Non-surgical management in urogynaecology

This article discusses the non-surgical management of both genuine stress incontinence and detrusor instability. Although the traditional treatment for genuine stress incontinence is surgical, there are numerous circumstances under which non-surgical treatment should be considered. Such non-surgical treatment includes various types of physiotherapy, especially pelvic floor exercises, the use of drugs, especially oestrogen and α-adrenergic agents, and the use of mechanical devices. The treatment of detrusor instability is primarily non-surgical and treatment modalities include the use of drugs, the use of behavioural therapy, especially bladder retraining, and the use of maximal electrical stimulation. The anticipated results from each modality of treatment will be discussed together with guidance to appropriate references for those who wish to explore the subject further. Wherever possible, the author has chosen to quote randomized trials rather than cohort studies.     

子宫肌瘤的非手术治疗进展

子宫肌瘤是发病率高且发病机制不明的良性疾病。目前子宫肌瘤剔除术或子宫切除术是传统治疗最常用的方式,但对于要求保守治疗或有生育要求的女性,追求最佳治疗选择显得尤其重要。目前,GnRH激动剂/拮抗剂、选择性孕激素受体调节剂、左炔诺孕酮宫内缓释系统、子宫动脉栓塞、高强度聚焦超声等非传统手术治疗从不同角度为子宫肌瘤的保守治疗提供了新的治疗选择。     

Non-surgical management of ectopic pregnancy: appropriate risk management must be in place

Introduction  

Advances in technology have facilitated early diagnosis of ectopic pregnancy, which in turn has increased the scope for non-surgical treatment. Unfortunately risks associated with such management, including maternal death, are coming to the fore. This paper highlights the risks and how they could be avoided.     

Uterine leiomyoma among women who conceived following fertility treatment

Objective The objective was to determine if uterine leiomyoma increases the risk of cesarean section (CS) among women who conceived following fertility treatment.Study design The study population consisted of all women who conceived after fertility treatment with singleton gestation and who delivered between the years 1988 and 1999 in the Soroka University Medical Center. A comparison was performed between patients with and without uterine leiomyomas. The Mantel–Haenszel procedure was used to obtain the weighted odds ratio (OR) for CS, while controlling for confounding variables.Results During the study period 1,995 women conceived following fertility treatment. Of these, 63 patients had uterine leiomyomas (3.2%). Women treated for fertility with uterine leiomyomas had statistically significant higher rates of CS than those without uterine leiomyomas (61.9% vs. 28.1%, OR=4.2, 95% CI 2.4–7.2; P<0.001). Stratified analysis (the Mantel–Haenszel technique) was used to control for possible confounders, such as gestational diabetes, hypertensive disorders, maternal age, failure of labor to progress, placental abruption, malpresentation, hydramnios, oligohydramnios, and a previous CS. None of those variables changed the significant association or explained the higher incidence of CS in the uterine leiomyoma group.Conclusions Uterine leiomyoma is an independent risk factor for CS among women who conceived following fertility treatment.     

Extra-uterine pelvic leiomyoma: diagnosis and practical management

Objectives

To analyze the possibilities of setting up a therapy for extra-uterine pelvic leiomyomas.

Methods

Three cases of leiomyomas of the broad ligament, of the round ligament and of the ovary, and literature review.

Results

Little is known about physiopathology of extra-uterine leiomyoma. The diagnosis of extra-uterine leiomyoma is based on histopathological analysis, using standard histology, and immunohistochemistry with anti-desmin and anti smooth muscle actin antibodies. The main differential diagnoses are fibroma, fibrothecoma, ovarian fibrosarcoma, and gastrointestinal stromal tumors. To define criteria of malignancy, we use Bell's classification without being sure that the uterine and extra-uterine models are comparable. So there is a risk of ignoring a low grade leiomyosarcoma. Providing therapy depends on the clinicopathologic features: the so called "parasitic leiomyoma", a tumor developed at the expense of local smooth muscle cells, metastasis of a benign metastasizing leiomyoma or leiomyomatosis peritonealis disseminata.

Conclusion

The extra-uterine leiomyoma has no precise nosologic status and no specific criteria of benignity; thus no precise evolution can be predicted. We must be extremely careful, and the issue of the monitoring and long-term therapy of patients must come up.     

The impact of pesticides on male fertility

PURPOSE OF REVIEW: Observations in several Western countries point toward a decline in semen quality which may be associated with exposure to environmental endocrine disruptors such as several frequently used pesticides. The scarce literature on the effects of pesticides on male fertility will be reviewed with a focus on semen quality and time-to-pregnancy. RECENT FINDINGS: The majority of studies published since 2000 reported some effects of pesticide exposure on semen quality or time-to-pregnancy. The results are not consistent, however, with some studies showing reduced sperm concentrations and others showing low percentages of morphologically normal and/or motile sperm. In time-to-pregnancy studies, reduced male fertility measured as prolonged time-to-pregnancy related to pesticide exposure was observed for first pregnancies only. Some of the inconsistencies may be explained by heterogeneity in populations, pesticide exposure, and study design. SUMMARY: Despite this heterogeneity, the conclusion can be drawn that pesticide exposure may affect spermatogenesis leading to poor semen quality and reduced male fertility. More research is needed to unravel the pathophysiological mechanisms and the role of endocrine disruption.     

子宫肌瘤与生育及妊娠安全的相关问题

子宫肌瘤是育龄女性常见良性肿瘤,发病率25%～30%。子宫肌瘤可以引起不孕,以及流产、早产、胎盘早剥、产后出血等不良妊娠结局,增加剖宫产率。子宫肌瘤对生育的影响与其位置以及大小密切相关。其治疗需要个体化,结合肌瘤的大小、位置及患者的生育情况综合考虑。     

Bartholin's gland leiomyoma: a diagnostic and management dilemma

There are limited reports in the literature about Bartholin's gland leiomyoma, mainly due to its rare occurrence. This case report describes a 56-year-old woman presenting with a lump in her vulva. The initial suspicion was that of a Bartholin's gland carcinoma based on her clinical signs and symptoms. The mass was excised and the histopathology report described a leiomyoma. Differentiating between benign and malignant tumors by inspection alone can pose a diagnostic dilemma. There are no clear management guidelines but some authorities recommend that enlarged Bartholin's gland in postmenopausal women should be completely excised so as to exclude adenocarcinoma of the gland. However, other case reports and reviews have tried to justify an initial biopsy before considering complete excision to avoid unnecessary intervention in women whose biopsy confirms a benign lesion. In the case described, surgical excision was necessary and beneficial to the patient to provide symptom control.     

The impact of intrauterine devices on subsequent fertility

PURPOSE OF REVIEW: To investigate the impact of intrauterine devices on subsequent fertility. RECENT FINDINGS: Intrauterine devices are safe, well tolerated and used by millions of women worldwide.Subsequent fertility is studied among women who remove the intrauterine contraceptive device for planning pregnancy or among women who have removed the intrauterine contraceptive device because of intrauterine contraceptive device-related complications and later on have become pregnant. Study participants are recruited from randomized clinical trials on intrauterine contraceptive device performance or in case series among women who remove the intrauterine contraceptive device. Pregnancy rates after removal are high and are similar to time-to-pregnancy rates in the general population. The birth rates are high with a normal distribution of preterm deliveries, normal birth weight and sex ratio of newborns. The ratio of extra-intrauterine pregnancies and the need for infertility work up are low, and the distribution of infertility causes among fully investigated couples is as seen in the general population. SUMMARY: Despite small sample size of studies investigating impact of intrauterine contraceptive devices on subsequent fertility, the results are consistent and reassuring on high pregnancy rates, and a normal distribution of pregnancy outcomes. There are limited data on return of fertility after usage of medicated intrauterine contraceptive devices--more studies are warranted among women who have used hormone-releasing intrauterine contraceptive devices.     

The impact of cesarean birth on subsequent fertility

PURPOSE OF REVIEW: Recently, the rate of cesarean delivery has increased to 25-30% of all births, the highest rate ever reported in the USA. Primary cesarean deliveries, especially elective procedures, mainly contribute to this increase. Currently, controversy concerning elective cesarean delivery is an area of growing debate. Women should be well informed about the benefits and risks of on-demand cesarean delivery. This may be problematic, however, due to the limited current scientific data on the benefits and risks. One of the issues causing debate is the association between cesarean section and subsequent infertility. In the present review, we aim to analyze the evidence for the impact of cesarean delivery on subsequent fertility. RECENT FINDINGS: Cesarean section has been reported to be associated with decreased subsequent fertility. Recent studies, which have tried to explain this association, suggest that this is most probably voluntary or due to some other biases, or possible confounding factors, which are due to organic or psychosocial effects of an emergency cesarean section or labor preceding the cesarean delivery. SUMMARY: Elective cesarean section does not appear to cause infertility. What we need now, however, are more qualitative studies to determine the contribution of cesarean section per se on fecundity.     

Diagnosis and management of tubal pregnancy: effect on fertility outcome

We analysed 188 ectopic pregnancies seen during a 2-year period. They represented 2.2% of the live births that occurred during the same time interval. Overall, 53% of the tubal pregnancies had ruptured at the time of examination. Location was ampullary in 51% of the cases, isthmic in 28%, and 10% had aborted. Sixty-nine (38%) patients had an IUD. Diagnostic sensitivity was 58%-93% for pregnancy tests, 79% for culdocentesis, 41% for ultrasound examination, 43% for dilatation and curettage, and 100% for laparoscopy. Salpingectomy was performed in 47% of the cases, salpingotomy in 27%, and tubal resection in 19%. During a follow-up of 116 women (mean 1.5 years, range 0.5-3 years) 49% delivered, 10% had repeat ectopic pregnancy, 10% had abortion, 17% were infertile and 15% practised birth control. Among those who delivered no difference was found between those who underwent salpingectomy and those who underwent conservative surgery.     

Non-surgical management of post-cesarean endomyometritis associated with myometrial gas formation

We present a case of post-cesarean delivery, nonclostridial endomyometritis in which uterine (myometrial) gas formation raised concern for myonecrosis and need for hysterectomy. The patient fully recovered without surgery. Myometrial gas formation in this setting and in an otherwise stable patient may be an insufficient reason for hysterectomy.     

The impact of HIV on a fertility problems clinic

This article describes the impact of the human immuno-deficiency virus (HIV) on clinical infertility practice. HIV is responsible for acquired immuno-deficiency syndrome (AIDS) and first became apparent in 1979, but was not fully recognised by clinicians and scientists until 1981. It is a new disease which now infects large numbers of humans, and there is the possibility that the virulence of the virus may change or mutations may render current testing strategies ineffective. For these reasons, it is important to have a cautious and flexible approach to minimise risk to infertile couples and to future children.     

The impact of commonly prescribed drugs on male fertility

To analyze the impact of commonly used drugs on male fertility, we assessed the clinical characteristics of patients with impaired semen quality while they were taking medication for chronic diseases and after switching therapies. Of 1768 infertile males, 201 patients were taking medications and had impaired semen quality without any seminal tract obstruction, spermatogenic abnormalities or hypogonadotropic hypogonadism. Of these 201 men, a total of 165 had no history of testicular diseases nor abnormalities in any examinations. Amongst them, H1 receptor antagonists were the most common medication taken, followed by antiepileptics and antibiotics. They were divided into two groups: an intervention group (73 patients), who could stop or switch their medications, and a control group (92 patients), who could not. In the intervention group, semen quality improvement rate and conception rate (93% and 85%, respectively) were much higher than those of the control group (12% and 10%, respectively). After switching therapies, the time interval before conception was 7.3 months, which was significantly shorter in asthenozoospermia than oligozoospermia. Our results confirm the potential fertility hazards of commonly used drugs and their reversibility. Moreover, after switching medication, drug-induced asthenozoospermia was cured more rapidly than oligozoospermia, suggesting that further delineation of such differences may help to elucidate mechanisms of spermatogenesis and might facilitate the development of non-hormonal male contraceptive agents.