The role of laparoscopy in the management of pelvic pain in women of reproductive age

Objective: To review the diagnostic and therapeutic roles of laparoscopy in women of reproductive age with acute and chronic pelvic pain.Data Identification: Studies relating to the use of laparoscopy in women with acute and chronic pelvic pain were identified through the literature and MEDLINE searches.Conclusion(s): Laparoscopy has an important place in the management of conditions that cause acute pelvic pain in women of reproductive age, including ectopic pregnancy, pelvic inflammatory disease, tubo-ovarian abscess, and adnexal torsion. The procedure frequently facilitates the diagnosis and provides the necessary access for surgical treatment. Prompt diagnosis and effective management prevent complications and help preserve fertility. The role of laparoscopy in women with chronic pelvic pain is more controversial and limited, but abnormal laparoscopic findings are detected in approximately 60% of those who have undergone a multidisciplinary investigation and received a tentative clinical diagnosis. The access provided by laparoscopy permits the effective surgical treatment of many of the conditions encountered, including endometriosis, pelvic adhesions, ovarian lesions, and symptomatic uterine retroversion.     

Restoration of fertility after tubal sterilization: tubo-tubal anastomosis versus in vitro fertilization

More than 1% of sterilized women seek restoration of their fertility. The large number of tubal sterilizations performed each year has created a significant demand for reversal. Microsurgical tubal anastomosis has yielded excellent results in these cases, and the reported viable pregnancy rates vary between 55-78%. An alternative approach is in vitro fertilization which yields a viable pregnancy rate of less than 20/pickup cycle. The primary approach in this study with previously sterilized women is tubal anastomosis, especially if the length of the reconstructed tube will exceed 4 cm. Tubal anastomosis and in vitro fertilization must be viewed as complementary rather than competitive procedures since the failure of 1 will, in most cases, allow the use of the other. Preliminary investigation of fertility parameters and proper assessment of the tubes (with hysterosalpingography and frequently by laparoscopy) is necessary to determine the most appropriate therapeutic approach. (author's modified)     

Thermal balloon ablation versus endometrial resection for the treatment of abnormal uterine bleeding.

This study compares the clinical efficacy and safety of a thermal uterine balloon system with hysteroscopic endometrial resection in the treatment of dysfunctional uterine bleeding. In all, 147 women were treated by two experienced gynaecological surgeons: one performed 73 thermal balloon ablations and the other 74 endometrial resections between November 1994 and April 1998. The inclusion criteria were similar in both groups. The operative time was reduced significantly with the uterine balloon technique. There were no intra-operative complications in either group and postoperative morbidities were minimal and not statistically different. Multivariate analysis noted two prognostic factors associated with failures: retroverted uterus with thermal balloon ablation and age under 43 years with endometrial resection. The overall success rate did not differ significantly between the two groups 83.0 +/- 5% for balloon ablation and 76.3 +/- 6% for endometrial resection. Uterine balloon ablation appears to be as efficacious as endometrial resection. The former is much easier to perform, making the technique readily reproducible, especially by those with limited expertise in hysteroscopic surgery, and thus more widely applicable and safer.     

Is routine amniocentesis for advanced maternal age still indicated?

OBJECTIVE: To evaluate a policy of selective rather than routine use of amniocentesis for advanced maternal age. METHOD: A consecutive series of 359 pregnant women aged 38-47 underwent nuchal translucency measurement (NTM) at 10-14 weeks, maternal serum screening (MSS) by alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG) at 15-17 weeks, and second trimester ultrasound at 21-23 weeks. Women with NTM <3 mm, MSS-derived risk <1/250, and a normal second trimester sonography were considered at low risk and were suggested not to have an amniocentesis. RESULTS: Either the NTM or MSS test was positive in 130 women; 105 (81%) of them elected to have an amniocentesis, versus 122 (53%) of 229 in whom both tests were negative (p < 0.001). Nineteen (5%) of 359 patients had NTM > or =3 mm; all 7 cases of Down's syndrome were in this group; 122 (34%) of 359 patients had a MSS-derived risk > or =1/250; 6 of the 7 cases of Down's syndrome were in this group: Ten patients had an abnormal second trimester ultrasound, 1 of which had trisomy 18. Of the 219 patients with MSS-derived risk <1/250, a NTM <3 mm, and a normal second trimester ultrasound, none had a baby with a chromosomal abnormality (95% confidence interval: 0-1.4%). CONCLUSION: Amniocentesis may be offered on a selective rather than routine basis in women over 38, based upon the results of noninvasive screening tests.     

Microsurgery for tubal infertility

In vitro fertilization/embryo transfer (IVF/ART) results have shown significant improvements during the last decade. In the United States the rate of live births per cycle improved gradually to become 27% in 2001. Assisted reproductive techniques (ARTs) are increasingly being used for the treatment of tubal factor infertility. In this review the data are derived largely from our department, where we have treated sufficient numbers of patients and have maintained substantial consistency in our surgical techniques. This 3-part review demonstrates a high success rate of intrauterine pregnancy (IUP) after anastomosis for sterilization reversal. This rate, for those who are < 35 years of age at the time of reversal, is >70%, with most pregnancies occurring within 18 months after surgery. Those who are 35 years of age or more will have a 55% rate of IUP. We note, too, the satisfactory IUP rate (50%) after tubocornual anastomosis for proximal tubal disease. We document the beneficial role of laparoscopic salpingoovariolysis, fimbrioplasty and salpingostomy performed during the initial diagnostic laparoscopy. The IUP rates after salpingoovariolysis and fimbrioplasty are 60% and 50%, respectively. The rates of IUP for salpingostomy are modest in comparison, yet they are 25% for liberal use of salpingostomy during the preliminary laparoscopy. Salpingostomy also provides a beneficial effect upon embryo implantation in both in vivo and in vitro attempts at conception. This stresses the need for an appropriate preliminary investigation and for the subsequent diagnostic laparoscopy to be performed at a center able to perform these procedures. The evidence suggests that surgery should retain its place in the treatment of tubal infertility. Surgery and ART are complementary approaches that can be used singly or in combination to improve the outcome for couples with tubal infertility.     

Fertility outcome following tubal pregnancy.

This study was undertaken to analyze the factors associated with fertility outcome following tubal pregnancy. Eighty-six patients were analyzed in this regard. The chances of a favourable outcome (intrauterine pregnancy) decreased and an unfavorable outcome (repeated tubal pregnancy or no pregnancy) increased with a history of previous tubal pregnancy and also with an absent or diseased contralateral tube at the time of surgery. History of infertility, prior reconstructive tubal surgery, status of the ipsilateral tube at the time of surgery, the treatment modality (laparoscopy vs laparotomy) or the surgical approach (conservative vs radical) did not significantly affect fertility outcome.     

Intraoperative management of ureteral injury during operative laparoscopy.

Injury to the ureter from operative laparoscopy is rare. The diagnosis is usually made radiologically, in the postoperative period, when the patient presents with symptoms and signs suggestive of ureteral injury. We report herein a case of ureteral injury resulting from operative laparoscopy for endometriosis. The injury was diagnosed and treated via laparoscopy during the same procedure. The increased utilization of operative laparoscopy to perform more complex procedures increases the potential for operative injury to the ureter. Prior visualization or retroperitoneal dissection of the ureter, in appropriate cases, will help reduce this complication and/or permit a prompt diagnosis in the event of such injury.     

Vacuum application through a nonfully dilated cervix: a viable option

The aim of this cross-sectional study was to assess the feasibility of vacuum delivery through a nonfully dilated cervix. The study group consisted of 39 women with vacuum deliveries through a nonfully dilated cervix larger than 9 cm and station of the head at S or more +2 cm. These were compared to a control group of 215 vacuum deliveries at a fully dilated cervix and 46 women who underwent cesarean section at a nonfully dilated cervix larger than 9 cm. The main indication for vacuum extraction in the study group was fetal distress and in the control groups prolonged 2nd stage, dysfunctional labor and fetal distress. Maternal and neonatal morbidity was low and not different between the groups. Neonatal well being, evaluated by cord pH and 5-min Apgar score, was not different. Based on predefined criteria, vacuum extraction through a nonfully dilated cervix is a viable alternative to emergency cesarean section and is apparently not associated with higher maternal or infant morbidity.     

Composite cardiovascular risk outcomes of a work-site intervention trial.

OBJECTIVES: Two composite outcome measures were used to assess the efficacy of work-site risk factor interventions: the Framingham multiple logistic function and a standardized composite equation that was an unweighted combination of risk factors. METHODS: Twenty-eight work sites in Sydney, Australia, were randomly assigned to health risk assessment, risk factor education, behavioral counseling, or behavioral counseling plus incentives. RESULTS: Over 12 months, scores on the multiple logistic function increased for the behavioral counseling plus incentives condition relative to the other conditions. Standardized scores decreased for behavioral counseling relative to the incentive condition and the average of all other conditions. CONCLUSIONS: Behavioral counseling produces larger changes in the life-style behaviors contributing to coronary heart disease risk than other commonly used interventions.