Pregnancy after in vitro fertilization in a patient with stage I endometrial carcinoma treated with progestins

A 35-year-old woman with chronic anovulation and bilateral tubal disease was found during infertility evaluation to have grade I endometrial carcinoma confined to an endometrial polyp. She was treated with polypectomy and endometrial curettage followed by high-dose progestagens for 6 months. Endometrial curettage at 3 and 6 months of therapy indicated regression of the lesion and the patient subsequently achieved successful pregnancy with IVF.     

Mullerian adenosarcoma of the uterus: a rare neoplasm with a need for onco-fertility

A 23-year-old nulliparous woman re-presented with menorrhagia and intermenstrual bleeding two years after her first presentation with a similar history. Her initial symptoms were thought to be due to a removed fibroid polyp with histological confirmation. However at the second presentation, following a polypectomy, a diagnosis of low-grade mullerian adenocarcinoma of the uterine body was made. She had total abdominal hysterectomy and pelvic lymph node dissection, peritoneal fluid for cytology with conservation of ovaries to conserve her fertility. No residual tumour was found and lymph nodes were negative. She remains well under clinical surveillance in a multidisciplinary team setting. Different management options that have been used in past reports have been examined and also fertility sparing surgical techniques available for use in successful management of gynaecological cancer are also being explored to shed more light on potential surgical techniques that may be used in treating such rare tumours, particularly in women wishing to retain their fertility.     

Unusual recurrence of cervical adenosquamous carcinoma after conservative surgery

The use of less radical procedures for the treatment of early cervical cancers is gaining interest among physicians and young patients. Some authors have described surgical procedures aimed at reducing the surgical aggressiveness but the safety of such procedures remains debated. After a polypectomy, a young patient had a diagnosis of stage Ia(2) cervical adenosquamous carcinoma in 1995. As she wished to preserve her fertility, she underwent a cone biopsy and pelvic lymphadenectomy, without evidence of tumor spread. In 1998, at the 13th week of gestation, she had a diagnosis of a pelvic mass. The mass was a recurrence of carcinoma involving the myometrium, just underneath the peritoneum. She underwent a radical hysterectomy with bilateral oophorectomy. An ovarian metastasis was also detected at pathological exam. She received chemotherapy postoperatively and remains alive without evidence of disease. The recurrence of cervical cancer is traditionally regarded as an issue concerning the cervix, the parametria, or the lymph nodes. When the uterus is preserved we must also consider the possibility of a recurrence involving the corpus. With wider acceptance of limited therapeutic approaches we must be prepared for the detection of previously unknown patterns of recurrence and the follow-up modalities must be consequently adapted.     

Treatment of endometrial polyps

OBJECTIVE: To determine the effectiveness of different treatments for abnormal uterine bleeding in women with known endometrial polyps. METHODS: We retrospectively assessed the effectiveness of polypectomy and other treatments of women with abnormal uterine bleeding who had benign polyps detected by sonohysterography. Women with endometrial polyps diagnosed by sonohysterography between January 1997 and July 1998 were sent questionnaires on pretreatment and posttreatment uterine bleeding and satisfaction with their treatments. Charts were reviewed to validate questionnaire responses and determine treatments administered. RESULTS: Seventy-eight women had endometrial polyps by sonohysterography, and 60 of them (77%) responded to the questionnaire. Two with endometrial adenocarcinoma were excluded. The average age of the remaining 58 was 49 years; 37 (64%) were premenopausal and 21 (36%) postmenopausal. The average time from treatment to follow-up was 13 months (range 5-24 months). Participants were grouped according to the following treatments: polypectomy, polypectomy plus endometrial ablation, polypectomy plus hysteroscopic myomectomy, hysterectomy, D&C, and nonsurgical treatment. The most frequent treatment was polypectomy (n = 26). Polypectomy, polypectomy plus endometrial ablation, polypectomy plus myomectomy, and hysterectomy each resulted in at least a twofold decrease in the number of bleeding days per month and led to high satisfaction rates. CONCLUSION: Our results showed that simple polypectomy and more invasive surgical procedures led to subjective improvement in symptoms of menorrhagia and metrorrhagia and a high satisfaction rate in women with endometrial polyps.     

A randomised controlled trial comparing outpatient versus daycase endometrial polypectomy

OBJECTIVE: To evaluate outpatient versus daycase endometrial polypectomy by comparing success rate, complications, patient tolerance, pain score, analgesia requirement and recovery. DESIGN: A randomised controlled trial. SETTING: A large UK Teaching hospital. POPULATION: Forty consecutive women diagnosed with an endometrial polyp at outpatient hysteroscopy were randomly assigned in equal proportions to outpatient or daycase polyp removal. METHODS: The outpatient cohort underwent endometrial polypectomy either using grasping forceps or a bipolar electrode (Versapoint; Gynecare Inc., Menlo Park, CA, USA) introduced down the operating channel of a rigid hysteroscope (Versascope; Gynecare Inc.). The daycase cohort underwent traditional endometrial polyp resection using a hysteroscopic, monopolar, electrosurgical resecting loop, performed under general anaesthetic. MAIN OUTCOME MEASURES: The main outcome measures were as follows: success rates and intra or postoperative complications, time away from home, analgesia requirements, pain scores on the day of and one day after endometrial polypectomy, return to work and preoperative fitness and preference for the location of a future endometrial polypectomy. RESULTS: The majority of women from both cohorts were premenopausal (62.5%), parous (85%) and in paid employment (62.5%). One woman allocated to outpatient polypectomy had cervical stenosis and dilatation was unsuccessful in the outpatient setting. There were no other intra or postoperative complications in either arm of the study. The mean intraoperative visual analogue style (0-100 mm) pain score during outpatient polypectomy was 23.7 mm (1-62). A proportion of women (20%) described no intraoperative discomfort; however, the majority (75%) described mild or moderate intraoperative discomfort. More women in the outpatient cohort (58%) described themselves as pain free for the remainder of the day than in the daycase cohort (28%) (P= 0.09). The day after the procedure, all women from the outpatient group described slight or no discomfort compared with only 41% of women from the daycase group (P= 0.02). All women undergoing outpatient polypectomy had a significantly shorter mean time away from home (3.24 [1.5-5] hours) than women undergoing daycase polypectomy (7.42 [6-10.5] hours), P < 0.0005. Similarly, women from the outpatient cohort had a significantly faster mean return to preoperative fitness (1 [0-4] day versus 3.2 [1-13] days; P= 0.001) and required less postoperative analgesia than the daycase cohort. Ninety-five percent of women from the outpatient cohort and 82% of women from the daycase cohort stated they would prefer to undergo an endometrial polypectomy in the outpatient setting should they require a further polyp removal. CONCLUSION: Endometrial polypectomy can be successfully performed in the outpatient setting with minimal intraoperative discomfort, a significantly shorter time away from home and faster recovery and is preferred by women when compared with daycase polypectomy. Resources need to be made rapidly available to undertake larger scale research and develop this service across the UK.     

宫腔镜手术治疗子宫内膜息肉的临床分析

目的　探讨宫腔镜手术治疗子宫内膜息肉的临床效果。方法　因子宫内膜息肉行各类宫腔镜手术 10 9例 ,其中绝经后子宫内膜息肉 15例、生育期子宫内膜息肉 94例。 10 9例中合并月经紊乱 84例、贫血 34例、痛经 16例、原发不孕 3例、继发不孕 2例。患者年龄 2 6～ 73岁 ,平均 (45± 9)岁 ;随访时间 3～ 2 2个月 ,平均 (12± 5 )个月。月经紊乱者在术前和术后分别填写月经失血图以评估月经血量。结果　 10 9例中 ,单纯息肉切除 35例 ,息肉切除同时浅层内膜切除 9例 ,息肉切除同时内膜切除 6 3例 ,息肉切除同时内膜剥除 2例。 84例月经紊乱者术后闭经 14例、阴道点滴出血 2 6例 ,其余 4 4例月经血量均较术前减少。 34例术前贫血患者 ,术后 1个月血红蛋白即恢复正常。 16例痛经者术后 7例症状消失、7例缓解、2例加重。 5例不孕者术后 4例妊娠。 15例绝经后患者术后无异常出血。结论　有月经改变且无生育要求者 ,息肉切除同时应行子宫内膜电切术 ,可避免息肉复发 ;需保留生育功能的患者 ,可行单纯息肉切除 ,如合并内膜息肉样增生 ,应同时行浅层内膜切除 ;绝经后患者 ,可行单纯息肉切除 ,如合并内膜息肉样增生 ,应同时行子宫内膜剥除。     

Polypectomy in premenopausal women with abnormal uterine bleeding: effectiveness of hysteroscopic removal

STUDY OBJECTIVE: To estimate the effectiveness of hysteroscopic polypectomy in premenopausal women with abnormal uterine bleeding and to identify prognostic factors for persistence or recurrence of symptoms after polypectomy. DESIGN: Retrospective study (Canadian Task Force classification II-3). SETTING: University teaching hospital. PATIENTS: Premenopausal women with abnormal uterine bleeding. INTERVENTION: Hysteroscopic polypectomy, regardless of whether combined with endometrial ablation or insertion of a levonorgestrel-releasing intrauterine device. MEASUREMENTS AND MAIN RESULTS: Seventy-eight consecutive patients met the inclusion criteria and were followed over time. Data were retrieved from medical records or from additional questionnaires sent to the patients. Failure of treatment was defined as persistence or recurrence of abnormal uterine bleeding after polypectomy, requiring further treatment. The mean age was 44.2 years (SD 5.2, 95% CI 33.9-54.4 years). Intervention-free survival after polypectomy, as calculated by Kaplan-Meier survival analysis, was 41.1% (SE 8.3%, 95% CI 24.8%-57.4%) after 4 years for patients who underwent only hysteroscopic polypectomy and 54.7% (SE 13.6%, 95% CI 28.0%-81.4%) for patients who underwent a polypectomy combined with endometrial ablation or insertion of a levonorgestrel-releasing intrauterine device (p = .08). Cox regression analyses revealed no statistically significant predictors for persistence or recurrence of symptoms after polypectomy. CONCLUSION: Nearly 60% of patients required further treatment for persistence or recurrence of abnormal uterine bleeding 4 years after hysteroscopic polypectomy. Although not significant, outcome of treatment tended to improve by combining polypectomy with either an endometrial ablation or insertion of a levonorgestrel-releasing intrauterine device.     

Pregnancy rates after hysteroscopic polypectomy depending on the size or number of the polyps

Objective To assess the reproductive benefits of hysteroscopic polypectomy in previous infertile women depending on the size or number of the polyps. Design and methods In this retrospective study, from February 2000 to September 2005, totally 83 selected women were included with: a) diagnoses of primary or secondary infertility, endometrial polyp/polyps and abnormal uterine bleeding. Endometrial polyps were diagnosed by transvaginal ultrasound followed by diagnostic hysteroscopy, to confirm diagnosis, and hysteroscopic polypectomy. All 83 subjects who consisted the study group, met inclusion criteria: age under 35 years, at least 12 months of infertility, from 3 to 8 months menstrual disorders (intermenstrual bleeding or spotting, menometrorrhagia or menorrhagia) and from 3 to 18 months of follow-up with attempts to conceive after hysteroscopic polypectomy. The endometrial polyp/polyps appeared to be the only reason to explain their infertility after infertility workup of the couples. There was a comparison of fertility rates after hysteroscopic polypectomy between patients having endometrial polyp ≤ 1 cm and patients with bigger or multiple polyps. Results Of the 83 subjects, all were found to have endometrial polyps in diagnostic hysteroscopy, confirmed at histologic examination after hysteroscopic polypectomy. Among patients of the study group, there were no significant differences in age, type or length of infertility, or follow-up period after the procedure. The mean size of the endometrial polyps was 1.9 ± 1.4.cm. Thirty-one patients had endometrial polyp ≤ 1 cm and 52 patients had bigger or multiple endometrial polyps. Following polypectomy, menstrual pattern was normalized in 91.6% of patients. Spontaneous pregnancy and delivery at term rates, in the total population of the study, increased after the procedure and were 61.4% and 54.2% respectively. There was no statistical difference in fertility rates between patients having polyps ≤ 1 cm and patients having >1 cm polyps or multiple polyps. Spontaneous abortion rate in the first trimester of pregnancy was 6% of the total number of patients and there was no statistical difference between patients with small or bigger/multiple polyps. Type of infertility did not affect fertility rates after hysteroscopic polypectomy. Complication rate after hysteroscopic polypectomy was as low as 2.4%, while recurrence rate of the procedure reached 4.9% of patients. Conclusion Hysteroscopic polypectomy of endometrial polyps appeared to improve fertility and increase pregnancy rates in previous infertile women with no other reason to explain their infertility, irrespective of the size or number of the polyps. Type of infertility of patients seems not to affect fertility rates after hysteroscopic polypectomy. Menstrual pattern was normalized in the majority of patients after hysteroscopic polypectomy. In addition, hysteroscopic polypectomy is a safe procedure with low complication rate.     

Pregnancy rates following hysteroscopic polypectomy,myomectomy, and a normal cavity in infertile patients

Objective: To assess the reproductive benefits of hysteroscopic myomectomy and polypectomy for infertility when compared to infertile couples with a normal cavity at hysteroscopy.Material and Methods: All patients with a diagnosis of infertility who underwent hysteroscopic evaluation by a single surgeon between 1975 and 1996 were sent a questionnaire as routine follow-up regarding their reproductive history. All 100 subjects who were located responded to the questionnaire, and 78 subjects met the inclusion criteria; age <45 years, 12 months of infertility, and 18 months of follow-up with attempts to conceive including in vitro fertilization in patients with bilateral tubal occlusion.Results: Of the 78 subjects, 36 had undergone a myomectomy, 23 a polypectomy, and 19 had a normal cavity. Among the three groups there was no significant difference in their ages, types of infertility, length of infertility, or follow-up after the procedure. Using the Cox proportional hazard model, and adjusting for age, polypectomy patients had a significantly higher pregnancy rate (RR 3.89, P < .01) and a higher live birth rate (RR 2.42, P = .06) than patients with a normal cavity. Patients who had undergone a myomectomy also had a higher pregnancy rate (RR 2.02, P = .11) and live birth rate, but this did not achieve statistical significance. Pregnancy following a hysteroscopic myomectomy was associated with a larger fibroid resection (3.15 cm vs 2.5 cm P = .05). The spontaneous abortion rate following the myomectomy, polypectomy, or a normal study was equivalent, 28.1%, 23.1%, and 29.2%, respectively.Conclusions: Both hysteroscopic polypectomy and hysteroscopic myomectomy appear to enhance fertility when compared to infertile patients with a normal cavity. Despite concern that hysteroscopic resection of a large myoma may ablate a large surface area of the endometrial cavity, patients with larger myomas were more likely to conceive following resection.     

Endoscopic sphincterotomy and endoscopic fulguration in the management of adenoma of the papilla of Vater

Adenoma of the papilla of Vater is a rare premalignant lesion usually treated by local surgical resection. Five patients with adenomas of the papilla, presenting with obstructive jaundice, underwent endoscopic sphincterotomy with reversal of hepatic biochemistry to normal. Thereafter, four patients underwent local surgical excision. The adenoma recurred in all four patients within six to 18 months after the operation. The recurrent adenomas were eradicated by diathermic fulguration through the endoscope and were not found during a 12 to 24 month follow-up period. Snare polypectomy was performed upon one patient (who refused surgical treatment) who had a flat, broad-based adenoma, with an incomplete resection of the adenoma. This patient had adenocarcinoma of the head of the pancreas develop 40 months later. We conclude that endoscopic sphincterotomy is effective for biliary decompression of adenoma of the papilla of Vater presenting with acute obstructive jaundice. Endoscopic snare polypectomy of the adenoma combined with fulguration may be used as an alternative to surgical treatment in high risk patients.     

Three-year follow-up results of polypectomy with endometrial ablation in the management of endometrial polyps associated with tamoxifen in Chinese women

Objective

The aim of this study was to investigate the role of hysteroscopic polypectomy with endometrial ablation in the management of tamoxifen-associated endometrial polyps in postmenopausal women with a more than 3-year follow-up period.

Study design

The medical records of 76 postmenopausal patients on tamoxifen who were performed hysteroscopic polypectomy with endometrial ablation were evaluated more than 3 years after the procedure with recurrence of polyps, recurrent abnormal uterine bleeding and surgical re-intervention.

Results

Average follow-up period was 74.91 ± 20.84 months. No patient underwent hysterectomy, 7 of 76 patients had a surgical re-intervention representing a total of 90.8% avoidance of additional surgery during the follow-up period, and 4 patients had a recurrent endometrial polyp representing the recurrence rate was 5.3%. 3 of 41 patients with postmenopausal bleeding had a recurrent abnormal uterine bleeding representing symptomatic relief rate is 92.7%. The treatment failed in 7 patients who requested surgical re-intervention: 4 patients requested a repeat polypectomy and ablation, 1 patient requested a repeat ablation and 2 patients requested a repeat hysteroscopy with uterine adhesion. No malignant endometrial pathological result was found.

Conclusions

For postmenopausal patients suffering from endometrial polyps associated with tamoxifen, hysteroscopic polypectomy with endometrial ablation continues to be proven as a safe and effective minimally invasive treatment method. The high rate of surgical re-intervention avoidance, great symptomatic relief and low recurrence rate are very encouraging for this technology.     

Ovarian remnant with bilateral duplicate ureters

A 27-year-old woman had a history of acute chronic pelvic pain. She had had a previous salpingo-oophorectomy for an endometrioma. A computerized tomographic scan showed a left adnexal mass. She was known to have bilateral duplicate ureters shown on intravenous pyelogram. She underwent laparoscopy and retroperitoneal dissection of endometriosis with excision of the mass from the pelvic sidewall. The final pathology was consistent with a hemorrhagic corpus luteal cyst.     

Pregnancy after transcatheter embolization of a uterine arteriovenous malformation

A 25-year-old woman with a congenital uterine arteriovenous malformation had a long history of repeated excessive vaginal bleeding. She was successfully treated with transarterial embolization. She had normal menstrual periods for 6 months and subsequently conceived. She was delivered of a normally grown baby at 35 weeks. To the best of our knowledge, this is the third pregnancy described after successful embolization of an arteriovenous malformation.     

Outpatient hysteroscopic polypectomy in postmenopausal women: a comparison between mechanical and electrosurgical resection

STUDY OBJECTIVE: Comparison of operating outcomes of office hysteroscopic polypectomy accomplished by mechanical or bipolar electrosurgical instrumentation. DESIGN: Prospective study (Canadian Task Force classification II-1). SETTING: Public hospital. PATIENTS: A total of 101 consecutive postmenopausal patients showing, during office hysteroscopy, 1 or more endometrial polyps measuring more than .5 cm. INTERVENTIONS: Hysteroscopy was carried out with a 2.9-mm optic and a 3.9- x 5.9-mm sheathed operative hysteroscope, without local anesthesia or systemic analgesia. The diagnostic phase was immediately followed by polyp resection, alternatively allocating the patients to mechanical or electrosurgical polypectomy. Hysteroscopic scissors were used for mechanical polypectomy, whereas 5F coaxial bipolar twizzle electrodes were used for electrosurgical polypectomy. MEASUREMENTS AND MAIN RESULTS: Effectiveness of polypectomy, operation time, and evaluation of induced pelvic pain (scored on a 1-10 cm visual analog scale), were the end points of comparison between the 2 techniques. Nine patients were excluded because of severe pelvic pain arising in the diagnostic phase or the finding of an oversize polyp requiring an estimated time of more than 30 minutes to be removed in the office setting. Of the remaining 92 patients, 46 underwent mechanical and 46 electrosurgical polypectomy. Clinical variables (i.e., age, age at menopause, parity, polyp size, and number) were similar in the 2 study arms. Polypectomy was accomplished in 79 (85.8%) of 92 patients. Among the considered clinical variables, effectiveness of resection was significantly related to age of patients (p = .04) and polyp size (p = .004). Mechanical and electrosurgical polypectomy was completed in 37 (80.4%) of 46 patients and in 42 (91.3%) of 46 patients, respectively (p = .13). Furthermore, mechanical and electrosurgical resections did not significantly differ as regards median surgical time (15.0 min [range 5-45] and 15.5 min [range 8-40], respectively; p = .53) and visual analog scale scores (3.7 +/- 2.5 and 3.2 +/- 1.9, respectively; p = .48). No major complications were recorded. Atypical polyp histology occurred in 9 (8.8%) patients, 5 of whom were asymptomatic. CONCLUSION: Outpatient see-and-treat polypectomy represents a safe and effective alternative to resectoscopic polypectomy, leading to a complete polyp excision in about 80% of postmenopausal patients. No differences in the rate of polyp excision, surgical time, or induced pelvic discomfort were observed between electrosurgical and mechanical techniques.     

Hysteroscopic polypectomy in 240 premenopausal and postmenopausal women

OBJECTIVE: To ascertain the therapeutic efficacy and safety of hysteroscopic polypectomy in 240 premenopausal and postmenopausal patients. DESIGN: Retrospective study. SETTING: Tertiary university hospital. PATIENT(S): Two hundred forty patients with intrauterine endometrial polyps, who mostly suffered from abnormal uterine bleeding and infertility. INTERVENTION(S): Hysteroscopic polypectomy using various instruments including microscissors, grasping forceps, or electrosurgery either with a monopolar probe or a resectoscope. MAIN OUTCOME MEASURE(S): Operating time, amount of glycine absorption, complications, resumption of normal menstruation, cumulative pregnancy rate, and recurrent rate of polyps after hysteroscopic surgery. RESULT(S): Resectoscopic polypectomy needed more operating time, had more glycine absorption and complications, but less recurrence than other hysteroscopic techniques. The resectoscope had a 0% recurrence rate and that grasping forceps had a 15% recurrence rate. A total of 21 (8.7%) complications occurred, but no major complications were noted. After long-term follow-up of 9 years and 2 months, those with abnormal uterine bleeding resumed normal menstruation in 93.1% and those with infertility had a cumulative pregnancy rate of 42.3%. There was no statistical difference in reproductive outcome between patients having polyps < or = 2.5 cm and >2.5 cm. CONCLUSION(S): We found hysteroscopic polypectomy to be effective, safe, minimally invasive procedure with low rate and mild complications. Restoration of reproductive ability did not depend on the size of the removed lesion. Resectoscopic surgery is more preferable to prevent recurrence of polyps.     

Long-Term Outcomes After Intrauterine Morcellation vs Hysteroscopic Resection of Endometrial Polyps

Study ObjectiveTo compare the long-term outcomes of intrauterine morcellation (IUM) of endometrial polyps vs a traditional operative polypectomy technique, hysteroscopic resection (HSR), and to identify factors predictive of recurrent abnormal uterine bleeding (AUB) after operative polypectomy.DesignRetrospective cohort study (Canadian Task Force classification II-2).SettingMinimally invasive gynecologic surgery practice in a tertiary care center.PatientsWomen who underwent operative hysteroscopic polypectomy between January 1, 2004 and December 31, 2009.InterventionsIntrauterine morcellation or HSR with evaluation and/or treatment of recurrent AUB after operative polypectomy.Measurements and Main ResultsOf 311 patients (IUM group, 139; HSR group, 172), 167 (53.7%) had at least 1 gynecologic follow-up visit and 57 (18.4%) had recurrent AUB. Subsequent gynecologic clinic visit rates were similar between the 2 groups (HSR, 58.1%, vs IUM, 48.2%; p = .08). Recurrence of AUB within the first 4 years of follow-up was similar between the IUM and HSR groups (hazard ratio for HSR vs IUM, 1.12; 95% confidence interval, 0.64–1.98; p = .59). However, recurrence of endometrial polyps approached statistical significance (hazard ratio, 3.3; 95% confidence interval, 0.94–11.49; p = .06). Premenopausal status, history of hormone replacement therapy, multiparity, and polycystic ovarian syndrome were independently associated with AUB recurrence. There were no reports of inability to establish a histopathologic diagnosis among all pathology specimens evaluated.ConclusionCompared with HSR, intrauterine morcellation may be associated with lower recurrence of endometrial polyps. However, the incidence of recurrent AUB is independent of polypectomy method.     

Case of atypical polypoid adenomyoma that possibly underwent a serial progression from endometrial hyperplasia to carcinoma

Atypical polypoid adenomyoma is a rare uterine tumor composed of atypical endometrial glands, which often exhibit squamous metaplasia, and a cellular smooth muscle stroma. Although atypical polypoid adenomyoma is categorized as a benign lesion, it is reportedly associated with endometrial cancer, and it shows persistence and recurrence even after conservative medical treatment. We present a rare case of atypical polypoid adenomyoma that possibly underwent a serial pathological change from endometrial hyperplasia to carcinoma in a 40-year-old woman with no history of pregnancy. She was diagnosed with atypical polypoid adenomyoma during polypectomy surgery. After resecting the atypical polypoid adenomyoma, endometrial hyperplasia complex was detected. This condition eventually progressed from atypical hyperplasia complex to endometrial adenocarcinoma, and total abdominal hysterectomy was performed. A patient with atypical polypoid adenomyoma who wishes to preserve her fertility should be carefully monitored for endometrial carcinoma. If endometrial hyperplasia is detected in such a patient, a meticulous follow-up examination by performing endometrial biopsy is mandatory.     

Breastfeeding and vegan diet

Vegan diet in lactating women can induce vitamin B12 deficiency for their children with risk of an impaired neurological development. A 9.5-month-old girl presented with impaired growth and severe hypotonia. She had a macrocytic anemia secondary to vitamin B12 deficiency. MRI showed cerebral atrophy. She was exclusively breastfed. Her mother was also vitamin B12 deficient, secondary to a vegan diet. She had a macrocytic anemia when discharged from the maternity. Vegan diet is a totally inadequate regimen for pregnant and lactating women, especially for their children. Prevention is based on screening, information and vitamin supplementation.     

Pregnancy rates after hysteroscopic polypectomy and myomectomy in infertile women.

OBJECTIVE: To compare reproductive benefits of hysteroscopic myomectomy and polypectomy for infertility to outcomes in infertile couples with normal hysteroscopic findings. METHODS: Women with diagnoses of infertility who had hysteroscopic evaluations by a single surgeon between 1975 and 1996 were sent a routine follow-up questionnaire regarding their reproductive histories. All 92 subjects who were located responded to the questionnaire, and 78 met inclusion criteria: age under 45 years, at least 12 months of infertility, and at least 18 months of follow-up with attempts to conceive, including in vitro fertilization in women with bilateral tubal occlusion. RESULTS: Of the 78 subjects, 36 had myomectomies, 23 had polypectomies, and 19 had normal cavities. Among the three groups, there were no significant differences in age, type of infertility, length of infertility, or follow-up after the procedure. Polypectomy subjects had significantly higher pregnancy and live birth rates than women with normal cavities. Women who had myomectomies larger than 2 cm had significantly higher pregnancy and live birth rates, achieving statistical significance at a myoma size of 3 cm or greater for live births. Spontaneous abortion rates among first pregnancies after myomectomy, polypectomy, or normal study were similar: 31.5%, 27.7%, and 37.5%, respectively. CONCLUSION: Both hysteroscopic polypectomy and hysteroscopic myomectomy appeared to enhance fertility compared with infertile women with normal cavities. Despite concern that hysteroscopic resection of a large myoma might ablate a large surface area of the endometrial cavity, the reproductive benefit appears greater than the risk.     

Intrauterine contraception: current evidence-based recommendations

A 28‐year‐old nulliparous female presented to our family planning clinic for initiation of a new contraceptive method. Her past medical history was significant for chlamydial infection at age 20, which was successfully treated with antibiotics. Her family history was essentially unknown because she was adopted as an infant. She began menstruation at 12 years old, with regular periods occurring every 28 days, lasting between 4 and 5 days each. She had no history of pelvic inflammatory disease (PID), abnormal Pap smears, or known uterine abnormalities. She had her first sexual experience at age 17, and has had a total of six partners, two within the past year. She was not in a relationship at the time of the clinical encounter. She reported sexual partnership with men only. Her contraceptive history consisted of intermittent condom use from age 17 to age 20, followed by oral contraceptives with consistent condom use recently. She stated a desire for a nonhormonal contraceptive method. Upon questioning, she reported no desire to have children within the next 5 years. After discussing her contraceptive alternatives, she opted for a copper intrauterine device (IUD). She was tested for chlamydia and gonorrhea, and the results of both tests were negative. She returned to the clinic for IUD insertion the following week. At that time, she was advised that expulsion is the most likely cause of IUD failure, and is most common in the first 3 months of insertion, usually during menstruation. 1 Instructions on how to check for the IUD and its threads were offered. She was instructed to assume the device had been expelled if she is unable to find the threads after menstruation, and that alternative contraception should be used until she is able to return to the clinic. Finally, she was informed of the signs and symptoms of pelvic infection and told to seek immediate medical care upon experiencing any of them, especially within the first 3 weeks following insertion. 1 Upon returning to the clinic 4 weeks after insertion, she reported complete satisfaction with the method. She was reminded that menstrual abnormalities, including spotting or longer menstrual periods, are common in the first 3 to 6 months of use, but that any serious abnormalities in her bleeding pattern after 6 months should be reported. 1