancy rate was 15.1% (28 pregnancies for 186 cycles) in the cervical mucus aspiration group and 9.9% (105 pregnancies for 1057 cycles) in the control group (P = 0.05). Mucus aspiration led to significantly increased pregnancy rates for women with unexplained infertility (24% in the aspiration group vs 9.5% in the control group; P = 0.04).

Conclusion

Cervical mucus aspiration before IUI might improve clinical pregnancy rates by yet-to-be-defined mechanisms.     

Length of the endometrial cavity and intrauterine contraceptive device expulsion

Objective

To evaluate the correlation between endometrial cavity length and expulsion rate in acceptors of the TCu380A intrauterine device (IUD) or the levonorgestrel-releasing intrauterine system (LNG-IUS).

Methods

The study included 235 nulligravida and parous women who received a TCu380A IUD or LNG-IUS and who were observed for up to 1 year. The length of the uterine cavity was measured by uterine sounding and ultrasonography.

Results

The endometrial cavity was shorter than 3.2 cm in 2 LNG-IUS users and at least 3.2 cm long in 87 LNG-IUS users, with expulsions occurring in 0 (0.0%) and 2 (2.3%) of these women, respectively (P > 0.999). Among the TCu380A IUD users, the endometrial cavity was shorter than 3.6 cm in 63 women and at least 3.6 cm long in 83 women, with expulsions occurring in 3 (4.8%) and 5 (6.0%) of these women, respectively (P > 0.999). The mean length of the endometrial cavity—evaluated via ultrasonography—among the 10 women whose devices were expelled was 3.9 ± 0.3 cm, compared with 3.9 ± 0.0 cm in those who retained their devices (P = 0.799).

Conclusion

The present results do not support the hypothesis of an association between uterine length and risk of intrauterine contraceptive expulsion.     

Bilateral uterine artery ligation plus B-Lynch procedure for atonic postpartum hemorrhage with placenta accreta

Objective

To assess the effectiveness of bilateral uterine artery ligation followed by B-Lynch compression suturing in women with atonic postpartum hemorrhage and placental site bleeding due to adherent placenta accreta.

Method

This protocol was followed in 26 women undergoing cesarean delivery for placenta accreta.

Results

Two women died from disseminated intravascular coagulopathy. In the remaining 24 women, placental remnants completely disappeared within 8 months and ovulation resumed after a mean ± SD of 51.6 ± 3.2 days. Moreover, 18 women (75%) became pregnant within 12 months.

Conclusion

Atonic postpartum hemorrhage and placental site bleeding due to adherent placenta accreta can be safely controlled by bilateral uterine artery ligation followed by B-Lynch compression suturing in women who desire to remain fertile.     

Reproductive outcome after letrozole versus laparoscopic ovarian drilling for clomiphene-resistant polycystic ovary syndrome

Objective

To compare the clinical outcomes of letrozole and laparoscopic ovarian drilling (LOD) in patients with clomiphene-citrate-resistant polycystic ovary syndrome (PCOS).

Methods

In the present prospective randomized trial, 140 women with clomiphene-citrate-resistant PCOS were randomly allocated to receive 5 mg letrozole from day 3 to day 7 of menses for 6 consecutive cycles, or to undergo LOD. When a leading follicle of at least 18 mm was present, ovulation was triggered with human chorionic gonadotropin (hCG). The 6-month rates of ovulation, pregnancy, abortion, and live births were evaluated.

Results

The groups were similar with regard to baseline clinical characteristics and hormonal profiles. The ovulation rate was significantly higher in the letrozole group than in the LOD group (59.0% versus 47.5%). On the days of the hCG injection, women in the letrozole group had a significantly thicker endometrium than those in the LOD group (P < 0.0001). Women receiving letrozole had a higher pregnancy rate (35.7% versus 28.6%) and a lower rate of spontaneous abortion (8.0% versus 20.0%, respectively), but these differences were not statistically significant.

Conclusion

Letrozole seems to be a suitable second-line ovulation-inducing alternative to LOD in women with PCOS who do not conceive with clomiphene citrate.     

Prepregnancy body mass index, gestational weight gain, and pregnancy outcomes in China

Objective

To look for associations between pregnancy outcomes and prepregnancy body mass index and gestational weight gain among Han women from Shenyang province, China.

Method

A total of 2586 women were distributed across 4 prepregnancy categories according to the Chinese classification of body mass index, and to 4 end-of-pregnancy categories according to median weekly gestational weight gain.

Results

The risks for gestational hypertension, pre-eclampsia, gestational diabetes, and preterm premature rupture of membranes were higher for those who were overweight or obese before becoming pregnant (P < 0.05). Moreover, a gestational weight gain of 0.50 kg per week or greater was associated with a higher risk for gestational hypertension, preterm premature rupture of membranes, and fetal macrosomia (P < 0.05). Women in the highest quartile for weight gain (≥ 0.59 kg per week) were at higher risk for pre-eclampsia (P < 0.05).

Conclusion

A high prepregnancy body mass index and excessive gestational weight gain were associated with increased risks for adverse pregnancy outcomes.     

Hot flashes during pregnancy: a comparative study

Objective

To conduct a preliminary study assessing the association of hot flashes with pregnancy.

Study design

268 pregnant and non-pregnant women matched on age and race completed a written questionnaire on sociodemographic and clinical information and the experiences of hot flashes. Binary logistic regressions were used to determine predictors of hot flashes.

Results

While controlling for significant bivariate associations, pregnant women were more likely to report hot flashes than non-pregnant women (odds ratio 5.22; confidence interval 2.75-9.89; p < 0.001). Hot flashes during pregnancy typically first occurred before the third trimester and were experienced on a weekly basis. Most pregnant women reported that their hot flashes were not severe or bothersome.

Conclusions

Findings suggest that hot flashes are common during pregnancy. Studies of hot flashes during pregnancy may further elucidate the causal mechanisms of hot flashes in other populations.     

Goserelin versus leuprolide before hysterectomy for uterine fibroids

Objective

To compare goserelin and leuprolide given before hysterectomy for symptomatic large fibroid uteri.

Methods

A randomized study of 66 premenopausal women with fibroid uteri at least 14 weeks of gestation in a gravid uterus. Women were randomized to receive either subcutaneous depot 3.6 mg goserelin or 3.75 mg leuprolide every 4 weeks for a total of 3 doses. Hysterectomy was performed within 1 month of the last dose.

Results

A total of 34 women randomized to the goserelin group and 31 women to the leuprolide group were available for analysis. Preoperative hemoglobin level (P = 0.89), operative blood loss (P = 0.72), and operating time (P = 0.39) were not different between the 2 groups. Postoperative hemoglobin was higher in the leuprolide group (P = 0.003), but blood transfusion requirement was not different between the groups (P = 1.0). Other outcomes and side effects of the drugs were similar.

Conclusions

Goserelin and leuprolide administered before hysterectomy for uterine fibroids have similar perioperative outcomes.     

The administration of metformin during pregnancy reduces polycystic ovary syndrome related gestational complications

Objectives

To prospectively evaluate the safety of metformin administration during pregnancy in a group of PCOS patients by assessing its effect on the prevalence of gestational complications and neonatal outcome.

Study design

Our prospective, single centre study included 98 pregnant women with PCOS treated with metformin throughout pregnancy and 110 normal pregnant controls. All PCOS patients were hyperinsulinemic and received metformin (1700-3000 mg/day) before conception and until 37 weeks’ gestation.

Results

Metformin treatment in the pregnant PCOS patients resulted in significant decrease in miscarriage rate (9.1% vs 20%; p < 0.05), gestational diabetes (0 vs 13%; p < 0.005), and gestational hypertension (0 vs 11%; p < 0.005) and a non-significant decrease in pre-eclampsia (0 vs 3%; p = .24), compared to the control group. Mean neonatal Apgar score, weight and length were comparable between the two groups.

Conclusions

Continuing metformin therapy throughout pregnancy resulted in significant reduction in pregnancy complications with concomitant improved neonatal outcome, with no serious deleterious side effects.     

Maternal serum protein S forms in pregnancies complicated by intrauterine growth restriction

Objectives

The clinical relevance of protein S deficiency in pregnant women remains controversial. Major debate exists regarding which parameter (total protein S antigen, free protein S antigen or functional protein S) should be evaluated in order to define protein S deficiency. The present study aimed to identify which of these parameters correlate with intrauterine growth restriction (IUGR).

Study design

A retrospective case-control study of women with IUGR (n = 27) and healthy controls (n = 123) in the third trimester of pregnancy.

Results

The maternal serum of women in the IUGR group had significantly lower levels of functional and free protein S compared with the control group: 54.07 ± 24.72% vs 65.20 ± 17.95% (p < 0.005) and 42.88 ± 11.01% vs 56.64 ± 13.30% (p < 0.0001), respectively. No significant correlation was found between total protein S and IUGR.

Conclusions

Levels of functional and free protein S are correlated with IUGR.