Immediate complications of tension-free vaginal tape (TVT): results of a French survey

BACKGROUND: The aim was to evaluate morbidity following operation using tension-free vaginal tape (TVT). METHODS: Between June 2002 and June 2003, a questionnaire was sent to French gynecologists and urologists. Participants reported the number of TVT procedures performed before January 2002, number of minor or major pre- and post-operative complications. RESULTS: The questionnaire was returned by 92 participants (21 urologists and 71 gynecologists) who reported 12,280 TVT procedures (median: 100, minimum: 5, maximum: 2100). Overall, 901 preoperative bladder injuries were reported (7.34%). For 809 patients (6.59%), complete post-operative urinary retention requiring catheterization was noted. There were 26 cases of vaginal defect healing (0.21%). Retropubic or vulvovaginal hematoma was reported for 39 patients (0.32%). Ten major organ injuries were reported (0.08%): one obturator nerve injury, three bowel perforations, four vessel injuries and two ureteral injuries. CONCLUSION: The risk of major complications following the use of tension-free vaginal tape is low. However, these potential complications require experienced surgeons for the practice of tension-free vaginal tape.     

Vaginal hysterectomy: results and complications of 886 patients.

The aim of this study was to determine the feasibility, results and complications of vaginal hysterectomy. A total of 886 consecutive patients who had undergone vaginal hysterectomy for benign gynecological diseases were retrospectively analysed. Vaginal hysterectomy was successfully performed in 96.1% of the nulliparous and 99.9% of the parous patients. The mean duration (min) of the operation was 89.1+/-29.1. The operation time (min) of the nulliparous women was significantly higher than that of the primiparous and multiparous women (109.3+/-40.2 vs 81.1+/-33.2 and 85.1+/-28.3, respectively). The overall complication rate was 14.6%. The intraoperative and postoperative complication rates were 4.1% and 10.5%, respectively. The most common intraoperative complication was bladder injury (2.5%). Vaginal hysterectomy for benign gynaecological diseases has high feasibility with acceptable complication rates.     

Laparoscopic sacral colpopexy: short-term results and complications in 83 patients

We retrospectively studied 77 laparoscopic sacral colpopexies performed from June 1996 to May 1998. Suspension was reinforced with two strips of synthetic mesh. Five patients had previously undergone hysterectomy and 4 others had experienced failure of surgery for prolapse of the uterus. Laparoscopy was performed in 83 women with symptomatic prolapse of the uterus. Six cases required conversion to laparotomy because of technical difficulties. All other 77 patients underwent laparoscopic sacropexy using anterior and posterior mesh reinforcement. Subtotal laparoscopic hysterectomy was associated in 60 cases, laparoscopic Burch colposuspension in 74 and levator myorraphy using the vaginal approach in 55. Operative time decreased from 292 to 180 minutes as the surgeon gained experience. The main operative complications were one rectal and two bladder injuries. Three patients required reoperations for haematoma or hemorrhage. One patient complained of chronic inflammation of the cervix and another experienced rejection of the posterior mesh 6 months after the operation. Mean follow up was 343 days. Three other patients required reoperation: one for a 3(rd) degree cystocele and two for recurrent stress incontinence. The conclusion of this study is that laparoscopic sacrocolpopexy is feasible. Operative time and postoperative complications are related to the surgeon's experience but remain comparable to those noted in laparotomy. Long term assessment is required to confirm the results of this procedure.     

Congenital toxoplasmosis: a prospective survey in Brussels

A prospective survey of antenatal patients was made at a hospital in Brussels over the period 1979-1982 to assess the incidence of congenital toxoplasmosis. Of 2986 patients assessed, 1403 (47%) had no toxoplasma antibodies and were at risk. The susceptible population was assessed every 6 weeks and 20 of these women (1.4%) seroconverted during pregnancy. Ten of the seroconverters had a therapeutic abortion; of the remaining 10 two gave birth to congenitally infected infants. Of the 1583 (53%) patients with a positive serology for toxoplasmosis initially, 17 (1.1%) had high antibody titres indicating that the infection could have taken place early in pregnancy. Nine infants born to these women were followed at our hospital and two of them were affected.     

A tumor necrosis factor-alpha promoter polymorphism and pregnancy complications: results of a prospective cohort study in 1652 pregnant women

The purpose of this article is to investigate the frequency of the tumor necrosis factor-alpha (TNF-alpha) -308 G/A single nucleotide polymorphism in women with intrauterine fetal death, preeclampsia, preterm delivery, and small-for-gestational-age (SGA) infants. In a prospective cohort study, DNA from 1652 consecutive pregnant women was analyzed for TNF-alpha -308 G/A by polymerase chain reaction. Women who developed at least 1 of the predefined pregnancy complications were used as cases and compared to women without pregnancy complications. Of 1652 women, 268 (16.2%) developed at least 1 pregnancy complication. TNF-alpha -308 G/A allele frequencies (G: 463/536 [86%] and A: 73/536 [14%] vs G: 2366/2768 [85%] and A: 402/2768 [15%], respectively; P = .6; odds ratio [OR], 0.93; 95% confidence interval [CI], 0.69-1.25) and genotype distributions (G/G+G/A: 259/268 [97%] and A/A 9/268 [3%] vs G/G+G/A: 1352/1384 [98%] and A/A 32/1384 [2%], respectively; P = .4; OR, 0.20; 95% CI, 0.002-14.81) were not significantly different between cases and controls. The authors observed no statistically significant difference in TNF-a -308 G/A genotype distributions comparing controls and women with intrauterine fetal death, preeclampsia, preterm delivery <34 weeks' gestation, preterm delivery >34 weeks' gestation, SGA infants <3rd percentile, and SGA infants of the 4th to 10th percentile. TNF-alpha -308 G/A is not a genetic marker for identifying women at increased risk of common pregnancy complications.     

Sonohysterography: a valuable tool in evaluating the female pelvis

A number of medical conditions, including abnormal uterine bleeding, endometrial cancer, monitoring tamoxifen therapy, infertility, and recurrent abortion, warrant investigation of the female genital tract. Diagnostic studies including hysterosalpingogram, ultrasound, and sonohysterography have proved useful in the investigation of these gynecologic conditions. This article discusses each of these tests with particular emphasis on sonohysterography and their current and potential contributions in both diagnostic and therapeutic applications. The utility of each as well as their comparative value to each other and existing gold standards is reviewed. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to outline the current screening methods for uterine cavity and pelvic abnormalities, to list the advantages of sonohysterography, and to describe the clinical situations where sonohysterography can be used.     

Uterine rupture and its complications in the Netherlands: a prospective study

OBJECTIVE: To determine maternal and perinatal morbidity and mortality after uterine rupture in the Netherlands. STUDY DESIGN: All 100 Dutch obstetric departments were asked to participate in a prospective nationwide registration of uterine rupture between 1st April 2002 and 1st April 2003. For every case, a questionnaire about obstetrical history, current pregnancy and delivery, maternal and neonatal outcome was completed. RESULTS: Eighty-nine percent of all hospitals in the Netherlands participated. Ninety-eight uterine ruptures were registered; 95 after a previous caesarean section (CS) of which 91 occurred during a trial of labour. The fetus was extruded in the abdominal cavity completely in 18 cases and partially in 13 cases. Major complications due to uterine rupture were: perinatal death (n=11, from 94 cases with a viable fetus, 11.7%) and hysterectomy (n=4, 4.1%). CONCLUSION: These severe complications, perinatal death and hysterectomy, have to be an issue when counselling women on an elective CS and women with a history of a CS on the route of delivery.     

Immunohistological demonstration of intermediate trophoblast in the diagnosis of uterine versus ectopic pregnancy: a retrospective survey and results of a prospective trial

Summary. Immunohistological demonstration of human placental lac-togen (hPL) in non-villous, mononuclear intermediate trophoblastic cells may be of routine diagnostic value, when chorionic villi are absent in endometrial curettings from patients suspected of miscarriage of an intrauterine pregnancy. The histological presence and distribution of hPL was investigated in endometrial curettings from 90 patients studied retrospectively (47 had ectopic pregnancies, 14 miscarriages, and 29 legal abortions), and a consecutive, prospective series of 50 patients (40 had miscarriages and 10 had ectopic pregnancies) without chorionic villi in their endometrial curettings. Non-specific background staining was not a problem. The retrospective survey disclosed that hPL was a highly sensitive marker of intrauterine pregnancy (sensitivity = 0.98). In the prospective series, the predictive value of positive staining for hPL for intrauterine pregnancy was 1.00, and the sensitivity of hPL, as an indicator of uterine gestation, was 0.62. In absence of specific hPL-staining, the risk of ectopic pregnancy was about 50%. The immunohisto-chemical demonstration of hPL is a useful tool for identifying patients who are suspected of having had a miscarriage, but for whom evidence in the form of chorionic villi in endometrial curettings is lacking.     

Immunohistological demonstration of intermediate trophoblast in the diagnosis of uterine versus ectopic pregnancy: a retrospective survey and results of a prospective trial

Immunohistological demonstration of human placental lactogen (hPL) in non-villous, mononuclear intermediate trophoblastic cells may be of routine diagnostic value, when chorionic villi are absent in endometrial curettings from patients suspected of miscarriage of an intrauterine pregnancy. The histological presence and distribution of hPL was investigated in endometrial curettings from 90 patients studied retrospectively (47 had ectopic pregnancies, 14 miscarriages, and 29 legal abortions), and a consecutive, prospective series of 50 patients (40 had miscarriages and 10 had ectopic pregnancies) without chorionic villi in their endometrial curettings. Non-specific background staining was not a problem. The retrospective survey disclosed that hPL was a highly sensitive marker of intrauterine pregnancy (sensitivity = 0.98). In the prospective series, the predictive value of positive staining for hPL for intrauterine pregnancy was 1.00, and the sensitivity of hPL, as an indicator of uterine gestation, was 0.62. In absence of specific hPL-staining, the risk of ectopic pregnancy was about 50%. The immunohistochemical demonstration of hPL is a useful tool for identifying patients who are suspected of having had a miscarriage, but for whom evidence in the form of chorionic villi in endometrial curettings is lacking.     

The midurethral polypropylene sling for stress incontinence: 22-month results of 81 patients

Objective The objective was to review a cost-effective procedure called the midurethral polypropylene sling (MPS) in the treatment of urodynamic stress incontinence (USI).Study design A self-fashioned sling (7.5×1 cm) was created from a polypropylene mesh with two lengthening polypropylene sutures at the ends. The sutures are carried through the rectus fascia by a special needle carrier. The sling is placed around the urethra and its sutures are tied on the fascia. The procedure was performed on 81 patients. Of these patients, 73 had USI. The remaining 8 patients with uterine prolapse, who did not have USI, underwent the MPS prophylactically. Of 81 patients, 35 underwent the MPS alone, 46 underwent the MPS and abdominal or vaginal procedures.Results Three patients had bleeding in excess of 300 ml necessitating a vaginal tamponade. One had hematoma and the other underwent a laparotomy. Urinary retention for more than 3 days was observed in 6 of the patients who had the MPS alone, in 7 of the patients who had both MPS and abdominal procedures, and in 13 of the patients who had MPS with vaginal procedures. The sling was cut in 3 patients due to persistent urinary retention. Of 73 patients with USI, 70 were completely cured (95.9%) at a mean of 22 months follow-up.Conclusion The cure rates and complications of the MPS were comparable to those of the tension-free vaginal tap (TVT) procedure for the treatment of USI. The procedure costs about US$ 9. We conclude that the MPS can be considered as an alternative to the TVT procedure.     

Metformin use in patients undergoing in vitro fertilization treatment: results of a worldwide web-based survey

PurposeTo identify trends regarding therapeutic approaches to metformin administration in patients undergoing in vitro fertilization (IVF) treatment worldwide.MethodsA retrospective evaluation utilizing the results of a web-based survey, IVFWorldwide (www.IVF-worldwide.com/), was performed.ResultsResponses from 101 centers performing a total of 50,800 annual IVF cycles was performed. Of these cycles, 10.4 % (n = 5,260) reported metformin use during IVF cycles. Indications for metformin use in IVF cycles included polycystic ovary syndrome (PCOS) patients who were habitual abortions (67 %), had prior poor egg quality (61 %), had high serum insulin levels (56 %). Less reported was PCOS with obesity/anvoulation (29 %), PCOS with multiple manifestations (23 %) and glucose intolerance and insulin resistance (23 %). Over half of cycles (54 %) treated patients with metformin up to 3 months prior to starting IVF. A majority (82 %) of IVF cycles utilized 1500–2000 mg/day of metformin. A nearly equal percentage of centers continued metformin up to a positive β-HCG test (35 %) or to 12 weeks gestation (33 %). 70 % of IVF cycles reported increased pregnancy rates and decreased miscarriage rates due to the use of metformin. 75 % reported the data in the literature is not sufficient for reaching a definitive conclusion concerning metformin treatment in patients undergoing IVF.ConclusionsWhile metformin is used worldwide as an adjunct to standard IVF protocols, there is much variation in its use and the majority of centers report lack of evidence supporting its use.Keyword: Metformin, Polycystic ovary syndrome, In vitro fertilization, Assisted reproductive technology     

Thrombocytopenia at delivery: a prospective survey of 6715 deliveries

Thrombocytopenia occurred in 513 (7.6%) of 6715 consecutive deliveries that occurred in our hospital over a 3-year interval. The patients with thrombocytopenia could be divided into three groups. The largest group (65.1%) consisted of healthy women whose thrombocytopenia was incidentally detected. The next group of patients (13.1%) was composed of healthy women who had an obstetric or medical condition such as diabetes or premature labor. No mother or infant in either group had excessive bleeding, and no infant had a cord platelet count less than 50 x 10(9) per liter. The last group (21%) was composed of hypertensive patients and patients with immune thrombocytopenia. Two infants in this group had cord platelet counts less than 50 x 10(9) per liter, but neither had bleeding. This study indicates that incidental thrombocytopenia in an otherwise well woman at term is the most frequent type of thrombocytopenia and poses no apparent risk for mother or infant at delivery.     

The use of complementary medicine and therapies by patients attending a reproductive medicine unit in South Australia: a prospective survey

BACKGROUND: There is limited research describing the use of complementary medicines (CM) and therapies among patients with infertility. OBJECTIVE: (i) To examine the use of CM by subjects attending an infertility clinic at their first consultation and six months later; (ii) to examine men's and women's views on the effectiveness and safety of these practices; and (iii) to examine the documentation of the use of CMs and therapies in clinical notes. DESIGN: A prospective survey of 100 consecutive new patients presenting to an infertility clinic. Subjects were requested to complete a self-administered questionnaire at their first visit and six months later. A retrospective audit of 200 patient records. RESULTS: A response rate of 72% was obtained. Sixty-six percent of patients attending the infertility clinic in South Australia used CMs. Six months following the initial consultation the use of CMs had declined. The most commonly used CMs included multivitamins, herbs, and mineral supplements, and subjects consulted most frequently with naturopaths, chiropractors and acupuncturists. The use of CMs and therapies was poorly documented by clinical staff. CONCLUSION: Complementary medicines and therapies are widely used by patients with infertility. Health-care practitioners and fertility specialists need to be proactive in acquiring and documenting the use of these practices. There is a need to provide further information to patients on the use of CMs and therapies. Further research examining the reasons for use of CMs and therapies is needed.     

Resident education and training in female sexuality: results of a national survey

IntroductionConsidering the prevalence of female sexual dysfunction, the lack of education and training in female sexual function and dysfunction (FSF&;D) during and obstetrics and gynecology residency highlights a need for greater focus on this topic.AimTo assess understanding and confidence among third and fourth year Ob/Gyn residents with respect to FSF&;D.MethodsAn Internet‐based survey was constructed to evaluate third and fourth year residents in American Council for Graduate Medical Education‐approved Ob/Gyn programs. Residents were asked about familiarity, knowledge, and confidence in treating various aspects of FSF&;D, based on the Council on Resident Education in Obstetrics and Gynecology (CREOG) Educational Objectives for Ob/Gyn training. They were also queried regarding areas of improvement for their education.Main Outcome MeasureResponses to survey instrument.ResultsTwo hundred thirty‐four residents responded. The majority (91.5%) reported attending ≤5 didactic activities on FSF&;D. Only 19.6% reported often or always screening women for sexual function problems; most had very little or no knowledge in administering or interpreting screening questionnaires. While many (82.8%) felt confident about obtaining a complete sexual history, only 54.7% felt able to perform a targeted physical exam. Although most residents had cared for women with dyspareunia (55.1%), a minority had managed many women with low desire (18.4%), arousal problems (8.1%), anorgasmia (5.6%), or vaginismus (16.7%). In treating patients, 34–56% reported rarely or never suggesting ancillary therapy such as counseling and medications. However, the majority believed that their confidence would increase through FSF&;D lectures (97.9%), FSF&;D patient observations (97.4%), rotating with a urogynecologist (94.4%), and online modules (90.6%).ConclusionDespite CREOG requirements for Ob/Gyn training in female sexuality, most residents feel ill‐equipped to address these problems. Additional evidence‐based educational and didactic activities would enhance residents' knowledge and confidence in treating these common, quality‐of‐life issues. Pancholy AB, Goldenhar L, Fellner AN, Crisp C, Kleeman S, and Pauls R. Resident education and training in female sexuality: Results of a national survey.     

Measurement of antral follicle count in patients undergoing in vitro fertilization treatment: results of a worldwide web-based survey

Purpose

The purpose of the present study was to identify trends in the therapeutic approaches used to measure antral follicle count (AFC) in patients undergoing in vitro fertilization (IVF) treatment worldwide.

Methods

A retrospective evaluation utilizing the results of a web-based survey, IVF-Worldwide (www.IVF-Worldwide.com), was performed.

Results

Responses from 796 centers representing 593,200 cycles were evaluated. The majority of respondents (71.2 %) considered antral follicle count as a mandatory part of their practice with most (69.0 %) measuring AFC in the follicular phase. Most respondents (89.7 %) reported that they would modify the IVF stimulation protocol based on the AFC. There was considerable variation regarding a limit for the number of antral follicles required to initiate an IVF cycle with 46.1 % designating three antral follicles as their limit, 39.9 % selecting either four or five follicles as their limit, and 14.0 % reporting a higher cutoff criteria. With respect to antral follicle size, 61.5 % included follicles ranging between 2 and 10 mm in the AFC. When asked to identify the best predictor of ovarian hyper-response during IVF cycles, AFC was selected most frequently (49.4 %), followed by anti-Mullerian hormone level (42.7 %). Age was selected as the best predictor of ongoing pregnancy rate in 81.7 % of respondents.

Conclusions

While a large proportion of respondents utilized AFC as part of their daily practice and modified IVF protocol based on the measurement, the majority did not consider AFC as the best predictor of ongoing pregnancy rate.