Laparotomy or laparoscopic surgery? Factors affecting the surgeons choice for the treatment of ectopic pregnancy

Purpose:In this study, we aim to compare the surgeons’ choice on the ectopic pregnancy cases during the last four years. The differences between laparoscopy and laparotomy cases and the factors which directed the surgeon to choose either of the surgical methods were evaluated. Methods:Our study comprises 135 patients who were diagnosed as ectopic pregnancy and were hospitalized in the Gynecology Department of Istanbul Medical Faculty during 1996–1999. Results: During 1996–1999 a total of 118 cases had been diagnosed as tubal ectopic pregnancy and had been treated surgically. Seventy three patients (62%) had been treated with laparotomy while the rest 45(38%) had been treated laparoscopically. When compared, the amount of intraabdominal free blood volume was significantly higher in laparotomy group [270.45±466.72 mL laparoscopy group – 889.75±714 mL laparotomy group, (p=0.0001)]. When we considered haemoperitoneum amount according to the patients’ parity, intraabdominal blood volume was interestingly higher in multiparas [507±599.32 mL nulliparas vs. 768.68±749.15 mL mulltiparas, (p=0.044)]. The percent of cases with ruptured tubes was 64% for the laparotomy and 38% the laparoscopic cases; and the difference between two groups was significant (p=0.0013). Conclusion: Our study implied that haemodynamic stability and less intraabdominal free blood affect the surgeons’ decision between laparotomy and laparoscopy. Fewer multiparous patients are suitable for these criteria which leads to less laparoscopic surgery. These findings, which need to be clarified, lead to the idea of human factor affecting the surgeons’ choice indirectly. Received: 20 February 2001 / Accepted: 28 March 2001     

Standard in vitro fertilization or intracytoplasmic sperm injection in advanced female age--what may be expected?

This study was conducted to evaluate the current results of standard in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) in the elderly (> or = 40 years of age) female population. Oocyte recovery, fertilization, embryo transfer, pregnancy and cumulative pregnancy rates were assessed. The results were analyzed for: the entire elderly population; the standard IVF group (group 1); all those in the ICSI group (group 2); and ICSI for severe male-factor category (group 3). A total of 330 IVF and 158 ICSI treatment cycles were carried out in 249 women. Forty-five (9.2%) clinical pregnancies were achieved. This rate was not statistically different from those achieved for groups 1, 2 and 3 (9.1%, 9.5% and 6.8%, respectively). The cumulative pregnancy rate for a total of five cycles was 19.2% and 26.4% for groups 1 and 2, respectively. For those who started their treatments at > or = 40 years, the cumulative pregnancy rate for three cycles was 26.5% and 36.5% in groups 1 and 2, respectively. These results clearly demonstrate that female age is a major success determinant, with similar influence on both standard IVF and ICSI therapy modalities.     

Progesterone/estradiol ratio <0.25 on the day of human chorionic gonadotropin administration is associated with adverse pregnancy outcomes in prolonged protocols for in vitro fertilization/intracytoplasmic sperm injection

Objective

It has been suggested that a progesterone/estradiol ratio (P/E2) ≥ 1.0 on the day of human chorionic gonadotropin (hCG) administration indicates premature luteinization and might be associated with an adverse pregnancy; however, a lower limit of this ratio has not been determined. We aimed to identify a lower limit of P/E2 that correlates significantly with an increase in adverse pregnancies in patients undergoing a prolonged in vitro fertilization/intracytoplasmic sperm injection therapy.

Optimal timing of periodontal disease treatment for prevention of adverse pregnancy outcomes: before or during pregnancy?

Several large randomized controlled clinical trials failed to find that standard periodontal therapy during pregnancy reduces the incidence of adverse pregnancy outcomes (eg, preterm birth and low birthweight). However, treating periodontal disease during pregnancy may be too late to reduce the inflammation that is related to the adverse pregnancy outcomes. Moreover, periodontal treatment during pregnancy can cause bacteremia, which itself may initiate the pathway leading to the adverse pregnancy outcomes. Finally, the periodontal treatments provided during pregnancy are not always effective in preventing the progression of periodontal disease during pregnancy. Pregnancy may not be an appropriate period for periodontal intervention(s). We hypothesize that periodontal treatment before pregnancy may reduce the rates of adverse pregnancy outcomes. Future randomized controlled trials are needed to test if treating periodontal disease in the prepregnancy period reduces the rate of adverse pregnancy outcomes.     

Timing of gestation after bariatric surgery: should women delay pregnancy for at least 1 postoperative year?

Bariatric surgery is both a popular and highly effective treatment for obesity. Pregnancy after these procedures has proved safe, with certain gestational complication rates lower than those associated with pregnancy in the obese. Current recommendations suggest delaying pregnancy until after the first postoperative year to avoid gestation during the rapid weight-loss phase. However, few controlled studies have examined the effects of postoperative pregnancy timing on gestational complications and outcomes. We discuss the current recommendations regarding timing of pregnancy after bariatric surgery. No conclusive evidence exists suggesting that pregnancy during the first postoperative year is unsafe, although more research is needed. Future studies should examine the safety of early postoperative pregnancy and determine whether or not its gestational complication rates are lower than those associated with obesity. Until the influence of pregnancy timing on post-bariatric surgery perinatal outcomes is better understood, clinicians should take into account all relevant data, consult with their postoperative patients, and create reproductive timelines best suited to individual needs.     

Invasive adenocarcinoma of the vagina following surgery for adenocarcinoma in situ of the cervix—Recurrence or implantation?

Abstract. Narayansingh GV, Cumming GP, Dighe S, Parkin DE, Millar I. Invasive adenocarcinoma of the vagina following surgery for adenocarcinoma in situ of the cervix—Recurrence or implantation?
A 51-year-old woman underwent cervical conization for severe glandular abnormal cells. Histology noted adenocarcinoma in situ (AIS) with incomplete excision margins. Four months later, hysterectomy revealed no residual disease. Six months subsequently she developed invasive adenocarcinoma of the upper vagina. This report documents the unusual behavior of AIS and its management difficulties.     

Laparoscopy versus laparotomy for the treatment of ovarian cysts in pregnancy: should we change our conventional way of practice?

Pregnant women may require nonobstetric-related abdominopelvic surgery. Traditionally, a laparotomy has been the preferred approach. Recent data suggest that this method should be reviewed in light of developments in minimal access surgical techniques. This article compares both approaches and, in particular, discusses the use of laparoscopy in the 2nd and 3rd trimesters of pregnancy.     

Do placental histologic findings of chorion-decidual hemorrhage or inflammation in spontaneous preterm birth influence outcomes in the subsequent pregnancy?

Introduction

Spontaneous preterm birth (SPTB) is the common endpoint of different underlying etiologies, including chorion-decidual bleeding and inflammation. However, specific histologic findings from a prior pregnancy do not always inform clinical management in subsequent pregnancies secondary to few prior studies having evaluated the relationship between prior pregnancy pathology and subsequent outcomes in patients with SPTB.

Methods

Included subjects had: 1) a SPTB with available placental pathology and 2) a subsequent consecutive delivery at >20 weeks gestational age at our institution. For included subjects archived placenta and membrane paraffin blocks from the index SPTB were cut, stained with Prussian Blue and evaluated by a perinatal pathologist for the presence of hemosiderin. The association between histologic findings and subsequent pregnancy outcomes were evaluated through logistic and linear regression.

Results

A total of 131 subjects were included, of whom 39.7% had a recurrent SPTB. Funisitis at the time of preterm delivery significantly increased the risk of early (<34 weeks) recurrent preterm birth (OR 3.38, p = 0.016), though this may have been confounded by gestational age at delivery. Several histologic features were significantly associated with reductions in birth weight in the subsequent pregnancies, even if they did not increase the risk of recurrent preterm birth.

Discussion

The presence of chorion-decidual bleeding or inflammation in a prior pregnancy can signal an increased risk in a future pregnancy beyond the recurrent risk of SPTB itself.

Conclusions

Placental histologic findings after SPTB maybe associated with differences in birth weight in a subsequent pregnancy.     

Are cytokines and growth factors responsible for the detrimental effects of hydrosalpingeal fluid on pregnancy rates after in vitro fertilization-embryo transfer?

Objective: To characterize the secretion of cytokines and growth factors in hydrosalpingeal fluid.

Design: Retrospective analysis.

Setting: Hospital-based infertility practice.

Patient(s): Ten infertile women who underwent laparoscopic aspiration of their hydrosalpingeal fluid before salpingectomy or neosalpingostomy.

Intervention(s): Samples were cryopreserved, then thawed and centrifuged to remove cellular debris.

Main Outcome Measure(s): The supernatants were analyzed for the presence of human interferon-γ, epidermal growth factor, transforming growth factor-β2, and tumor necrosis factor- by quantitative enzyme immunoassay kits.

Result(s): Interferon-γ and transforming growth factor-β2 were not detected in any of the hydrosalpingeal fluid samples. Epidermal growth factor was present in 5 of 10 hydrosalpingeal fluid samples, with a mean (±SE) concentration of 26.7 ± 11.4 pg/mL. Tumor necrosis factor- was detected in 7 of 10 samples, with a mean (±SE) concentration of 6.2 ± 3.6 pg/mL. Three of the 10 samples contained both tumor necrosis factor- and epidermal growth factor.

Conclusion(s): For the first time, we described the absence of interferon-γ and transforming growth factor-β2, and the presence of epidermal growth factor and tumor necrosis factor- in human hydrosalpingeal fluid. Because the fundamental role of the human fallopian tube is secretory in nature, the alteration in substances secreted from the tubal epithelium that reflux into the uterine cavity may explain the deleterious effects that hydrosalpingeal fluid has on pregnancy rates after IVF-ET.     

Impact of the “physician factor” on pregnancy rates in a large assisted reproductive technology program: do too many cooks spoil the broth?

Objective: To determine whether in one program with unified treatment protocols, patients can expect varying treatment outcomes with different physicians.

Design: Retrospective data analysis.

Setting: University-affiliated infertility center with 14 physicians.

Patient(s): One thousand eight hundred fifty IVF cycles performed consecutively between August 1995 and June 1997.

Intervention(s): The pregnancy rate and implantation rate per ET were evaluated for individual physicians between August 1995 and June 1996 (phase I). Physicians with lower success rates underwent strict supervision from July 1996 to June 1997 (phase II).

Main Outcome Measure(s): Variations in success rates between physicians.

Result(s): The pregnancy rate varied among the physicians from 13.2%–37.4%, and the implantation rate varied from 4.4%–14%. Some physicians’ outcomes improved between phase I and phase II of the study, whereas others’ did not. The pregnancy and implantation rates varied significantly for some physicians, depending on whether they were responsible for the choice of stimulation protocol, supervision of cycle monitoring, or ET in their own or other physicians’ patients.

Conclusion(s): Outcomes of IVF vary depending on the treating physician. Lower than expected pregnancy and implantation rates usually are not caused by poor ET techniques alone, but appear to be disproportionately the consequences of poor cycle stimulation.     

Should multifetal pregnancy reduction be used for prevention of preterm deliveries in triplet or higher order multiple pregnancies?

This article reviews the arguments for the use of multifetal pregnancy reduction (MFPR) for the prevention of preterm deliveries in triplet and higher order multiple pregnancies and evaluates its effectiveness based on data from published studies. The arguments in favour of pregnancy reduction are based on the substantial mortality and morbidity associated with these pregnancies. Triplets and higher order multiples have increased rates of preterm delivery and intrauterine growth retardation, both of which are independent risk factors for death and handicap. Even controlling for gestational age, rates of mortality and handicap are higher for multiples than for singletons. Moreover, the family's risk of losing a child or having a handicapped child is greater because there are more infants at risk. MFPR effectively lowers these risk by reducing the frequency of preterm delivery. However, its effectiveness may be limited. In some studies, the proportion of preterm deliveries in reduced pregnancies remains above levels found in spontaneous twin or singleton pregnancies and MFPR does not appear to reduce the prevalence of low birth weight. Furthermore, the procedure itself has unwanted side effects: it increases the risk of miscarriage, premature rupture of the membranes and causes adverse psychological effects such as grief or depression for many patients. The authors note that a majority of the higher order multiple pregnancies result from a medical intervention in the first place, either through IVF techniques or the use of ovulation stimulation drugs. Although MFPR is an effective measure for reducing the substantial morbidity and mortality associated with higher order multiple pregnancies, preventive methods, such as limiting to 2 the number of embryos transferred for IVF and better control of the use of ovulation induction drugs, remain more effective and less intrusive.