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PubMed1997

Small diameter versus conventional laparoscopy: a prospective, self-controlled study.

The objective of this study was to determine visual quality, diagnostic accuracy, and surgical merits of small diameter laparoscopy (SDL). Thirty-seven patients were randomly selected. The indications for laparoscopy were infertility, desire for tubal sterilization or chronic pelvic pain. Patients underwent SDL, followed by conventional laparoscopy (CL) as a control under general anaesthesia. Findings at operation were compared. The mean time for diagnostic work-up was longer with SDL than CL, 11.7 +/- 5.6 versus 7.6 +/- 3.2 min respectively (P < 0.04). Visual quality was scored from 4 to 1 by the operator; mean visual quality, mean endometriosis score and mean adnexal adhesions score were slightly lower with SDL than CL. Sensitivity of SDL in diagnosing endometriosis, adhesions, ovarian, uterine and pouch of Douglas lesions were 71, 58, 81, 89 and 73% respectively; specificity was 100, 96, 100, 100, 100% in the same order. Suction irrigation, cyst aspiration, tissue biopsies, simple adhesiolysis, tubal ligation and cauterization were easily performed with SDL. We conclude that SDL seems a good alternative to CL in diagnosing macro-pelvic anatomy and coarse pelvic pathologies and may also be good in performing surgical procedures such as: tubal ligation, biopsies and differential diagnosis of pelvic fluids. But SDL must be used cautiously in micro-oriented, functional conditions such as infertility, pelvic pain, endometriosis and adhesion scoring or treatment. SDL may be regarded as a less invasive but less sensitive tool with limited surgical merits.

Adult↗
PubMed1999

Endometrial cell dissemination at diagnostic hysteroscopy: a prospective randomized cross-over comparison of normal saline and carbon dioxide uterine distension.

The incidence of pelvic spreading of endometrial cells at diagnostic hysteroscopy was studied comparing the two distension media carbon dioxide (CO(2)) and normal saline (N/Saline). Thirty patients requiring laparoscopy and hysteroscopy were included in this study, the main indication for surgery being subfertility. Hysteroscopy was performed using both CO(2) and N/Saline distension on each patient, the order of the distension media being randomly allocated. Samples of peritoneal fluid were aspirated from the pouch of Douglas before and after hysteroscopy with each distension medium, and the specimens were investigated cytologically for the presence of endometrial cells. Endometrium was present in 2/30 (6.7%) peritoneal aspirates before and in 15/60 (25%) collected after the hysteroscopies. There was no major difference between liquid or gaseous distension, transtubal reflux of endometrial cells occurring in 7/30 (23.3%) and in 8/30 (26.7%) hysteroscopies respectively. Positive peritoneal cytology was observed significantly more often in patients who were in the proliferative phase of the menstrual cycle [9/14 (64.3%) versus 0/11, P < 0.004]. In conclusion, transtubal dissemination of endometrium occurs in about one quarter of patients, irrespective whether N/Saline or CO(2) is used for uterine distension; there is no advantage to using gaseous distension for hysteroscopy when investigating high-risk cases for endometrial malignancy.

Carbon Dioxide↗
PubMed1999

Evaluation of the performance of fertiloscopy in 160 consecutive infertile patients with no obvious pathology.

We have defined fertiloscopy as the combination in one investigation of transvaginal hydropelviscopy, dye-test, optional salpingoscopy, and hysteroscopy, performed on an outpatient basis under local anaesthesia or neuroleptanalgesia. We have applied this approach in a routine manner to 160 infertile patients with no obvious pathology. Fertiloscopy was achieved in 154 patients (96.2%). In five patients visualization was not satisfactory because of technical problem or adhesions in the pouch of Douglas. We had one (0.6%) rectal injury, which was treated conservatively. Sixty patients (37.5%) had normal fertiloscopic examination. Endometriosis was discovered in 21 patients (13.1%) post-pelvic inflammatory disease (PID) lesions in 58 cases (36.2%), and subtle abnormalities in 15 cases (9.3%). Salpingoscopy was completed when post-PID lesions were encountered. In 39% of cases only partial examination was possible because of external tubal adhesions, but it was nevertheless sufficient to obtain a good view of the first one-third of the ampulla. In all, 74 patients (46.2%) were referred directly to in-vitro fertilization (IVF) procedures, and so avoided a further laparoscopy. Quality of imaging, accuracy of the pelvic examination in a physiological manner, and safety of the procedure are the main advantages of this minimally invasive technique. Selection of the patients for surgery is therefore enhanced, and indication for IVF is better balanced, avoiding the performance of extensive procedures in patients who should thus benefit from this less traumatic alternative.

Adult↗
PubMed2000

Transvaginal hydrolaparoscopy compared with laparoscopy for the evaluation of infertile women: a prospective comparative blind study.

Standard diagnostic laparoscopy is considered the gold standard to investigate tubo-peritoneal infertility. It requires general anaesthesia and full operative facilities. Due to the risk of complications, laparoscopy is frequently postponed to the final stage of infertility evaluation or even after treatment trials have failed. Transvaginal hydrolaparoscopy (THL) is based on vaginal access using a needle puncture technique and saline for distention. THL can be performed on an outpatient basis under local anaesthesia. However, little data exist concerning the accuracy of THL in comparison with laparoscopy. We conducted a prospective comparative blind trial to assess the feasibility and accuracy of THL compared with diagnostic laparoscopy in infertile women. Sixty women were assigned to undergo THL immediately prior to laparoscopy. Different operators evaluated the findings of the two procedures. In order to evaluate the accuracy of THL, findings in terms of tubal pathology, endometriosis and adhesions were analysed. The success rate of accessing the pouch of Douglas was 90.2%. Complication rate was 1.6%. THL diagnosis was correlated with that of laparoscopy in 92.3% of cases. In cases of abnormal findings by THL, there were no normal laparoscopies. Our pilot study suggests that THL is a safe and reproducible method. Retroverted uterus should be considered as a relative contraindication to THL. When a complete evaluation by THL is available, it is a highly accurate technique in comparison with the laparoscopy.

Adult↗
PubMed2001

Usefulness of transvaginal hydrolaparoscopy in investigating infertile women with Chlamydia trachomatis infection.

BACKGROUND: A new technique called transvaginal hydrolaparoscopy (THL) was recently developed for the exploration of the tubo-ovarian structures in infertile patients without obvious pelvic pathology. This study was performed to investigate the usefulness of THL to evaluate Chlamydia trachomatis tubal infertility. METHODS: Forty-one women with primary and secondary infertility participated in this study. Fourteen had past C. trachomatis infection. In 38 (92.7%) of the 41, access to the pouch of Douglas was obtained. In total, 71 (93.4%) out of 76 adnexa were clearly visualized. Thirty-seven patients were analysed and compared their tubal passages and peritubal adhesions using both hysterosalpingography (HSG) and THL. Twenty-four tubes from 14 patients with past C. trachomatis infection and 44 tubes from 23 patients without a history of C. trachomatis infection were compared. RESULTS: For the diagnosis of the tubal passage, there were no significant differences in the discrepancy rates between HSG and THL, in patients with and without past C. trachomatis infection. In 14 (58.3%) of the 24 tubes from patients with past C. trachomatis infection and in eight (18.2%) of the 44 tubes from patients without infection, peritubal adhesion was diagnosed only by THL. There was a significant difference in the discrepancy rates of the diagnosis of peritubal adhesion between HSG and THL in the two groups (P = 0.0007 ). CONCLUSIONS: These results suggest that C. trachomatis infection is highly associated with peritubal adhesion which is difficult to diagnose by HSG. Therefore, in C. trachomatis antibody-positive patients, exclusion of tubal pathology by THL or standard laparoscopy should be carried out to consider appropriate treatments. Although THL is not a substitute for laparoscopy, it can be proposed as a first line procedure in the early stages of the infertility investigation.

Adult↗
PubMed2002

Embryotoxicity of peritoneal fluid in women with endometriosis. Its relation with cytokines and lymphocyte populations.

BACKGROUND: The goals of the present work were to study the embryotoxic effects of peritoneal fluid (PF) in women with or without endometriosis, and to relate any embryotoxicity to the severity of endometriosis, infertility or achievement of pregnancy, cytokine concentrations and lymphocyte populations. METHODS: Sixty-six consecutive women of reproductive age, 54 with endometriosis (21 infertile) and 12 infertile without endometriosis, and another 12 fertile women as control group, were included in this study. They all underwent laparoscopy or laparotomy in the second half of the cycle, and PF was collected from the pouch of Douglas. The embryotoxicity of the PF was assessed by means of a mouse embryo assay, and expressed as the number of embryos that did not reach blastocyst stage. Cytokines and lymphocyte populations present in PF were also studied and correlated with embryotoxicity. RESULTS: PF embryotoxicity was increased in women with endometriosis, but there was little correlation with the severity of the disease. However, although a clear relationship to the presence of infertility was not found, embryotoxicity appeared to be lower in those infertile patients with endometriosis who later became pregnant. We found a significant increase in embryotoxicity in the presence of high cytokine concentrations, especially with interleukin-6, and less so with interleukin-8 (P < 0.05). No good correlation was observed with lymphocyte populations, but CD56 (NK) cells were significantly increased in the PF of women with endometriosis. In general, the correlations for embryotoxicity were better when PF was diluted at 20% (91.4 +/- 17 versus 68.1 +/- 31, P < 0.01). CONCLUSIONS: These results suggest that alteration in the production of cytokines in the PF, especially IL-6, besides contributing to the endometriosis and its evolution, probably increases embryotoxicity. However, no correlation was found between the latter and associated infertility.

Adult↗
PubMed2006

Predicting the outcome of pregnancies of unknown location: Bayesian networks with expert prior information compared to logistic regression.

BACKGROUND: As women present at earlier gestations to early pregnancy units (EPUs), the number of women diagnosed with a pregnancy of unknown location (PUL) increases. Some of these women will have an ectopic pregnancy (EP), and it is this group in the PUL population that poses the greatest concern. The aim of this study was to develop Bayesian networks to predict EPs in the PUL population. METHODS: Data were gathered in a single EPU from all women with a PUL. This data set was divided into a model-building (599 women with 44 EPs) and a validation (257 women with 22 EPs) data set and consisted of the following variables: vaginal bleeding, fluid in the pouch of Douglas, midline echo, lower abdominal pain, age, endometrial thickness, gestation days, the ratio of HCG at 48 and 0 h, progesterone levels (0 and 48 h) and the clinical outcome of the PUL. We developed Bayesian networks with expert information using this data set to predict EPs. RESULTS: The best Bayesian network used the gestational age, HCG ratio and the progesterone level at 48 h and had an area under the receiver operator characteristic curve (AUC) of 0.88 for predicting EPs when tested prospectively. CONCLUSIONS: Discrete-valued Bayesian networks are more complex to build than, for example, logistic regression. Nevertheless, we have demonstrated that such models can be used to predict EPs in a PUL population. Prospective interventional multicentre studies are needed to validate the use of such models in clinical practice.

Adolescent↗
PubMed1989

Clinical efficacy of amoxycillin/clavulanate in laparoscopically confirmed salpingitis.

To test the efficacy and safety of amoxycillin/clavulanate (Augmentin), 102 hospital patients with laparoscopically confirmed acute salpingitis were treated with parenteral amoxycillin/clavulanate (1.2 g qid for three days) followed by oral amoxycillin/clavulanate (two tablets of 625 mg tid for a further six days). Bacteriological samples were obtained from the cervix uteri and the pouch of Douglas. One hundred patients were assessable for clinical outcome using several variables including pain scores. Amoxycillin/clavulanate alone was effective in 95 patients (95%). Three patients (3%) responded to amoxycillin/clavulanate with marked improvement but another antibiotic was subsequently added to their treatment regimen. Treatment failed in two patients. At follow-up two weeks after hospital discharge, three patients (3.8%) had relapsed or were re-infected. Adverse drug events included one case of drug fever, one case of rash and one case of severe diarrhoea. Treatment was stopped in all three cases. Gastrointestinal reactions, mainly mild diarrhoea, were seen in 31 patients. No clinically relevant changes in haematological or clinical chemical indices were attributable to the amoxycillin/clavulanate treatment. We conclude that amoxycillin/clavulanate is a clinically effective and safe treatment for acute salpingitis.

Acute Disease↗
PubMed1989

Transvaginal hysterosalpingo-contrast-sonography (Hy-Co-Sy) compared with conventional tubal diagnostics.

Transvaginal hysterosalpingo-contrast-sonography (Hy-Co-Sy) is described as a new method for direct imaging of the tubal passage in tubal diagnostics. During one period of anaesthesia, a transvaginal Hy-Co-Sy was followed by either hysterosalpingography or chromolaparoscopy in 42 patients with sterility disorders. The contrast-enhanced sonography of the tubes was performed in eight cases with sterile saline solution (group 1) and 34 cases with a specially developed ultrasound contrast medium (SH U 454, group 2). The findings obtained by transvaginal Hy-Co-Sy were compared with those of the conventional method. By both methods, there was complete agreement with respect to the same evaluation of tubal passage for both sides, partial agreement when firstly the tubes were assessed as unilaterally or bilaterally open--without precise localization of the side--depending on the appearance of fluid in the pouch of Douglas, or secondly, only one side, when compared, showed agreement. In group 1 complete agreement was found once, partial agreement five times and non-agreement twice, while in group 2 complete agreement was found 22 times (65%), partial agreement 11 times and non-agreement once.

Adult↗
PubMed1989

In-vivo transperitoneal fertilization.

We present the technique of in-vivo transperitoneal fertilization (IVTPF) as a first approach to infertility treatment in couples with male subfertility or unexplained factors. The technique is statistically less successful but also less invasive than either gamete intra-Fallopian transfer (GIFT) or in-vitro fertilization - embryo transfer (IVFET) and offers considerable advantages over intrauterine insemination (IUI). The IVTPF technique involves transperitoneal transfer of processed spermatozoa within the pouch of Douglas after induction of ovulation. We report our 4-year experience with IVTPF which includes 136 treatment cycles in 89 couples. Eight pregnancies were achieved in 89 patients (9%) and 136 treatment cycles (7%). Fifty-one patients (57%) received IVTPF for only one treatment cycle; seven of the eight IVTPF pregnancies occurred in this group. An ectopic pregnancy resulted in one of the eight IVTPF pregnancies (13%). The functional quality of the sperm in those couples who achieved pregnancy was statistically superior to those couples who did not conceive. However, pregnancy was also obtained in case of severe oligozoospermia. Based on our experience, we feel IVTPF to be a very reasonable first approach in patients with no pelvic pathology and with infertility secondary to male factors or unexplained causes.

Adult↗
PubMed1990

The influence of human follicular fluid on the acrosome reaction, fertilizing capacity and proteinase activity of human spermatozoa.

The present study was designed to assess physiological and enzymatic changes in human spermatozoa following incubation in human follicular fluid (HFF). Initially, it was determined that infertility patients (n = 29) scored dramatically higher on the hamster egg penetration test (HEPT) when spermatozoa were incubated with HFF (22.9 +/- 4.4%) rather than the standard swim-up alone (4.6 +/- 1.1%). To further evaluate this effect, in experiment I, spermatozoa were obtained from proven fertile individuals and evaluated following exposure to three different HFF samples as well as control treatments (medium, cul de sac fluid and heparin). There were no significant differences in HEPT scores following sperm incubation in the three different follicular fluids although incubation in all the fluids significantly (P less than 0.01) enhanced sperm penetration (%PEN) when compared to the standard swim-up and other control treatments. The absence of an effect of cul de sac fluid on spermatozoa indicates that not all body fluids contain factors which stimulate sperm fertilizing capacity. The effect of HFF was demonstrated in a infertile patient population as well as in donors of proven fertility. In experiment II, the effect of HFF on the acrosome reaction (%AR), sperm fertilizing capacity and changes in sperm proteolytic enzymes were determined. There was no significant difference in the %AR between freshly ejaculated (7.9 +/- 3.1) and medium incubated (9.4 +/- 1.6) spermatozoa; however, in both of these treatments the %AR was less (P less than 0.01) than for spermatozoa treated with HFF (45.6 +/- 4.7). The %PEN following incubation of spermatozoa in HFF (52.2 +/- 6.8) was greatly increased (P +/- 0.01) compared to the standard swim-up (19 +/- 3.9).

Acrosome↗
PubMed1993

Formation of antisperm antibodies in women treated with fallopian tube sperm perfusion.

Fallopian tube sperm perfusion (FSP) is a combination of ovarian stimulation and intra-uterine insemination using a large volume (4 ml) of inseminate containing 10(7)-10(8) spermatozoa. The inseminate will flush the Fallopian tubes and some of it will end up in the pouch of Douglas. In the present study, we have investigated whether the FSP method will result in the formation of serum antisperm antibodies in the female. A total of 184 treatment cycles were given to 128 women. The indications for treatment were: unexplained infertility (n = 35), various infertility diagnoses (n = 28) and donor insemination (n = 65). Prior to treatment, 11 (8.6%) women had a positive tray-agglutination test (Friberg) and/or a positive immunobead test. After completing one to four treatment cycles, another six (4.7%) women had developed serum antisperm antibodies. The antibodies induced by the treatment were of isotype IgM and directed against the tail-tip of the spermatozoa. Two of the women, who prior to the treatment had antisperm antibodies, showed an increase in antibody titre during treatment. There was no statistically significant difference in the pregnancy rate between the women with antisperm antibodies and the women without. In our opinion, the small risk of developing antisperm antibodies is no contra-indication for treating infertile couples with FSP.

Adult↗
PubMed1988

Intraperitoneal hyperthermic perfusion combined with surgery effective for gastric cancer patients with peritoneal seeding.

Fifteen patients with far-advanced gastric cancer were given surgical treatment followed by intraperitoneal hyperthermic perfusion (IPHP) with mitomycin C (MMC) and misonidazole (MIS), a thermosensitizing drug. Immediately after extensive resection of the abdominal tumors, a 2-hour IPHP was performed at the inflow temperature of 44.7 to 48.7 C, using equipment designed for treatment of cancerous peritoneal seeding as a closed circuit, and under hypothermic general anesthesia at 30 to 31 C. In nine of the 15 patients with peritoneal seeding and/or ascites, cancerous ascites was absent after this treatment. In all cases, repeated cytologic examinations of the lavage from Douglas's pouch were negative. The postoperative courses were uneventful except for Patients 1 and 10, in whom slight leakage occurred. All patients were discharged and are in good health at the time of this writing, 7.2 +/- 4.6 months after the treatment. The Case 4 Patient recently died in a traffic accident. In all patients, transient hepatic dysfunction and hypoproteinemia occurred after the operation. This extensive surgery combined with IPHP using MMC and MIS was well tolerated and is a safe antitumor treatment for gastric cancer with peritoneal dissemination. Neurotoxicity due to MIS was nil.

Adult↗
PubMed1984

CT demonstration of pelvic hydatid cysts.

We describe the computed tomographic findings in two cases of bilateral hydronephrosis due to hydatid cyst located in the pouch of Douglas. In both cases this location was secondary to the spontaneous rupture of an hepatic cyst.

Adolescent↗
PubMedDate not supplied

Correlation of ultrasonography and bacteriology of the endocervix and posterior cul-de-sac of patients with severe pelvic inflammatory disease.

We evaluated 30 patients admitted with a diagnosis of pelvic inflammatory disease (PID) by culdocentesis and ultrasonography to determine the severity of disease in relation to endocervical and culdocentesis bacteriology. Specimens from the endocervix were cultured for Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma hominis, and Ureaplasma urealyticum. In addition, culdocentesis fluid was cultured for aerobes and anaerobes. Patients with N. gonorrhoeae or C. trachomatis had significantly milder disease (P less than 0.05) compared with patients whose specimens were negative for those organisms. Furthermore, those patients with ultrasound confirmation of a tubo-ovarian complex had significantly (P less than 0.0001) greater recovery of aerobes and anaerobes from culdocentesis fluid than did patients with milder disease.

Adult↗
PubMed2006

Pseudomyxoma peritonei associated with a mucinous ovarian tumor arising from a mature cystic teratoma. A case report.

It has generally been accepted that pseudomyxoma peritonei/disseminated peritoneal adenomucinosis originates from appendiceal low-grade adenomatous mucinous tumors. A woman who underwent an appendectomy 42 years ago, presented with a unilateral ovarian tumor whose immunohistochemical phenotype and its association with a teratoma, strongly suggest that pseudomyxoma peritonei originated from a ruptured mucinous tumour arising from a mature cystic teratoma.

Adenoma↗
PubMed1987

Rectal prolapse: relationship with joint mobility.

Joint mobility was assessed in 25 patients who had undergone surgery for complete rectal prolapse and in 25 age- and sex-matched control subjects. A significant increase in extensibility of the fifth finger was found in the patients with rectal prolapse. It was further found that there was a progressive decrease in joint mobility with age in both groups. The pathophysiology of rectal prolapse is complex. Factors considered to be important include rectal intussusception associated with the commonly observed lack of rectal fixation within the sacral hollow, with a deep Pouch of Douglas and weak pelvic floor musculature. The joint hypermobility demonstrated in these patients suggests an underlying connective tissue abnormality which perhaps contributes to the lack of rectal fixation within the pelvis and to the rectal wall intussusception.

Adolescent↗