Prospective evaluation for the feasibility and safety of vaginal birth after laparoscopic myomectomy

STUDY OBJECTIVE: To estimate the feasibility and safety of vaginal birth after laparoscopic myomectomy (LM). DESIGN: Prospective clinical study (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: The study was performed on 1334 patients who underwent LM at our hospital from January 2000 through December 2005. INTERVENTIONS: Laparoscopic myomectomy. MEASUREMENTS AND MAIN RESULTS: The potential of a safe vaginal birth after LM was discussed with all 1334 patients before and after their LM. A strict protocol for a vaginal birth after LM was prepared using the criteria for a vaginal birth after cesarean section (CS). Of the 221 women who became pregnant after LM by December 2006, 111 were scheduled to deliver at our hospital. The findings at LM in these patients were as follows: mean diameter of the largest myoma (mean +/- SD, 95% CI), 66.1 +/- 18.8 (62.6-69.6) mm; and mean number of enucleated myomas, 3.5 +/- 3.6 (2.8-4.2). The endometrium was opened in 13 patients. Of the 111 patients, 82 patients opted for a vaginal delivery and 29 patients requested a CS. Of the 82 patients, 8 underwent an elective CS because of complications of pregnancy. Vaginal delivery was completed in 59 (79.7%) of the remaining 74 patients. The 15 patients who failed vaginal delivery underwent a CS: eleven because of failure to progress in labor or absence of spontaneous labor by 42 weeks of gestation; and 4 because of a nonreassuring fetal status during labor. No significant differences in delivery outcomes existed between the successful and failed group. None of the patients had a uterine rupture. CONCLUSION: Uterine rupture during pregnancy after LM is rare, and vaginal birth after LM appears to be safe in selected patients who meet our criteria.     

Caesarean section and tubal infertility: is there an association?

Rising Caesarean section (CS) rates have fuelled concerns about the effect of abdominal delivery on female fertility due to post-surgical complications affecting the Fallopian tubes. The association between exposure to CS and subsequent tubal infertility was explored by means of a case-control study. This study compared 220 women with secondary infertility due to tubal factor with 1244 women with secondary infertility due to non-tubal causes and 18,376 fertile women (women with a previous live birth followed by another live birth during the time period when the infertile cases were trying to conceive) in terms of exposure to CS. Exposure to CS in women with secondary tubal infertility was similar to other infertile women (21.4% versus 21.6%) but lower in fertile controls (14.5%). After adjusting for confounding factors, CS does not appear to be significantly associated with tubal infertility [adjusted odds ratio (95% confidence interval) for previous CS for infertile and fertile controls were 1.06 (0.73-1.52) and 1.2 (0.9-1.7), respectively]. However, other factors that were found to be predictive of secondary tubal infertility include history of intrauterine device use, pelvic inflammatory disease, ectopic pregnancy, endometriosis and previous pelvic surgery.     

Effect of clomiphene citrate administration during the early luteal phase on the luteal function and pregnancy rate of women

To study the effect of clomiphene citrate (clomiphene) administration during the early luteal phase of the menstrual cycle on the luteal function and the pregnancy rate in women, 75 infertile women who ovulated but did not conceive after clomiphene treatment during the early follicular phase and 6 normal cycling women were chosen. Clomiphene was administered orally to 35 of the 75 infertile women at a dose of 50 mg per day for 5 days from the second day of the rise in the basal body temperature (BBT) as well as during the follicular phase, while 40 control patients received clomiphene only during the follicular phase. In the test patients, the rate of pregnancy (25.7%) was significantly (p less than 0.05) higher than that of control patients (10.0%). On the 7th of the rise of BBT, the mean serum progesterone levels of the test patients and normal cycling women treated with clomiphene were significantly (p less than 0.05) higher than those of the control patients. However, the levels of serum estradiol, LH and FSH, the gonadotropin pulsatilities, and the pituitary responses to LH-RH in the test women were not significantly different from those of the control. These data suggest that, when administered during the early luteal phase, clomiphene may act directly on the ovary, enhancing the secretion of progesterone from the corpus luteum, and thereby increasing the rate of pregnancy in infertile women with clomiphene-induced ovulation.     

Pregnancy rates after laparoscopic treatment. Differences related to tubal status and presence of endometriosis

OBJECTIVE: To examine how preexisting tubal adhesions and endometriosis affect pregnancy outcome after laparoscopic treatment in infertile women with no apparent causes of infertility other than tubal factors. STUDY DESIGN: Pregnancy outcomes in 186 infertile women for a follow-up period of 18 months after laparoscopy were analyzed. Laparoscopic manipulations consisted of adhesiolysis of tubes and removal of endometriotic lesions. RESULTS: The patients were classified into three groups, those with no tubal adhesions (group A, n = 83), unilateral tubal adhesions (group B, n = 46) and bilateral tubal adhesions with at least one tube patent (group C, n = 57). The cumulative pregnancy rate in group C (13.2%) was lower than in groups A (41.8%) and B (45.7%) 18 months after laparoscopy. The average time to conception in group A (6.7 +/- 0.8 months) tended to be shorter than that in group B (10.6 +/- 1.2 months). In group A, pregnancy rates were essentially the same between minimal/mild endometriosis and moderate/severe endometriosis. Regarding group B, women with minimal/mild endometriosis exhibited significantly higher pregnancy rates than those with moderate/severe endometriosis, while pregnancy rates in women without endometriosis fell in between. CONCLUSION: Pregnancy rates after laparoscopic treatment are different in relation to tubal status and the presence of endometriosis.     

Effects of metformin on insulin resistance, androgen concentration, ovulation and pregnancy rates in women with polycystic ovary syndrome following laparoscopic ovarian drilling

AIM: To evaluate the effects of metformin on insulin resistance, androgen concentration, ovulation rates and pregnancy rates in infertile women with polycystic ovary syndrome (PCOS). METHODS: Forty-two infertile women with PCOS were selected in this randomized clinical study. Basal steroid and gonadotropin levels were measured, and oral glucose tolerance test (OGTT) was performed. The patients were randomly divided into group 1 (n = 21) and group 2 (n = 21). Group 1 patients were treated with laparoscopic ovarian drilling (LOD). Group 2 patients underwent laparoscopic ovarian drilling (LOD) and received 1700 mg per day of metformin for 6 months. LOD was performed in women with PCOS using a unipolar electrode. Serum progesterone (P) level > 5 ng/mL was considered as a confirmation of ovulation. Ovulation and pregnancy rates were determined after six cycles. RESULTS: Serum androgens and insulin response to OGTT decreased significantly after metformin therapy. Mean serum P levels and endometrial thickness were significantly higher in cycles treated with metformin plus LOD (34.6 +/- 25.4 ng/mL, 8.4 +/- 1.1 mm) than in those treated with LOD alone (26.2 +/- 24.7 ng/mL, 7.9 +/- 2.8 mm) (P < 0.05). The ovulation (56 of 65 cycles, 86.1% vs 29 of 65 cycles, 44.6%) and pregnancy rates (nine of 21 women, 47.6% vs four of 21 women, 19.1%) were significantly higher in group 2 than in group I. CONCLUSIONS: Metformin improves insulin resistance, reduces androgen levels and significantly increases the ovulation and pregnancy rates in infertile women, following LOD.     

输卵管积水性不孕症的临床研究

目的:探讨不孕症患者合并输卵管积水的临床特点和妊娠结局。方法:回顾性分析149例输卵管积水不孕症患者(积水组)和532例单纯输卵管阻塞不孕症患者(单纯阻塞组)的临床资料。结果:经标准输卵管通液术后,积水组累积自然受孕率、宫内妊娠率、自然流产率和异位妊娠率分别为24.8%、86.5%、13.5%和0%,平均获孕时间为治疗后4.5±4.2个月;单纯阻塞组累积自然受孕率、宫内妊娠率、自然流产率和异位妊娠率分别为24.1%、85.9%、9.4%和7.0%,平均获得妊娠时间为治疗后4.6±3.7个月;组间各项指标均无统计学差异(P>0.05)。91.9%的患者输卵管积水≤3 cm,积水>3 cm的患者仅有1例自然受孕;单侧输卵管积水的患者占90.6%,双侧输卵管积水患者无1例自然受孕。结论:与单纯输卵管阻塞的不孕症患者相比,输卵管积水患者经治疗后也能获得较为理想的妊娠结局。不孕妇女输卵管积水具有以下特点:以≤3 cm和单侧积水为主,当积水>3 cm或出现双侧积水时,患者基本不能自然受孕。     

177例不孕症患者宫腔镜下子宫内膜息肉摘除术的临床疗效分析

目的:探讨宫腔镜下子宫内膜息肉摘除术对不孕患者生育功能的改善和治疗效果。方法:对177例子宫内膜息肉(endometrial polyp,EP)的不孕患者(研究组)行宫腔镜下内膜息肉摘除结合刮宫术,术后追踪观察EP复发情况,并与374例同期行宫腔镜检查提示宫腔正常的不孕患者(对照组)进行术后妊娠情况的比较。结果:术后妊娠率研究组(25.99%,46/177)与对照组(29.14%,109/374)无差异,术后平均获得妊娠时间研究组为4.8±3.8个月,对照组为5.0±3.9个月,组间也无统计学差别(P>0.05)。研究组中131例EP患者未妊娠,另76例于术后1￣36个月进行了第二次宫腔镜检查:结果宫腔正常53例,EP复发23例。结论:子宫内膜息肉是引起不孕症的主要宫腔病因之一,宫腔镜下子宫内膜息肉摘除术可去除病因,使患者获得妊娠。     

Laparoscopic myomectomy: a 6-year follow-up single-center cohort analysis of fertility and obstetric outcome measures

Purpose

To evaluate fertility, pregnancy and delivery outcomes after laparoscopic myomectomy (LM) during long-term follow-up.

Methods

In this single-center retrospective observational study, data were analyzed from 59 women aged 23–42 years with the desire to have children and who underwent LM for symptomatic uterine leiomyoma between January 2001 and December 2006 and subsequently delivered at our hospital.

Results

During a mean follow-up period of 73.55 months, the post-LM conception rate was 68 %. The proportion of miscarriages (n = 16) among all pregnancies (n = 55) was lower after (24 %) than before (43 %) LM. Thirty-nine (46 %) deliveries were primary cesarean sections (CSs). CS was performed due to patients’ preference, placental complications, and uterine rupture (UR). Labor was successful in 62 % of all vaginal delivery trials. UR and placental complications occurred in 10 and 13 % of all pregnancies, respectively.

Conclusions

LM reduced the abortion rate and increased the CS rate in our cohort. UR risk may have been affected by suturing technique, the size and location of myomas removed.     

Pregnancy outcome after hysteroscopic myomectomy

The objective of this longitudinal retrospective study was to evaluate the influence of submucosal myomas on pregnancy outcome in infertile patients after resectoscopic myomectomy. One-hundred and four women with at least a 1-year-long history of infertility and the presence of submucosal myomas as the only cause of infertility were selected after surgical treatment. Pregnancy, delivery and abortion rates were investigated. Patients were divided into three groups according to the myoma classification (G0, G1 and G2). Gestational outcomes were analyzed in the three groups correlated by size, location and number of fibroids. The total pregnancy rate was 85.8% and no difference was shown regarding myoma classification (G0 82.05% versus G1 87.09% versus G2 88.2%; p?=?ns). Pregnancy and delivery rates were not significantly related to the number, localization or diameter of the fibroids. The abortion rate was not statistically influenced by myoma type, but it was significantly interelated with myomas situated in the anterior uterine wall (p?=?0.03). Pre-term delivery was significantly influenced by myomas localized in the fundic wall (p?=?0.02). Caesarean section rates were not affected by the characteristics of the myomas. Our results support the idea that resectoscopic myomectomy should be offered to infertile women who wish to become pregnant independently of their localization and number.     

Laparoscopy should be strongly considered for women with unexplained infertility

AIM: Women with unexplained infertility frequently become pregnant after diagnostic laparoscopy. In this study the effect of laparoscopic surgery on such women was evaluated by the pregnancy rate after laparoscopic surgery. METHODS: A total of 47 unexplained infertile women underwent laparoscopic evaluation during the period August 2002 to January 2005 in our center. The percentage of positive laparoscopic findings and the pregnancy rate after laparoscopy were calculated. The patients were divided into 5 subgroups according to maternal age, pregnancy rates were calculated for each group, and compared with the outcome of assisted reproductive technology (ART) treatment for the same age groups. RESULTS: In 87.2% of the women, laparoscopy revealed abnormal findings; endometriosis lesions, peritubal adhesions and tubal obstructions were found in 21, 17 and 3 cases, respectively. After laparoscopy 23 achieved pregnancy (pregnancy rate: 48.9%). The pregnancy rates of the groups at the age of 25 years old or less, 26-30, 31-35, 36-40 and over 41 years old were 100%, 75.0%, 45.5%, 27.2% and 0%, respectively. In the case of the 26-30 years old group, the pregnancy rate after laparoscopy was significantly higher than that in the ART treatment group (33.3%, P < 0.05). CONCLUSIONS: Laparoscopy should be strongly considered for examining women with unexplained infertility.     

Thyroid autoimmunity and infertility

We aimed to study the prevalence of thyroid autoimmunity in infertile women; to assess whether thyroid autoantibodies were associated with non-organ-specific autoantibodies; and to investigate the influence of this dysfunction on the couples' chances of pregnancy. We assayed serum levels of thyroid stimulating hormone (TSH) ,free thyroxine ,and microsomal and thyroglobulin autoantibodies in 149 infertile women. In patients with serum TSH levels in the hypothyroid or hyperthyroid range and/or with thyroid autoantibodies ,we performed thyroid ultrasound examinations and assayed some non-organ-specific autoantibodies. We compared the duration of infertility in infertile patients with normal thyroid (control group) ,with thyroid abnormalities ,and with thyroid autoantibodies in euthyroidism. Thirty infertile patients (20.1%) had thyroid abnormalities. The prevalence of thyroid autoantibodies was 17.4%. In infertile patients with thyroid autoantibodies ,we found a poor association with non-organ-specific autoantibodies. Only the women with thyroid abnormalities and ovulatory dysfunction had a mean duration of infertility significantly longer than that of the control group. When the data were analyzed for euthyroid women with thyroid autoantibodies ,we found no significant variation in the duration of infertility. Although we found a high prevalence of thyroid autoantibodies in infertile patients ,the presence of these autoantibodies per se did not reduce the chance of pregnancy.     

Intrauterine insemination as a treatment of infertility in women with antisperm antibodies.

Twenty-four women with infertility caused by antisperm antibodies were treated by homologous intrauterine insemination. Initially, all the women had timed intrauterine insemination by washed spermatozoa for three cycles. The pregnancy rate per couple was 4.20%. The remaining 23 patients received a combined treatment of chlomiphene citrate and intrauterine insemination for three cycles, which did not increase the pregnancy rate per couple and per cycle (4.3% and 1.4% respectively). Thereafter, the remaining 22 patients received a combined treatment of hMG and intrauterine insemination for another three cycles which resulted in a pregnancy rate per cycle (6.1%) and per couple (18.20%) that was significantly greater (P less than 0.01). We conclude that infertile women with antisperm antibodies can benefit after a trial of induction of multiple follicular development with hMG in combination with intrauterine insemination.     

益丹内异方治疗子宫内膜异位症的临床疗效观察

目的:观察益丹内异方治疗子宫内膜异位症(EMs)的疗效。方法:由腹腔镜检查诊断为EMs不孕症患者127例,在腹腔镜下作相应的治疗后,按随机号对其中66例进行中药益丹内异方治疗(实验组):口服益丹内异中药水煎剂,每日1剂,分早晚2次顿服;另61例为对照组,采用传统的达那唑阴道栓治疗,50mg/次,bid;所有患者经6个月治疗后,进行临床疗效比较。结果:治疗后实验组不孕症者受孕率为53.0%,总有效率为87.9%;对照组不孕症者受孕率为30.0%,总有效率为52.5%,二组间有显著差异(P<0.05)。在免疫调节方面,实验组抗子宫内膜抗体(EMAb)转阴率为100.0%,对照组为53.8%,二者有极显著差异(P<0.01);实验组和对照组在用药期间血清癌抗原(CA125)值均降低,自身对照服药前后二组均有极显著差异(P<0.01)。结论:中药益丹内异方治疗EMs疗效可靠,无毒副作用且用药期间不影响自然排卵及受孕。     

Auricular acupuncture in the treatment of female infertility.

Following a complete gynecologic--endocrinologic workup, 45 infertile women suffering from oligoamenorrhea (n = 27) or luteal insufficiency (n = 18) were treated with auricular acupuncture. Results were compared to those of 45 women who received hormone treatment. Both groups were matched for age, duration of infertility, body mass index, previous pregnancies, menstrual cycle and tubal patency. Women treated with acupuncture had 22 pregnancies, 11 after acupuncture, four spontaneously, and seven after appropriate medication. Women treated with hormones had 20 pregnancies, five spontaneously, and 15 in response to therapy. Four women of each group had abortions. Endometriosis (normal menstrual cycles) was seen in 35% (38%) of the women of each group who failed to respond to therapy with pregnancy. Only 4% of the women who responded to acupuncture or hormone treatment with a pregnancy had endometriosis, and 7% had normal cycles. In addition, women who continued to be infertile after hormone therapy had higher body mass indices and testosterone values than the therapy responders from this group. Women who became pregnant after acupuncture suffered more often from menstrual abnormalities and luteal insufficiency with lower estrogen, thyrotropin (TSH) and dehydroepiandrosterone sulfate (DHEAS) concentrations than the women who achieved pregnancy after hormone treatment. Although the pregnancy rate was similar for both groups, eumenorrheic women treated with acupuncture had adnexitis, endometriosis, out-of-phase endometria and reduced postcoital tests more often than those receiving hormones. Twelve of the 27 women (44%) with menstrual irregularities remained infertile after therapy with acupuncture compared to 15 of the 27 (56%) controls treated with hormones, even though hormone disorders were more pronounced in the acupuncture group. Side-effects were observed only during hormone treatment. Various disorders of the autonomic nervous system normalized during acupuncture. Based on our data, auricular acupuncture seems to offer a valuable alternative therapy for female infertility due to hormone disorders.     

The treatment of endometriosis at laparoscopy for infertility

Endometriosis is found in some infertile women, and treatment by laparotomy and/or hormonal therapy is associated with subsequent pregnancy. In this study, 100 consecutive patients with mild/moderate endometriosis were treated at laparoscopy. Forty of these women achieved a pregnancy within 37 months postoperatively; 73% of these pregnancies occurred within 6 months, and 88% within 12 months of operation. Although this pregnancy rate is similar to rates obtained after treatment by laparotomy and/or hormonal therapy, the pregnancies in this study population occurred significantly earlier than after laparotomy or combined therapy. The age of the women, duration of infertility, parity, extent of endometriosis, or presence of additional treatable factors of infertility did not affect the pregnancy rate. There was no significant morbidity, and the procedure can be performed on an outpatient basis with local anesthesia. Laparoscopy offers a practicable alternative for the treatment of mild/moderate endometriosis in infertile women.     

Thyroid autoimmunity and infertility.

We aimed to study the prevalence of thyroid autoimmunity in infertile women; to assess whether thyroid autoantibodies were associated with non-organ-specific autoantibodies; and to investigate the influence of this dysfunction on the couples' chances of pregnancy. We assayed serum levels of thyroid stimulating hormone (TSH), free thyroxine, and microsomal and thyroglobulin autoantibodies in 149 infertile women. In patients with serum TSH levels in the hypothyroid or hyperthyroid range and/or with thyroid autoantibodies, we performed thyroid ultrasound examinations and assayed some non-organ-specific autoantibodies. We compared the duration of infertility in infertile patients with normal thyroid (control group), with thyroid abnormalities, and with thyroid autoantibodies in euthyroidism. Thirty infertile patients (20.1%) had thyroid abnormalities. The prevalence of thyroid autoantibodies was 17.4%. In infertile patients with thyroid autoantibodies, we found a poor association with non-organ-specific autoantibodies. Only the women with thyroid abnormalities and ovulatory dysfunction had a mean duration of infertility significantly longer than that of the control group. When the data were analyzed for euthyroid women with thyroid autoantibodies, we found no significant variation in the duration of infertility. Although we found a high prevalence of thyroid autoantibodies in infertile patients, the presence of these autoantibodies per se did not reduce the chance of pregnancy.     

子宫畸形合并妊娠母儿妊娠结局临床分析

目的探讨妊娠合并子宫畸形对于母儿妊娠结局的影响。方法选取北京大学人民医院收治的妊娠合并子宫畸形患者108例,并以372例正常子宫妊娠患者作为对照,对其临床资料进行回顾性分析。结果①在29245例分娩的病例中,妊娠合并子宫畸形共108例,发生率约为0.4%。其中以子宫纵膈最为常见,占49.1%,其次为双子宫,占21.3%;②子宫畸形合并妊娠的患者中,胎位异常发生率（46.3%）及剖宫产率（73.2%）均显著升高;③子宫畸形组的平均孕周（37.2周）,新生儿平均出生体重（2873g）显著低于对照组,而早产率（24.1%）及足月低体重儿发生率（6.5%）均显著高于对照组;④纵膈子宫、单角子宫（83.3%合并残角子宫）、双角子宫、及双子宫在终止妊娠方式上存在差异,剖宫产率在纵膈子宫为最低（64.2%）。各组在早产率、孕周、胎儿体重方面差异无统计学意义（P〉0.05）。结论子宫畸形对于妊娠结局可产生不良影响,临床医生应加强孕前及孕期管理。     

Pregnancy rates after laparoscopy for infertility

To obtain prognostic data on the likelihood of pregnancy in infertile women with no observable abnormalities at diagnostic laparoscopy, the occurrence of pregnancy was studied in a series of 229 patients. The cumulative conception rate during a follow-up period of at most 5 yr was 50%. The probability of pregnancy proved to decline with age and duration of infertility. The cumulative conception rate during the first year after laparoscopy was approx. 30%, and there was no significant difference between the patients that were treated with respect to other sub-optimal fertility factors (subfertile group) and the patients in whom no rational treatment could be instituted (unexplained infertility group). Implications of these findings with respect to the treatment of long-term infertility are discussed. Knowledge of pregnancy rates after infertility laparoscopy seems important for the evaluation of results of therapy in unexplained infertility.     

Office hysteroscopic-guided selective tubal chromopertubation: acceptability,feasibility and diagnostic accuracy of this new diagnostic non-invasive technique in infertile women

The aim of this study was to evaluate accuracy, tolerability and side effects of office hysteroscopic-guided chromoperturbations in infertile women without anaesthesia. Forty-nine infertile women underwent the procedure to evaluate tubal patency and the uterine cavity. Women with unilateral or bilateral tubal stenosis at hysteroscopy with chromoperturbation, and women with bilateral tubal patency who did not conceive during the period of six months, underwent laparoscopy with chromoperturbation. The results obtained from hysteroscopy and laparoscopy in the assessment of tubal patency were compared. Sensitivity, specificity, accuracy, positive-predictive value and negative-predictive value were used to describe diagnostic performance. Pain and tolerance were assessed during procedure using a visual analogue scale (VAS). Side effects or late complications and pregnancy rate were also recorded three and six months after the procedure. The specificity was 87.8% (95% CI: 73.80–95.90), sensitivity was 85.7% (95% CI 57.20–98.20), positive and negative predictive values were 70.6% (95% CI: 44.00–89) and 94.7% (95% CI: 82.30–99.40), respectively. Pregnancy rate (PR) within six months after performance of hysteroscopy with chromoperturbation was 27%. Office hysteroscopy-guided selective chromoperturbation in infertile patients is a valid technique to evaluate tubal patency and uterine cavity.     

Antigonadotropin (danazol) in the treatment of endometriosis. Evaluation of posttreatment fertility and three-year follow-up data

Ninety-nine women who completed danazol treatment for endometriosis proved by operation were re-evaluated clinically an average of 37 months later. The recurrence of symptoms was reported by 39 per cent and pelvic findings suggestive of endometriosis were noted in 33 per cent. An average time interval between the end of treatment and the recurrence was 15 months for the entire group. However, 31 women who conceived subsequent to treatment had a much lower recurrence rate of the disease (15 per cent) and a much longer average time until the recurrence (31 months). Of 84 infertile women who desired pregnancy after treatment, 39 conceived, for a pregnancy rate of 46.4 per cent. However, when patients with absolute sterility due to other causes were excluded, the corrected pregnancy rate was 72.2 per cent. The majority of conceptions (23) occurred within the first six months after discontinuation of danazol and a total of 30 occurred within the first year. Four second- and third-trimester intrauterine fetal deaths were observed among women who conceived within the first three cycles after discontinuation of the drug.