Tubal reanastomosis using absorbable stent.

A procedure for performing tubal reanastomosis using an absorbable stent is described. The procedure utilizes a microsurgical technique with an absorbable suture for a stent in end-to-end tubal reanastomosis. The procedure is described and diagrammed. Of 14 such operative procedures performed so far, patency of at least 1 fallopian tube has been achieved in all cases. 6 intrauterine pregnancies have resulted, 5 are too recent to determine success with regard to pregnancy, and 1 has elected to postpone pregnancy. The use of delicate instruments, fine suture materials, and adequate hemostasis are considered critical to the success of the procedure. The absorbable stent provides optimal healing at the site.     

Immunization by paternal leukocytes for prevention of primary habitual abortion: results of a matched controlled trial

Habitual abortion is a difficult clinical problem, as no cause can be found for abortion in over 50% of patients. At the habitual abortion clinic of the Sheba Medical Center, immunological activity is tested and patients who are considered suitable are offered immunopotentiation with paternal leukocytes. Patients are only treated if they have no other cause for habitual abortion, no lupus anticoagulant and no antipaternal complement-dependent antibodies (APCA). Immunization is thought to potentiate the maternal immune response to paternal antigens encountered on the trophoblast. The production of APCA antibody indicates that an immune response has occurred. Of the 156 patients so far immunized, 109 have developed these antibodies. To date, 79 of these 156 patients have become pregnant. Sixty-seven patients (with 3-12 miscarriages each) belong to the antibody-positive group. Sixty-four of the 89 subsequent pregnancies have been carried past their previous dates of abortion. Forty-seven live births have occurred. By contrast, 12 patients have been pregnant in the antibody-negative group, of the 16 subsequent pregnancies only 6 were successful. A control group is available for comparison. This consists of patients suitable for immunization, but not immunized. Of these patients, only 11 of 30 pregnancies have been carried to term.     

Puerperal weck clip sterilization: study II (second study of two consecutive studies).

Forty-five puerperal inverted V Weck clip applications have been completed with either the Samuel's or (modified) Weck pistol-grip applicator. Of the 45 applications, 31 have been followed for 25 to 36 months (69%), 12 have been followed for 13 to 25 months (27%), and 2 have been followed for 9 to 12 months (4%). The failure rate thus far is 2.2%. No mechanical difficulties were encountered with the Samuel's or the (modified) Weck pistol-grip applicator. Reversibility has been observed in one interval patient, while pre-admission evaluation of a puerperal patient suggests postremoval tubal patency.     

Umbilical cord blood--a perfect source of stem cells?

Because of their biological features and unlimited range of use, stem cells have been the object of great interest for some time. There are two main kinds of stem cells: primary embryonic stem cells and adult organism stem cells. The first kind derives from early stages of embryo development and are toti- and pluripotential. The second kind of stem cells are non-differentiated cells of mature tissues and have the capability of transforming into type of cell of the tissue there are present in. Recently, the umbilical blood has become the new source of hematopoiesis precursors thus increasing greatly the scope of possible recipients; umbilical blood is a reservoir of mesenchyme stem cells out of which we can culture in vitro offspring cells of various tissues. So far the clinical application of umbilical blood stem cells have been limited to the hematological transplantology, but it seems that soon they can become the "material of choice" in the surgical transplantology, immunotherapy and gene therapy.     

Degradation of paternal mitochondria after fertilization: implications for heteroplasmy, assisted reproductive technologies and mtDNA inheritance

Maternal inheritance of mitochondrial DNA has long been regarded as a major paradox in developmental biology. While some confusion may still persist in popular science, research data clearly document that the paternal sperm-borne mitochondria of most mammalian species enter the ooplasm at fertilization and are specifically targeted for degradation by the resident ubiquitin system. Ubiquitin is a proteolytic chaperone that forms covalently linked polyubiquitin chains on the targeted proteinaceous substrates. The polyubiquitin tag redirects the substrate proteins to a 26-S proteasome, a multi-subunit proteolytic organelle. Thus, specific proteasomal inhibitors reversibly block sperm mitochondrial degradation in ooplasm. Lysosomal degradation and the activity of membrane-lipoperoxidating enzyme 15-lipoxygenase (15-LOX) may also contribute to sperm mitochondrial degradation in the ooplasm, but probably is not crucial. Prohibitin, the major protein of the inner mitochondrial membrane, appears to be ubiquitinated in the sperm mitochondria. Occasional occurrence of paternal inheritance of mtDNA has been suggested in mammals including humans. While most such evidence has been widely disputed, it warrants further examination. Of particular concern is the documented heteroplasmy, i.e. mixed mtDNA inheritance after ooplasmic transplantation. Intracytoplasmic sperm injection (ICSI) has inherent potential for delaying the degradation of sperm mitochondria. However, paternal mtDNA inheritance after ICSI has not been documented so far.     

Role of laparoscopy in the treatment of patients with endometrial cancer

Patients with endometrial cancer (EC) are conventionally staged by surgery. Depending on the tumor risk factors and the surgical findings, adjuvant treatment is indicated in the form of radiotherapy or chemotherapy. The FIGO guidelines on surgical staging are clear on the importance of assessing the presence of extra-uterine spread of disease, but are elusive on how extensive the surgical staging should be. Also, the role of lymphadenectomy and adjuvant radiotherapy in these patients is the object of controversy, as confirmed by recent results of clinical trials. With surgery remaining the cornerstone of treatment, the surgical approach associated with the least complications should be pursued, particularly since the association of surgery and radiotherapy can escalate the overall treatment morbidity. Therefore, in the last 15 years, laparoscopy has slowly been replacing the traditional midline laparotomy. The results of the few clinical trials and several retrospective studies are unanimous. The laparoscopic approach is feasible, safe and effective and has a lower complication rate as compared to laparotomy in all patients. The number of patients with endometrial cancer included in published studies so far is too low to achieve statistical significance with respect to survival outcomes. However, for some groups of patients, there are results from clinical trials showing that laparoscopy is the method of choice in view of the outstanding reduced surgical morbidity.     

Centers of excellence in minimally invasive gynecology: Raising the bar for quality in women's health

The ‘‘Center of Excellence’’ concept has been employed in healthcare for several decades. This concept has been adopted in several disciplines; such as bariatric surgery, orthopedic surgery, diabetes and stroke. The most successful model in surgery thus far has been the bariatric program, with a very extensive network and a large prospective database. Recently, the American Association of Gynecologic Laparoscopists has introduced this concept in gynecologic surgery. The ‘‘Center Of Excellence in Minimally Invasive Gynecology’’ (COEMIG) designation program has been introduced with the goals of increasing safety and efficiency, cutting cost and increasing patient awareness and access to minimally invasive surgical options for women. The program may harbor challenges as well, such as human and financial resources, and difficulties with implementation and maintenance of such designation. This commentary describes the COEMIG designation process, along with its potential benefits and possible challenges. Though no studies have been published to date on the value of this concept in the field of gynecologic surgery, we envision this commentary to provoke such studies to examine the relative value of this new program.     

Prognostic elements of cancer of the endometrium. Therapeutic deductions

The authors report a series of 120 cancers of the endometrium treated between 1970 and 1985 included. Of all "morphological" factors, the degree of tumor differentiation is the one which has the greatest predictive value for the prognosis. The general condition of the patient have, stricto sensu, a very significant influence on the prognosis of cancer. The Wertheim's procedure offer results which are far superior to those of a simple hysterectomy. It must be favored in all patients who can withstand it. In patients with poor general condition, perform a simple total vaginal hysterectomy. This will be performed with all the less reserve as the tumor was well differentiated.     

Taking an integrated approach: managing women with phytoestrogens

An integrated approach can be employed when counselling women about menopausal management options, where lifestyle, complementary therapies and hormone replacement therapy (HRT) are discussed. Women might opt to use an alternative approach to HRT for a variety of reasons, e.g. fear of side-effects and risks or contraindications to HRT. There are many choices of dietary and herbal approaches for menopausal symptoms, which essentially divide into food supplements and herbal medicines. The choice can often be overwhelming and confusing for the woman. Of concern, the evidence for efficacy and safety of some of these complementary therapies can be extremely limited or non-existent. In order to enable women to make a fully informed choice, it is important that, when a recommendation is made regarding a specific complementary therapy, it should focus on preparations for which a significant dataset exists for efficacy and safety and in which there is ongoing research and development. One of the most extensively studied food supplements has been the phytoestrogenic preparation containing red clover isoflavones. There have been six randomized trials thus far studying the impact on vasomotor symptoms, three of which have shown a significant benefit compared to placebo. There are also data from small randomized and observational trials showing positive outcomes for surrogate markers of osteoporosis and cardiovascular disease. A recent study using validated depression scales has shown that women using red clover isoflavones may also derive psychological benefits. Safety data are reassuring for the endometrium and breast, although further studies would be welcome, particularly in women with significant medical risks.     

Screening by Ultrasonography for Endometrial Carcinoma in Postmenopausal Breast Cancer Patients under Adjuvant Tamoxifen

Seven-hundred thirty-seven asymptomatic postmenopausal breast cancer patients under long-term adjuvant tamoxifen therapy (average, 50 months) were screened by endometrial ultrasonography. Abnormal endometrial thickness (6 mm or larger) was observed in 209 subjects and was significantly associated with patients’ age and duration of tamoxifen therapy. Outpatient endometrial biopsy was recommended in presence of abnormal endometrial thickness: 25 subjects refused biopsy, whereas 76 were not biopsied because of cervical stenosis and were followed-up by repeat sonography. Of 108 biopsied subjects, one case of endometrial carcinoma (as expected in the screened cohort according to age-specific incidence rates provided by the regional cancer registry) and one case of endometrial hyperplasia were histologically confirmed, whereas endometrial atrophy was evident in the remaining cases. No other case of endometrial carcinoma has been recorded so far in the studied cohort according to the local cancer registry and no further change of the endometrium has been observed at sonographic follow-up. The cohort will be followed-up by repeat annual endometrial sonography. Thus far, we did not find evidence of increased prevalence of endometrial pathology (carcinoma or hyperplasia) which may be ascribed to tamoxifen therapy. The apparent increase in endometrial thickness observed at sonography might be explained by tamoxifen-induced changes of endometrial stroma and myometrium, misinterpreted as hyperplasia, while causing no real epithelial disease.     

Pregnancy after autografting and allografting vascularized ovaries and en bloc vascularized ovaries with adnexa in rabbits

Summary. Initially, techniques for autografting ovaries with or without adnexa were developed but a 30% vascular failure rate was experienced by day 14. Of the technically successful grafts, 50% proved fertile. Single vascularized ovaries with their oviducts were then allografted into bilaterally ovariectomized rabbits by microsurgical techniques and the vascular failure rate was reduced to 5% of 40 grafts. The time-course of rejection in untreated recipients was mapped by histological examination and by 24-h culture of fallopian tubes after autopsy at different times after transplantation. Control allografts were consistently rejected by day 20. Striking prolongation of both types of graft was obtained with a short 17-day course of cyclosporin A at 10 or 15 mg day⁻¹kg⁻¹. Indeed, significant evidence of rejection was found in only two ovaries out of 20 so far examined histologically. Mating behaviour, ovulation, ciliary function and transport of ova appeared normal in 80% of the recipients as long as 18 weeks after stopping cyclosporin A treatment. Only one of the ovarian allografted rabbits has so far been mated and this produced seven normal young 126 days after transplantation. However, none of the five animals mated after being allografted with en bloc adnexa have so far become pregnant.     

Anonymat du don de gamètes : protection d'un modèle social ou atteinte aux droits de l'homme ?

The French legislation about gamete donation imposes anonymity between the donor and the demanders, in reference to the principles of protection of the human dignity that are applied in other fields of biomedicine. We are here wondering about this choice: does this obligation really protect the human rights that are one of the ethical bases of law? At the time the French law was written, anonymity in gamete donation was inherited from the practice of the French CECOS but it has now become controversial. Many European countries have opened the access to the genetic origins. There is no evidence for this practice to be an efficient protection of the respect of human body and the disinterested nature of donation. Concerning gametes, it seems that it protects a social object, the parental project, but that it has no influence on the protection of parenthood, filiation, and the concept that humankind is not only biological. At last, we analyse the most important human rights documents to assume the hypothesis that anonymous gamete donation, although not violating the human rights, is an implement for Foucault's biopower, far from protecting the ethical foundations of human dignity.     

Künstliche Herstellung von Gameten und Embryonen aus pluripotenten Stammzellen

So far, the possibility of creating gametes out of pluripotent stem cells has hardly been discussed in Germany. Both human embryonic stem cells and induced pluripotent stem cells can be used as sources for such gametes. Ethical deliberations should be based on the principle of normative consequential responsibility. Research on gametes can be useful for several purposes. These include the increase of knowledge in human developmental biology, new insights into the causes of human infertility and the analysis of fertility-damaging substances in the environment. Such research is of benefit to human health as well as to environment-related health protection. Moreover, it is theoretically possible to use gametes in reproductive medicine. Should relevant individual treatments in reproductive medicine reach a more concrete stage of development, such treatments would then have to be considered in the light of the ethical criteria that will have developed meanwhile in the field of reproductive medicine. Of particular importance is both the best interest of the child as well as procedural certainty.     

Analgesia and anaesthesia in labour

Labour is one of the most painful experiences women encounter. Modern practice encompasses a number of techniques to alleviate this, from complementary therapies to invasive procedures. Pain induces a physiological stress response which has a number of deleterious effects on the body. Pharmacological methods of pain relief are the most popular – namely nitrous oxide, opioids and epidural analgesia. The latter is by far the most effective and is regarded as the gold standard. Importantly, intrapartum opioid use may be associated with the risk of neonatal respiratory depression. Nonpharmacological techniques vary in their efficacy. Of these hydrotherapy, acupuncture, continuous labour support and intradermal water blocks show the most promise. None of the methods available constitute the ideal analgesic for labour and choice should be based on maternal preference, with regular re-evaluation to ensure adequate effect.     

Labor analgesia for the tobacco and ethanol abusing pregnant patient: a routine management?

Introduction Illicit substance use in pregnancy has received significant media attention over the past 25 years. However, far too little attention has been given to the consequences of the use/misuse of social drugs such as tobacco and ethanol, which are by far the most commonly used/misused substances in pregnancy.Discussion While the deleterious effects of amphetamines or cocaine on the mother and the fetus are more pronounced and easier to detect, the addiction to tobacco and ethanol is usually subtle and more difficult to diagnose. As a result, recreational use of tobacco and alcohol in pregnancy may continue undetected, significantly impacting pregnancy outcome and the peripartum management of these patients.     

First experience with continuous pH measurements on fetus during delivery.

First experience with continuous pH measurement is reported. It was possible to apply well calibrated electrodes to the fetal scalp in 22 cases. Of these 22 cases eight must be regarded as failures because of unstable values. Of the remaining 14 measurements, seven were of good (or acceptable) quality and seven of poor quality. The size of the electrodes and the excessive depth of penetration are probable reasons for these failures. An important condition for obtaining reliable pH values is a perpendicular position of the electrode in the fetal scalp. An indicator for correct position of the electrode appears to be the irregularity in the recording of the pH curve. Experience so far indicates that the pH electrode in its present form is not suitable for routine use.     

Invasive treatment in complicated monochorionic twin pregnancies: indications and outcome of 120 consecutively treated pregnancies

Objective. Monochorionic twin pregnancies are associated with increased risk of severe complications. Umbilical cord occlusion (UCO) and fetoscopic selective laser coagulation (FSLC) are used as invasive treatment. The study aim was to document treatment indications and pregnancy outcome where UCO and FSLC were used for treating fetal discrepancies and twin-to-twin transfusion syndrome (TTTS). Design. Cohort study of all consecutively treated monochorionic twin pregnancies 2004-2010. Setting. Tertiary care center. Population. One hundred and twenty pregnancies treated by FSLC (55) or UCO (65). Umbilical cord occlusion was undertaken in 49 TTTS cases, in four cases with fetal abnormality and TTTS and in 12 cases because of fetal anomaly only. Main outcome measures. Overall survival per fetus, survival per pregnancy of at least one fetus and further survival according to the Quintero stages. Infant survival until at least one week after birth. Results. Of the pregnancies studied, 84% had TTTS, 13% had a fetal malformation and 3% had both. Of TTTS cases, 69% were Quintero stage 3 and 4. In the UCO group with TTTS, 87% were in stage 3 and 4. Survival in the UCO group was 82%. In the laser group, the survival of at least one fetus was 85%. Overall survival per fetus was 60%. Conclusions. By far the most common indication for invasive treatment was TTTS in Quintero stage 3. Outcome by means of survival after FSLC and UCO were similar to what has been reported elsewhere. Cord occlusion was an acceptable treatment alternative to fetoscopic selective laser coagulation in severe TTTS cases.     

Spontaneous pregnancy after successful ICSI treatment: evaluation of risk factors in 899 families in Germany

There are only scarce data on the incidence of spontaneous pregnancy in infertility patients. Contraception after infertility treatment is another topic that has been neglected so far. Therefore, a questionnaire was sent to 1614 couples with a child conceived by intracytoplasmic sperm injection (ICSI) aged 4-6 years. A total of 899 couples responded (response rate 55.7%). A total of 10.9% of couples had used contraception. Of the couples that had actively tried to conceive, 20.0% had conceived spontaneously, resulting in a live-birth rate of 16.4%. 74.5% of these pregnancies were conceived within 2 years after delivery. A further 26.6% of couples conceived again by ICSI, with a live-birth rate of 20.9%. Maternal age was the only prognostic factor for spontaneous conception. Parents of multiples after ICSI did not have a higher chance of spontaneous conception than parents of singletons. Couples can be counselled that one out of five couples conceive spontaneously after successful ICSI. Even when assuming that none of the families that were lost to follow-up had conceived spontaneously, one out of eight couples would have conceived spontaneously. Therefore, it is important to counsel patients about the possibility of natural conception and necessity to use contraception despite their history of subfertility.     

Catamenial pneumothorax--a literature review and report of an unusual case

As already mentioned, only a few cases of CPT were described in the international medical literature, though there probably are some publications in languages unknown to us. It is quite possible that this syndrome is much more common than known to us, but until now there has been a lack of awareness of it. It may be presumed that in some of the cases of women complaining of some discomfort during menstruation, thorough examination would reveal a mild spontaneous pneumothorax which doesn't require any special treatment and is self-resolving; but most gynecologists are not thoroughly aware of this entity. While examining the clinical findings it is possible to demonstrate that this syndrome has its own clinical characteristics, totally different from those of spontaneous pneumothorax in the population as a whole. One of the characteristics of the syndrome is the assumption that women who do not ovulate, as women during the menarche, pregnant women and women taking contraceptive medications, are not subject to CPT. A case described in this review contradicts this assumption, although treatment with ovulatory suppressants, successfully used so far, should not be undervalued. The etiology and pathogenesis of this syndrome was and still is enigmatic. The accumulated knowledge so far does not point to any one etiologic factor. Therefore the suggested treatment, before definitive operative treatment, is so far experimental only, and its chances of success in any particular case are unpredictable.     

Antiretroviral combination therapy in HIV-1 infected women and men: are their responses different?

Women are the fastest growing segment of the AIDS cases in the United States. They constitute nearly half of all the AIDS cases worldwide. Recent advances in Highly Active Antiretroviral Therapies (HAART) have reduced AIDS mortality remarkably. But as longer use of these combination regimens makes evident, unexpected side effects are now reported that might reflect gender-based differences in occurrence. Controversy still exists in relation to the level of HIV-1 quantification in men and women and its association with disease progression. Women have been reported to have lower viral loads with equal progression or higher progression with equal viral loads. This finding has not been consistent in all studies. Psychosocial variables, such as poverty, lack of care and young age, adversely affect more women than men. If the viral dynamics are thought to be different, then the response to treatment might be as well. So far, the effectiveness of HAART has been seen equally among men and women. Barriers to adherence, such as caregiving burdens, multiplicity of roles and fear of disclosure, might disproportionately affect women. By far the best news is that the survival of both men and women has improved with the newer therapeutic advances.