Serum Ca-125 concentrations in endometriosis

Serum Ca-125 levels were measured in 154 patients undergoing laparoscopy or laparotomy for infertility and/or pelvic pain. Pelvic endometriosis at various stages was observed in 102 of the patients, and 52 had a visually normal pelvis and served as a control group. We found a significantly higher mean serum Ca-125 concentration in the patients with stages III and IV endometriosis compared with the controls (P less than 0.001) whereas in the patients with stages I and II disease the mean antigen level was comparable to that of the control group. Considering its low sensitivity (14.7%) the usefulness of serum Ca-125 measurements as an initial diagnostic test for endometriosis is scanty. On the contrary, because of its elevated specificity (100%), this test may be useful in indicating early surgical exploration of the pelvis in cases of infertility and/or dysmenorrhea which are associated with high values of Ca-125.

Laparotomy versus laparoscopy in the surgical treatment of endometriosis: the end of an era?

The Authors compare the efficiency of laparoscopic treatment with laparotomic surgical management of endometriosis. When the disease causes mechanical distortions and adnexal adhesions, there is an obvious explanation for infertility; in these cases laparotomic surgery has so far proved the only treatment to produce significantly valid results. No findings have yet been reported to demonstrate that cytoreduction, either pharmacological, laparoscopic or laparotomic, offers concrete advantages compared with simple observation when the disease is in the early stage.

Ultrastructure of endosalpingeal biopsies in infertile patients: correlation with reproductive success

We calculated the percentage of ciliated cells (PCC) in salpingeal microbiopsies of 41 patients with tubal infertility and ampullary microbiopsies of 36 fertile women, using the planimetric method at 500-1000 x at the scanning electron microscope. No relation was found between PCC and fertility after surgery. Thus normal ciliation does not seem to be essential for reproductive success and other factors such as the state of preservation of the tubal wall may be important.

Ultrasonography in the differential diagnosis of "double" uteri

A total of 43 infertile patients with hysterosalpingographic diagnosis of bifid uterus underwent sonography and subsequent laparoscopy/hysteroscopy to evaluate the capacity of ultrasound to demonstrate the peritoneal profile of the malformed uteri correctly. Sonographic visualization was adequate in 39 cases (90.7%) and the following were identified correctly: 1 of 2 didelphic uteri, all of 11 bicornuate uteri, all of 4 complete septate uteri, and all of 22 partial septate uteri. The sensitivity of ultrasound in detecting the presence of a perimetrial fundal notch was 92.3% and its specificity 100%. Thus, a precise differential diagnosis of "double" uteri was possible with this technique, which may in some clinical situations provide an alternative to laparoscopy.

Serum CA 125 measurements in the diagnosis of endometriosis recurrence

Seventy-one women underwent follow-up laparoscopy for persistent infertility six to 24 months after conservative treatment of endometriosis. The disease was staged according to the revised American Fertility Society classification of 1985. The serum CA 125 concentration was also measured in each patient to evaluate its efficacy in the diagnosis of endometriosis recurrence. The patients with stages I and II endometriosis had serum CA 125 levels not significantly higher than in the patients with negative findings, whereas those with stages III and IV endometriosis presented significantly higher levels (P less than .005 and P less than .001, respectively) than the disease-free women. The sensitivity of serum CA 125 measurements in the diagnosis of endometriosis recurrence was 14.8%, the specificity was 100%, and the predictive values of normal (less than 35 U/mL) and elevated levels were 27 and 100%, respectively. In some cases, serum CA 125 measurements may be used instead of follow-up laparoscopy, or to indicate when laparoscopy should be performed or postponed.

Second-look laparoscopy in the treatment of endometriosis

The results of second-look laparoscopy were compared with subjective symptomatology and findings at pelvic exploration in 36 patients who had received conservative treatment for endometriosis. In the 14 patients given pharmacologic treatment, second-look laparoscopy demonstrated active endometriosis in 57.1%, whereas pelvic pain was present in 64.3% and gynecologic examination was positive in 28.6%. In the 22 patients who underwent surgery, active endometriosis was detected by second-look laparoscopy in 31.8%, whereas 40.9% reported pelvic pain and pelvic examination was positive in 31.8%. Thus clinical signs and symptoms were unreliable in the diagnosis of endometriosis recurrence, whereas laparoscopy was indispensable. It should be programmed for 6 months from the end of medical treatment and 12 months after surgery; however, if the pain symptomatology recurs, then laparoscopy is performed immediately.

Communicating uteri: description and classification of a new type

A case of bicornuate-bicervical communicating uterus with atresia of the right hemicervix is reported. This cannot be included in any of the nine groups of Toaff's classification of uterine malformations proposed in 1984, and should be classified as a new, tenth type.

Gestational aspects of uterus didelphys

The reproductive history was analyzed of 13 women with a laparoscopic or laparotomy diagnosis of uterus didelphys and followed for two to six years. Two patients (15.4%) presented with primary infertility; the other 11 had a total of 27 pregnancies, the outcome of which was spontaneous abortion in 20 cases (74%), premature labor in 6 (22.2%) and term birth in 1 (3.7%), with a live birth rate of 18.5%. Metroplasty was performed in five cases, with live birth in three, spontaneous abortion in 1 and no postoperative conceptions in one. Cervical cerclage was performed in only one case and bilateral ovarian resection in one. The live birth rate, considering all pregnancies before and after treatment, was 35%. The compromised fertility of the uterus didelphys is probably attributable to congenital alterations in vascularization that may have a negative influence on developmental phases following implantation, particularly the structuralization of the fetomaternal relations that precede placentation.

Ultrasound in the diagnosis of subclasses of unicornuate uterus

Fourteen infertile women with hysterographic diagnoses of unicornuate uterus underwent pelvic ultrasonography and, subsequently, laparoscopy to evaluate the ability of ultrasound to diagnose the subclasses of this malformation. Seven women underwent laparotomy to remove a rudimentary horn. Ultrasound demonstrated a sensitivity of 85.7% and a specificity of 100% in diagnosing the presence of a rudimentary horn, and a sensitivity of 80% and a specificity of 100% in diagnosing the presence of a cavity in the rudimentary horn. Urography confirmed the supplementary information on the urinary tract provided by ultrasound. Ultrasound appears to have a role in the clinical management of women with unicornuate uterus.

CA 125 in serum, peritoneal fluid, active lesions, and endometrium of patients with endometriosis

Ca 125 levels in serum and peritoneal fluid were measured in 39 patients with endometriosis and 18 patients with normal pelvic anatomy at laparoscopy, and the presence of this antigen in endometriotic tissue and endometrial mucosa was also investigated. Serum CA 125 concentrations were elevated in patients with Stage III or IV endometriosis compared with control subjects (32.9 +/- 11.2 versus 16.4 +/- 8.9 U/ml, means +/- SD; p less than 0.001). CA 125 values were greater than 35 U/ml in 36.8% of women with Stage III or IV endometriosis and in none of the control subjects. No significant differences in CA 125 levels in peritoneal fluid were found between patients with endometriosis and control subjects. The immunohistochemical studies found CA 125 in 10% of the endometriotic lesions and 37.5% of the endometrial samples of patients with endometriosis and in 33.3% of the endometrial samples of control subjects.

GnRH agonists in the treatment of endometriosis

GnRH agonists, synthetic peptide analogs of GnRH, desensitize pituitary receptors for the native molecule, thus causing reversible hypogonadotropic hypogonadism. Numerous clinical studies have suggested that these compounds are efficacious in the treatment of endometriosis, but it is not clear whether they are superior to the other drugs used in treatment of this disease. The frequency of recurrence of pain symptoms at the end of treatment is high and the data on recovery of fertility are conflicting. Long-term administration of GnRH agonists is a safe and well tolerated treatment but its role in the management of endometriosis is still not well defined.

Reproductive performance of women with unicornuate uterus

The reproductive history of 19 women with a diagnosis of unicornuate uterus confirmed by laparoscopy or laparotomy is analyzed. The patients were followed for 2 to 10 years. One patient had a cavitary communicating rudimentary horn, four a cavitary noncommunicating rudimentary horn, seven a noncavitary rudimentary horn, and seven no rudimentary horn. Six of the patients presented with primary infertility. The other 13 women had a total of 29 pregnancies, 1 (3.4%) in a rudimentary horn determining rupture; abortions occurred in 17 (58.6%), premature labor in 3 (10.3%), and term births in 8 (27.6%), with a live birth rate of 38%. Of the 11 births, 6 (54.5%) were breech presentations, and 9 (81.8%) were cesarean sections. In five cases the rudimentary horn was removed, with associated salpingooophorectomy in three patients. Cervical cerclage was not performed in any of the patients.

Sonographic evaluation of uterine morphology: a new scanning technique

Through sonographic sections with mid-empty bladder it is possible to evaluate all uterine biometric data. This technique was evaluated in thirty-four cases of uterine malformations and satisfactory results were obtained in thirty-two of them. If further studies on randomized patients confirm the specificity of this technique, it could become a basic non invasive investigation for the screening of uterine malformations.

Conservative surgical treatment of endometriosis

In the period 1979-1983, 102 patients with endometriosis underwent conservative surgery at Ia Clinica Ostetrica e Ginecologica, Milan University. Treatment indications, techniques and results are presented. 34.3% of the women were in stage I, 51% in stage II and 14.7% in stage III of the American Fertility Society classification. Postoperatively, the incidence of dysmenorrhea fell from 63.7% to 15.7%, deep dyspareunia from 53.3% to 17.6% and chronic pelvic pain 21.6% to 11.8%. In 1-6 years' follow-up of the 53 women wanting children, the postoperative birth-rate was 68.3% in stage I patients, 59% in stage II and 37.5% in stage III. Endometriosis treatment is still only symptomatic, and conservative surgery, using atraumatic procedures, should aim at restoring fertility and resolving pain symptomatology.

Degree of endosalpingeal deciliation (by S.E.M.) in hydrosalpinx is not prognostic for post-surgical fertility

In 21 infertile patients, operated on for bilateral hydrosalpinges, multiple tubal biopsies, removed during surgery, were studied by light microscopy and scanning electron microscopy. Compared with control biopsies, taken from 12 fertile women, all cases but one showed flattening or loss of major and minor mucosal folds and epithelial deciliation. However postsurgical fertility rate, after 1-3 years follow-up, is not proportional to the percentage of ciliated cells.

The significance of scanning electron microscopy findings from the endosalpinx in tubal pregnancies

Authors report the endosalpingeal scanning electron microscopy (S.E.M.) findings in eleven tubes removed for ectopic pregnancies. The first aim of this study is to verify whether there is a corresponding morphological common aspect in all cases. The second aim is that of locating, with the aid of S.E.M. findings, some prognostic indications for predicting the future fertility of the patient.