Efficacy, safety and acceptability of a benzalkonium chloride spermicide cream in women aged 40 years and over needing contraception: A prospective multicentre study

OBJECTIVE

This multicenter prospective study (BZK40+) aims to determine the efficacy and tolerance of a benzalkonium chloride-containing spermicide as contraceptive among women aged 40 and over.

PROCEDURE

Fertile women enrolled in this open single-arm study were instructed to systematically use the benzalkonium chloride spermicide before each intercourse. At the end of a 6-month mandatory period, participants were given the option of continuing the study for a further 6 months. The primary endpoint for contraceptive efficacy was the Pearl Index (PI) up to 12 months of typical use.

MAIN FINDINGS

A total of 151 women (mean age: 45.9 years) were enrolled, 144 (95.4%) completed the initial 6-month period and 63 (41.7%) completed the optional 6-month period. The median number of intercourses ranged from 3 to 5 per month. The spermicide was applied before 96.3% of the 5,895 sexual intercourses. The PI up to 12 months of typical use was 0 pregnancies (95% confidence interval: 0-2.88). The cumulative treatment exposure was 1249.7 women-months.

CONCLUSION

This first study in women aged 40 years and over shows that benzalkonium chloride spermicide (Pharmatex®) is effective, well tolerated and well accepted in this population. Although very interesting, these results with a PI equal to zero are surprising and not in accordance with the low efficacy of spermicides in the overall population according to the WHO. So, our results should be interpreted with caution and confirmed by future research. Clinical trial registration number (EudraCT): 2016-004,188-38.

DOES HYALURONIC ACID GEL REDUCE INTRAUTERINE ADHESIONS AFTER DILATION AND CURETTAGE IN WOMEN WITH MISCARRIAGE? MULTICENTRIC RANDOMIZED CONTROLLED TRIAL (HYFACO STUDY)

BACKGROUND

Miscarriage is a frequent problem that requires dilation and curettage in 30 % of cases. This routine surgery may lead to intrauterine adhesions and severe infertility. Hyaluronic acid gel is known to reduce intrauterine adhesions after hysteroscopic surgery.

OBJECTIVE

This study aimed to evaluate the rate of intrauterine adhesions after dilation and curettage for miscarriage with and without hyaluronic acid gel.

STUDY DESIGN

This was a multicentric (nine hospitals in France), prospective, open-labelled randomized trial. Patients who had a miscarriage between weeks 7 and 14 of gestation, requiring dilation and curettage, and who were wishing for another pregnancy were eligible for the study. Women were randomly assigned 1:1 to surgery alone (control group) vs surgery with intrauterine instillation of hyaluronic acid gel (gel group). An office hysteroscopy was planned six to eight weeks after surgery. The primary endpoint was the rate of intrauterine adhesions during this office follow-up hysteroscopy. Two different follow-up fertility surveys were sent at 6 months and one year after the end of the intervention respectively.

RESULTS

Among the 343 patients who had curettage, 278 had hysteroscopy. After multiple imputation, the rate of intrauterine adhesions was lower in the gel group compared to the control group (9.1% vs. 18.4%, respectively, p=0.0171). Among the 110 responders to the surveys, the overall pregnancy rate twelve months after surgery was 64.5% (71/110), and similar in both groups (57.4 % (27/47) in control group vs. 69.8% (44/63) in gel group, p=0.1789).

CONCLUSION

Intrauterine instillation of hyaluronic acid gel reduces the rate of intrauterine adhesions in women treated with dilation and curettage for miscarriage.

Using a new diagnostic tool to predict lymph node metastasis in advanced epithelial ovarian cancer leads to simple lymphadenectomy decision rules: A multicentre study from the FRANCOGYN group

OBJECTIVE

The aim of this study was to develop a new diagnostic tool to predict lymph node metastasis (LNM) in patients with advanced epithelial ovarian cancer undergoing primary cytoreductive surgery.

MATERIALS AND METHOD

The FRANCOGYN group's multicenter retrospective ovarian cancer cohort furnished the patient population on which we developed a logistic regression model. The prediction model equation enabled us to create LNM risk groups with simple lymphadenectomy decision rules associated with a user-friendly free interactive web application called shinyLNM.

RESULTS

277 patients from the FRANCOGYN cohort were included; 115 with no LNM and 162 with LNM. Three variables were independently and significantly (p<0.05) associated with LNM in multivariate analysis: pelvic and/or para-aortic LNM on CT and/or PET/CT (p<0.00), initial PCI ≥ 10 and/or diaphragmatic carcinosis (p = 0.02), and initial CA125 ≥ 500 (p = 0.02). The ROC-AUC of this prediction model after leave-one-out cross-validation was 0.72. There was no difference between the predicted and the observed probabilities of LNM (p = 0.09). Specificity for the group at high risk of LNM was 83.5%, the LR+ was 2.73, and the observed probability of LNM was 79.3%; sensitivity for the group at low-risk of LNM was 92.0%, the LR- was 0.24, and the observed probability of LNM was 25.0%.

CONCLUSION

This new tool may prove useful for improving surgical planning and provide useful information for patients.

Uterine metastasis from invasive ductal breast carcinoma: A case report with literature review

Breast cancer is the leading cause of cancer death in women, and most breast cancer related deaths are due to metastases. Uterine metastases from breast cancer are uncommon and rarely reported in the literature. We described the case of a 50 years-old-woman who developed a uterine metastasis, 6 years after the diagnosis of an invasive ductal breast carcinoma. Indeed, although the patient was asymptomatic, the monitoring imaging examinations, particularly the computed tomography (CT) and the positron emission tomography/computed tomography (PET/CT), showed a myometrial lesion. Non-conservative total hysterectomy was performed. The anatomo-pathological examination revealed a myometrial metastasis from an invasive ductal breast carcinoma. Seventeen months after surgery, the patient had no pelvic recurrence, but lungs and bones metastases progressed despite chemotherapy. In the lack of guidelines of uterine metastases from breast cancer's management, we reviewed the existing literature with the aim to provide a rational framework for clinical presentation, diagnostic approach, histological findings and treatment of this rare and heterogeneous pathology. Uterine metastases of breast cancer are frequently revealed with metrorrhagia. They occur preferentially in tumours with initial lobular carcinoma, initial lymph node involvement and positive hormonal receptors.

A Pre-operative Score to Discriminate Fibroepithelial Lesions of the Breast: Phyllode Tumor or Fibroadenoma?

BACKGROUND/AIM

Fibroepithelial lesions (FEL) of the breast include fibroadenomas and phyllodes tumors (PT). Their histologic characteristics on core needle biopsy can overlap, while their clinical management is different. The aim of this study was to develop and to validate a pre-operative score for the diagnosis of PT with surgical decision rules.

PATIENTS AND METHODS

We developed a pre-operative score for the diagnosis of PT by performing logistic regression on 217 FEL of the Rene Huguenin Hospital. This score and the surgical decision rules were validated on 87 FEL of the Lariboisiere Hospital.

RESULTS

Three variables were independently and significantly associated with PT: age ≥40 years, mammography's tumor size ≥3 cm and PT diagnosed by CNB. The pre-operative score was based on these three criteria with values ranging from 0 to 10. Surgical decision rules were created: the low-risk group of PT (score≤2) had a sensitivity of 92.6% and a LR- of 0.2, the high-risk group (score>7) had a specificity of 93.5% and a LR+ of 4.4. In the validation sample, surgical decision rules were applied.

CONCLUSION

These surgical decision rules may prove useful in deciding which FEL needs surgical resection.

Hippocampal Radial Glial Subtypes and Their Neurogenic Potential in Human Fetuses and Healthy and Alzheimer's Disease Adults

Neuropathological conditions might affect adult granulogenesis in the adult human dentate gyrus. However, radial glial cells (RGCs) have not been well characterized during human development and aging. We have previously described progenitor and neuronal layer establishment in the hippocampal pyramidal layer and dentate gyrus from embryonic life until mid-gestation. Here, we describe RGC subtypes in the hippocampus from 13 gestational weeks (GW) to mid-gestation and characterize their evolution and the dynamics of neurogenesis from mid-gestation to adulthood in normal and Alzheimer's disease (AD) subjects. In the pyramidal ventricular zone (VZ), RGC density declined with neurogenesis from mid-gestation until the perinatal period. In the dentate area, morphologic and antigenic differences among RGCs were observed from early ages of development to adulthood. Density and proliferative capacity of dentate RGCs as well as neurogenesis were strongly reduced during childhood until 5 years, few DCX+ cells are seen in adults. The dentate gyrus of both control and AD individuals showed Nestin+ and/or GFAPδ+ cells displaying different morphologies. In conclusion, pools of morphologically, antigenically, and topographically diverse neural progenitor cells are present in the human hippocampus from early developmental stages until adulthood, including in AD patients, while their neurogenic potential seems negligible in the adult.

Cesarean scar pregnancy with deep serosal invasion at 16 weeks: Uterus-sparing surgery with posterior hysterotomy after transcatheter arterial embolization

We report a case of cesarean scar pregnancy at 16 weeks. Magnetic resonance imaging confirmed the isthmic ectopic location with an empty fundus and a high suspicion of placental invasion to the anterior myometrium. Because of pelvic pain, bleeding and the major risks of hysterectomy, a decision was made to terminate the pregnancy. After a preventive pelvic artery embolization, we performed an unusual posterior isthmic hysterotomy for the extraction of the fetus, followed by conservative management of the placenta. Bleeding loss was 300 mL, and no complication was reported. Successive magnetic resonance imaging was planned and 6 months later, there were no placental remnants. At 7 months, an office hysteroscopy revealed a normal uterine cavity. In case of cesarean scar pregnancy in the second trimester with an emergency need to interrupt pregnancy, posterior hysterotomy with conservative treatment of placenta may be an option to avoid massive bleeding and hysterectomy.

In-vitro fertilization and spontaneous pregnancies: matching outcomes in Douala, Cameroon

BACKGROUND

Couples are considered infertile if they do not conceive over a 12-month period of unprotected intercourse. Studies have shown that female causes accounted for between 25 to 37 percent of infertility worldwide (with larger proportions in sub-Saharan Africa and Southeast Asia) and male causes accounted for between 8 to 22 percent. Both male and female causes accounted for between 21 to 38 percent. Although the majority of ART children are normal, there are concerns about the increased risk for adverse pregnancy outcomes. More than 30 % of ART pregnancies are twins or higher-order multiple gestations (triplets or greater) and more than one half of all ART neonates are the products of multifetal gestations, with an attendant increase in prematurity complications. The aim of this study was to evaiuate the outcome of pregnancies conceived by In-vitro fertilisation compared to those conceived naturally in two hospitals in Douala, Cameroon.

METHODS

This was a prospective study carried out from October 1, 2011 to September 30, 2012. Participants were recruited from two hospitals: the Douala General Hospital (DGH) and the Clinique de l' Aéroport (CDA), also in Douala. A total of 102 women were recruited for study: 51 who conceived by IVF (cases) and 51 who conceived naturally (controls). Of the 102 women, 52.9 % were between 31 - 39 years of age, while 21.6 % were above 40.

RESULTS

Participants who conceived through IVF-ET were 4.1 times more likely to undergo cesarean delivery than those who conceived naturally [OR 4.10, 95 % CI 1.78-9.42]. Similarly, a higher percentage of patients in the IVF group than those in the control group have never given birth (33.3 % vs 2.0 %) (P < 0.0001). The percentage of multiple pregnancies was 7.5 times higher in the IVF group than in the control group (14.7 % vs.1.96 %) (P = 0.000). The leading indication for cesarean delivery was advanced maternal age (27.3 %) followed by IVF or precious pregnancy (18.2 %).

CONCLUSIONS

Cesarean delivery was more frequent amongst the IVF group than in the control group. The leading indications for cesarean delivery were advanced maternal age and IVF or precious pregnancy. The long-term neonatal outcomes of IVF babies beyond 5-min Apgar scores should be studied in Cameroon and follow-up beyond 1 year encouraged.

From knowledge to planning considerations: a matrix to assess health needs for the perinatal network in eastern Paris

BACKGROUND

Regionalization of perinatal care is required throughout networks to reduce perinatal morbidity and mortality and to organize access to health services for high-risk new borns, such as in the eastern Paris in 2007. Our study sought to design a matrix to build a perinatal knowledge base for assessing health needs and facilitating public health planning process for the perinatal network in eastern Paris.

METHODS

Our matrix listed as its columns 'perinatal stages' from conception through the age of 6 years, whereas the rows covered components related to public health planning (i.e. target population, perinatal risk factors and health services). For each situation, the matrix lists require information and potential data sources to measure health status and health services.

RESULTS

Our matrix structures the cyclical process for building knowledge for action. The eastern Paris has a population of 670,000. Its nine maternity units are distributed into three levels of care, a level-3 unit opened up in June 2007. A total of 16,400 deliveries occur every year in the nine units; 2500 women living in the eastern area deliver outside the area.

CONCLUSION

Our matrix is useful for building a comprehensive perinatal knowledge base depending upon perinatal stages and health-care dimensions. It should imply stakeholders in collecting, synthesizing and analysing massive amounts of data. It can be adapted to any health network or local health policy.

Uterine adenosarcoma associated to lymphovascular emboli: a case report

INTRODUCTION

Uterine adenosarcoma is a rarely observed polypoid tumor with a mixed benign epithelial element and malignant stromal component. The treatment is total hysterectomy with bilateral salpingo-oophorectomy. It could be difficult to diagnose and associated to lymphovascular invasion.

CASE PRESENTATION

A 45-year-old caucasian uniparous woman presented with uterine bleeding. She had several surgical procedures and pathology of removed recurrent polyps showed no malignancy. Finally, a total abdominal hysterectomy was performed because of atypical cells and suspected uterine adenosarcoma. The hysterectomy specimen confirmed the presence of uterine adenosarcoma associated with lymphatic and vascular tumor emboli. Surgery was completed with a second bilateral salpingo-oophorectomy and pelvic lymphadenectomy.

CONCLUSION

In our report, we present a case of uterine adenosarcoma which was diagnosed after multiple surgical procedures and associated to lymphovascular emboli known to have a significant impact on overall survival and distant metastasis-free survival.

Post-voiding residual volume in 154 primiparae 3 days after vaginal delivery under epidural anesthesia

OBJECTIVES

To use 3-dimensional ultrasonography (3D-US) to determine the frequency of post-voiding residual volume (PVRV) > or =100 mL in primiparae 3 days after receiving epidural anesthesia for vaginal delivery. Potential relationships between day-3 PVRV > or =100 mL and obstetrical-pediatric parameters, especially those possibly implicated in post-obstetrical bladder dysfunction, were examined.

STUDY DESIGN

We recruited 154 primiparae who vaginally delivered term singletons following uncomplicated pregnancies in the maternity unit of a French teaching hospital. All women had been systematically catheterized 2-h postpartum to measure precisely the volume of urine retained. On the morning of discharge (day 3), when the patient felt the urge to urinate, her 3D-US pre-voiding bladder volume was determined with BladderScan (BVI-3000), then her spontaneously voided urine was collected to accurately quantify its volume and 3D-US was repeated immediately to evaluate the PVRV. PVRV > or =100 mL on day 3 was considered pathological.

RESULT

Among these 154 women, 88 (57%) felt the need to urinate and 97 (63%) had a retained volume > or =500 mL at 2-h postpartum. On day-3 postpartum, the median [range] volumes for the entire cohort were: 426.7 [158-999.7] mL 3D-US-measured pre-voiding, 350 [15-1000] mL collected by spontaneous urination, 82.2 [5.3-433.3] mL 3D-US-determined post-voiding; PVRV exceeded 100 mL for 55 (36%). According to our univariate analysis, no factor considered was able to predict PVRV > or =100 mL on day 3.

CONCLUSION

Our observations confirmed the existence of PVRV > or =100 mL on day 3 in more than one-third of these primiparae who delivered vaginally under epidural anesthesia. No obstetrical-pediatric factor could be implicated in this bladder dysfunction. Therefore, we recommend frequent and systematic non-invasive 3D-US monitoring of all postpartum patients at least until day 3 to avoid excessive urine retention.

Vaginal delivery after tension-free vaginal tape procedure

To treat genuine stress urinary incontinence, the surgical technique of choice at present is suburethral tension-free vaginal tape (TVT) procedure. Because of its good results and low morbidity, TVT is now offered to younger women still of childbearing age. We describe a patient who delivered vaginally 2 years after undergoing a retropubic TVT procedure. The woman remained continent throughout her pregnancy and at 6 months postpartum, with normal urodynamic parameters.

Transhepatic Ultrasound-Guided Cardiac Catheterization in the Fetal Lamb

BACKGROUND

Percutaneous transventricular and fetoscopic umbilical catheterization have been applied to animal and human fetuses. These methods have a high rate of failure and complications. Here, we propose an alternative route for anterograde echocardiography-guided cardiac catheterization through a transhepatic approach of the intra-abdominal vessels in the fetal lamb.

METHODS AND RESULTS

After exteriorization of the uterus in 12 pregnant ewes between 118 to 122 days' gestation, a 4F sheath mounted over a 1.2-mm needle was placed into the intra-abdominal portion of the umbilical vein (n=2) and into the subdiaphragmatic portion of the inferior vena cava via a transhepatic approach (n=10) under ultrasound guidance. In the first 2 animals using a transumbilical approach, it was impossible to reach the heart through the ductus venosus. In the next 10 animals, using a conventional technique, echocardiography-guided catheterization of the 4 chambers was performed in the all fetuses, atrial or ventricular pacing in 6 fetuses, and ballooning of the pulmonary valve in 9 of 10 fetuses. Among the 10 fetuses catheterized through the transhepatic approach, 2 were euthanized immediately after the procedure to evaluate intraperitoneal bleeding (23 and 29 mL, respectively), and 3 died after the procedure (1 of major bleeding and 2 deaths related to balloon catheter manipulation). Finally, 5 were delivered vaginally after an uneventful pregnancy, and autopsy at day 5 did not show significant liver, vascular, or cardiac injury.

CONCLUSIONS

Echocardiography-guided fetal cardiac catheterization through a transhepatic approach is feasible and provides an interesting alternative approach for human fetal cardiac interventions.

Prospective 3D ultrasonographic evaluation of immediate postpartum urine retention volume in 100 women who delivered vaginally

Our objective was to determine the reproducibility and validity of urine retention volumes measured by 3D ultrasonography (3D-US) 2 h postpartum. This was a longitudinal prospective study of 100 women who delivered vaginally. Each woman underwent five successive urine retention measurements with the Bladder Scan 2 h after vaginal delivery, followed by transurethral catheterization to determine the real volume. The reproducibility of only the last four scan values was analyzed with an intraclass correlation coefficient, and that of determinations 4 and 5 with a Bland-Altman plot. The validity of the device was similarly evaluated using the mean four-scan and real values. Pearson's correlation coefficient was calculated and a least-trimmed squares robust linear-regression model was used. All tests were two-sided with a 5% alpha risk. Results showed that 3D-US measurements were highly reproducible, with an intraclass correlation coefficient of 0.974 (95% CI:0.964-0.981). 3D-US also accurately estimated the real urine volume (intraclass correlation coefficient 0.924; 95% CI:0.888-0.949), but tended to underestimate by about 6.8%. The between-technique Pearson correlation coefficient was 0.94 (P < 0.0001) and the regression analysis gave an R2 of 0.914. Urine retention volumes exceeded 500 ml in 55 women, and 11 in 7. We concluded that 3D-US was reliably able to measure postpartum urine retention volume.

Using intercostal muscle EMG to quantify maternal expulsive efforts during vaginal delivery: A pilot study

AIMS

The expulsive forces of childbirth can be included among the many potential risk factors implicated in the subsequent development of stress urinary incontinence (SUI) in women. The objective of this study was to devise a non-invasive way to measure abdominal pushing that would accurately represent the expulsive forces during childbirth.

METHODS

By means of intravesical and intrauterine manometry, and electromyography (EMG) of intercostal muscles, we quantified these forces in 21 women during vaginal delivery.

RESULTS

A mathematical analysis of variance (ANOVA) model showed the integral of intravesical pressure to be significantly associated (P < 0.001) with the integral of intercostal muscle electrical activity during the first six uterine contractions during the phase of fetal expulsion.

CONCLUSIONS

EMG is a non-invasive measurement that can replace intravesical determinations to quantify these forces as it reflects the real intra-abdominal pressure.

Hepatitis C virus detection in follicular fluid and culture media from HCV+ women, and viral risk during IVF procedures

BACKGROUND

Hepatitis C virus (HCV) has been detected in sperm, but no data are available on follicular fluid (FF) collected on IVF procedures. The aim of this study was to: (i) search for HCV RNA in FF and in culture media at each step of IVF undergone by HCV(+) women; (ii) investigate the impact of blood contamination of FF induced by vascular injury associated with transvaginal ovarian puncture; (iii) assess risk for the embryo and the impact on the contamination rate of the newborn; and (iv) determine the viral risk presented by these fluids in order to define guidelines for the laboratory.

METHODS

FF from 22 IVF procedures performed in 17 HCV(+) women were classified as either clear, lightly bloody or bloody FF. Oocytes from each FF were washed and incubated in separated fertilization media. At 20 h after puncture (day 1), the fertilized oocytes were washed and transferred to fresh media until embryo transfer. HCV RNA was detected and quantified in FF and media using Cobas Amplicor and Cobas Monitor HCV RNA kits.

RESULTS

HCV RNA was positive in 39 of 44 FF samples, and viral loads increased with blood contamination. At day 1, after rinsing of oocyte-cumulus complexes, only 8 of 44 media were still positive. Viral loads were quantified in 5 of 8 positive media, were below the test sensitivity threshold in 4 of 5 HCV RNA-positive media, and just above it in the fifth medium. The day of transfer HCV RNA was undetectable in all media.

CONCLUSIONS

HCV RNA was detected in 89% of FF irrespective of the degree of blood contamination, and in 25% of the media at day 1. FF must be considered as potentially infected. Blood contamination increases HCV load in the FF. Rinsing oocytes seems significantly to discard the HCV RNA. It is too early to assess the impact of IVF on the contamination rate of HCV mothers' offspring. After counselling, attempting IVF in HCV(+) women is justified. Universal guidelines prevent nosocomial infection, and IVF does not specifically increase the professional risk.

Effects of a Gonadotropin-Releasing Hormone agonist and Follicle Stimulating Hormone on the incidence of apoptosis in human luteinized granulosa cells

OBJECTIVE

Previous studies have shown the importance of apoptosis in follicular atresia occurring especially in granulosa cells (GC) and its relation to the outcome of in vitro fertilization (IVF). The aim of this study was to evaluate the effects of a Gonadotropin-Releasing Hormone agonist (GnRHa) and of Follicle-Stimulating Hormone (FSH) on the apoptosis rate of human luteinized GC.

STUDY DESIGN

GC were isolated from follicular fluids of 15 women undergoing IVF cycles, cultured for 1 day and then treated for 1 day in serum-free medium with triptorelin at 100 or 1000pg/ml or with FSH at 100 or 500ng/ml. GC cultured without any hormone addition were used as controls. Treatment of cultured GC with triptorelin 100pg/ml and FSH 100ng/ml was performed five times each. GC were analysed by flow cytometry after propidium iodide staining to measure the percentage of apoptotic GC. Some triptorelin-treated GC were also examined by electron microscopy.

RESULTS

Percentages of GC apoptosis were after hormone treatment respectively: FSH: 100ng/ml, 2.9+/-0.6%; 500ng/ml, 2.9%; triptorelin: 100pg/ml, 18.6+/-2.8%; 1000pg/ml, 86.5% versus 9.8+/-1.8% in GC controls (FSH 100ng/ml versus control; triptorelin 100pg/ml versus control: P<10(-6)). Electron microscopy confirmed apoptosis of GC incubated with triptorelin.

CONCLUSIONS

This study demonstrated that FSH decreased apoptosis in human luteinized GC. In contrast, triptorelin was possibly implicated in a dose-dependent increase in the incidence of apoptotic GC. This last result suggests that clinical use of GnRHa should perhaps be reconsidered in the context of its apoptosis-inducing effect.

[Risk factors for maternal thromboembolism: obstetrical circumstances]

We analyzed the statistical relationship described between the principal laboratory anomalies related to thrombophilia and obstetrical pathology and risk of maternal thromboembolism.

Pregnancy outcome after laparoscopic and laparoconverted myomectomy

OBJECTIVE

To compare fertility and pregnancy-related complications after laparoscopic and laparoconverted myomectomy.

METHODS

Retrospective analysis of 106 infertile women with uterine leiomyomas, of whom 88 women underwent laparoscopic myomectomy and 18 laparoconversion.

RESULTS

There was no difference in the patients' baseline characteristics or the mean number of fibroids between the laparoscopic and laparoconversion groups. The mean (+/-S.D.) diameter of the largest fibroid in the laparoscopic and laparoconversion groups was 6.2+/-1.8 and 8.1+/-1.4 cm, respectively (P<0.001). There was no difference in operating time between the two groups. The hospital stay was shorter in the laparoscopic group: 3.0+/-1 versus 5.5+/-1 days (P<0.001). The mean follow-up in the laparoscopic and laparoconversion groups was 27.3+/-7.0 and 32.0+/-3.1 months, respectively (NS). No difference in the pregnancy rate was noted between the laparoscopic and laparoconversion groups (48 and 56%, respectively). The mean time before conception in the laparoscopic and laparoconversion groups was 7.5+/-2.6 and 15.1+/-2.4 months, respectively (P<0.001). There was no difference between the two groups as regards the rates of pregnancy-related complications and vaginal delivery. No uterine rupture occurred.

CONCLUSION

Laparoscopic myomectomy is feasible and safe, and should be considered for infertile women with uterine fibroids. Fertility and pregnancy outcomes following laparoscopic myomectomy are comparable with those following myomectomy after laparoconversion.

Safety of cryopreservation straws for human gametes or embryos: a study with human immunodeficiency virus-1 under cryopreservation conditions

BACKGROUND

The possibility of assisted reproductive technology (ART) for couples carrying viruses, especially HIV-1, necessitates consideration of the safety of cryopreserving human gametes or embryos in liquid nitrogen tanks. Following our evaluation of the safety of three kinds of straws containing HIV-1 at 37 degrees C, we have now examined the HIV-1 imperviousness of the same straws under cryopreservation conditions.

METHODS

Polyvinyl chloride (PVC), polyethylene terephthalate glycol (PETG) and high-security ionomeric resin (IR) straws (24 each) were tested. Each straw was filled with 100 microl of HIV-1-containing supernatant [reverse transcriptase (RT) activity: 15 000 c.p.m./50 microl]. Then PVC and PETG straws were sealed ultrasonically only at their free-end, and IR straws were thermosoldered at both ends. Each straw was put in a 15 ml Falcon tube which was capped and submerged in a liquid-nitrogen tank for 7 days. After bleach decontamination or not, the outside of each end of the straw was rinsed with RPMI medium (1 ml) before cryopreservation and after thawing. Viral RNA was extracted from the medium and then amplified by RT-polymerase chain reaction (PCR) followed by nested-PCR using HIV-1 protease-specific primers.

RESULTS

HIV-1 RNA was detected in some PVC and PETG rinse media, probably resulting from splashing during ultrasonic sealing, but not in the rinse media of thermosoldered IR straws.

CONCLUSION

Under cryopreservation conditions, IR straws would appear to be safe for HIV-1 storage in ART. For PVC and PETG straws, as highlighted in this study, the ultrasonic sealing could be the weak safety link.

Predictive value of urethral mobility before suburethral tape procedure for urinary stress incontinence in women

PURPOSE

We determined whether preoperative urethral mobility predicts the outcome of the suburethral tape procedure outcome in women with urinary stress incontinence.

MATERIALS AND METHODS

This retrospective study included 78 women who underwent preoperative cystourethrography while standing. Proximal urethral support was assessed by lateral cystourethrograms at rest and during straining. The 2 images were anatomically superimposed and the angle formed by the 2 proximal urethra axes determined urethral mobility. Surgical outcome was assessed by stress and pad tests.

RESULTS

Median followup was 9 months (range 1 to 37) and the objective success rate was 85% (66 of 78 cases). Median rotation of the proximal urethra was 67 degrees in cases without previous surgery for incontinence, 33 degrees in those with 1 and 28 degrees in those with 2 or more procedures (p <0.0001). The success rate was 97% (29 of 30 cases) when urethral mobility exceeded 60 degrees versus 86% (18 of 21) for mobility between 30 and 60 degrees, and 70% (19 of 27) when it was less than 30 degrees (p = 0.023). The success rate was 96% (26 of 27 cases) without previous surgery for incontinence versus 84% (31 of 37) when 1 unsuccessful procedure had been performed and 64% (9 of 14) with 2 or more surgical failures (p = 0.026). Patient age at surgery, menopausal status, mixed incontinence, body mass index, parity, overactive bladder and low maximal urethral closure pressure had no significant prognostic value.

CONCLUSIONS

The suburethral sling procedure takes advantage of urethral mobility to avoid leakage. The more the proximal part of the urethra moves while under stress, the better the continence achieved. Risk factors for failure are poor proximal urethral mobility and previous surgery for incontinence.

A modified RT-PCR technique to screen for viral RNA in the semen of hepatitis C virus-positive men

BACKGROUND

Our objective was to use an adapted RT-PCR technique to assess the presence of hepatitis C virus (HCV) in semen and also in different density gradient semen fractions collected from men with chronic viral hepatitis participating in an assisted reproduction programme.

METHODS

This study included 50 semen samples from 35 HCV(+) men, with active viral replication assessed by RT-PCR, collected the day of oocyte retrieval and used for assisted reproduction. These samples were subjected to standard assisted reproduction sperm preparation conditions, using density-gradient centrifugation with 45 and 90% layers. Aliquots of semen, 45 and 90% fractions, and embryo culture media were frozen at -80 degrees C for subsequent virological analyses. All aliquots were tested with a commercially available HCV RNA assay, adapted for use with semen after a number of technical changes. This assay yielded a sensitivity of 50-100 HCV RNA copies/ml and strongly diminished the effect of seminal amplification inhibitors.

RESULTS

HCV RNA was detected in 7/50 (14%) semen samples tested, 5/35 (14.3%) men. HCV RNA was found in only 1/50 45% fractions but never in the 90% fraction or embryo culture media. Sera from 3/5 men contained 3.19-7.40 x 10(5) IU/ml, while the two others had 4.5 and 11.7 x 10(6) IU/ml. However, HCV RNA was quantified at <600 IU/ml in the HCV(+) semen of these five patients. The ongoing pregnancy rate was of 20% (10/50) with one delivery at the time of the present report. No anti-HCV antibody was found in any of the women or the newborn.

CONCLUSIONS

Although HCV is present at low concentrations in the semen of a few HCV(+) patients, no purified sperm fraction (i.e. 90% fraction) used in assisted reproduction was HCV(+) and no seroconversion was observed in the women and the newborn, thereby suggesting a very low risk of virus transmission. Nevertheless, because the presence of HCV in semen implies a possible risk of nosocomial contamination, safety regulations must be strictly applied in assisted reproduction laboratories.

Predictive value of urethral mobility before suburethral tape procedure for urinary stress incontinence in women

PURPOSE

We determined whether preoperative urethral mobility predicts the outcome of the suburethral tape procedure outcome in women with urinary stress incontinence.

MATERIALS AND METHODS

This retrospective study included 78 women who underwent preoperative cystourethrography while standing. Proximal urethral support was assessed by lateral cystourethrograms at rest and during straining. The 2 images were anatomically superimposed and the angle formed by the 2 proximal urethra axes determined urethral mobility. Surgical outcome was assessed by stress and pad tests.

RESULTS

Median followup was 9 months (range 1 to 37) and the objective success rate was 85% (66 of 78 cases). Median rotation of the proximal urethra was 67 degrees in cases without previous surgery for incontinence, 33 degrees in those with 1 and 28 degrees in those with 2 or more procedures (p <0.0001). The success rate was 97% (29 of 30 cases) when urethral mobility exceeded 60 degrees versus 86% (18 of 21) for mobility between 30 and 60 degrees, and 70% (19 of 27) when it was less than 30 degrees (p = 0.023). The success rate was 96% (26 of 27 cases) without previous surgery for incontinence versus 84% (31 of 37) when 1 unsuccessful procedure had been performed and 64% (9 of 14) with 2 or more surgical failures (p = 0.026). Patient age at surgery, menopausal status, mixed incontinence, body mass index, parity, overactive bladder and low maximal urethral closure pressure had no significant prognostic value.

CONCLUSIONS

The suburethral sling procedure takes advantage of urethral mobility to avoid leakage. The more the proximal part of the urethra moves while under stress, the better the continence achieved. Risk factors for failure are poor proximal urethral mobility and previous surgery for incontinence.

[Diagnosis of ectopic pregnancy]

The knowledge of ectopic pregnancies risk factors (intra-uterine device; past history of pelvic inflammatory disease; history of tubal pathology and tubal surgery; positive chlamydiae serology; and smoking), the high sensitivity and specificity of radioimmunological assay of beta-HCG and the availability of high resolution sonography using vaginal probes had improved the routinely diagnosis of ectopic pregnancy. Today, diagnosis was made with beta-HCG and vaginal echography. Uterine vacuity, peritoneal liquid and latero-uterine masse represent the major ultrasound signs. However, diagnosis can be uncertain below discriminative zone of beta-HCG (< 1,500 to 2,000 UI/L). Other new diagnostic markers are also described, as progesterone, creatine kinase, VEGF and CA 125. The place of ponction of the Douglas, endouterine curettage, hysteroscopy and laparoscopy are also defined for diagnosis of ectopic pregnancy.

Effects of hepatitis C virus on the apoptosis percentage of granulosa cells in vivo in women undergoing IVF: preliminary results

BACKGROUND

The aim of this study was to investigate the relationship between the apoptosis percentage of human luteinized granulosa cells (GC) and the presence of hepatitis C virus (HCV) in follicular fluid (FF).

METHODS

GC were isolated from FF of 12 women undergoing 12 IVF cycles: six were HCV+ with active viral replication and six HCV- serving as controls. No male partner was HCV+. HCV detection and quantification were assessed by reverse transcriptase-polymerase chain reaction in serum, FF and embryo-incubation medium. GC were analysed by flow cytometry after propidium iodide staining to measure the percentages of apoptotic GC. Routine IVF parameters were tabulated.

RESULTS

Mean +/- standard deviation (SD) serum and FF HCV viral loads were 3.58 +/- 4.25 x 10(6) and 0.14 +/- 0.10 x 10(6) IU/ml respectively. Mean percentages of apoptotic GC from HCV+ and HCV- women were 3.08 +/- 1.14 and 3.14 +/- 1.40% respectively. No statistically significant difference was found between these two groups concerning GC apoptosis and when we compared all IVF parameters. No HCV RNA was detected in embryo incubation media after 2 days of culture.

CONCLUSIONS

Comparing GC apoptosis percentages and usual IVF parameters in the HCV+ group versus the HCV- group, our preliminary study shows that active chronic HCV infection does not affect follicle development and IVF outcome in HCV+ women undergoing IVF. Furthermore, the risk of newborns becoming HCV-infected might not be increased by assisted reproductive technologies when performed in couples in which women are HCV+ and men HCV-.

Induced apoptosis and expression of related proteins in granulosa cells from women undergoing IVF: a preliminary study

BACKGROUND

Because apoptosis may be involved in the outcome of IVF, the expression of pro- and anti-apoptosis proteins in a model of induced granulosa cell (GC) apoptosis was evaluated in 25 women with normal FSH levels undergoing IVF.

METHODS

After 1 day of culture, apoptosis was induced with interferon (IFN)-gamma (200 IU/ml), followed 24 h later by an agonistic anti-Fas antibody (0.5 microg/ml). On day 3, apoptotic GC, identified by chromatin condensation and/or nuclear fragmentation after DAPI staining, were counted among 1000 cells in randomly chosen fields under UV microscopy, and enabled allocation of women into two groups with either low (group 1) or high (group 2) percentages of apoptosis (11.6 +/- 4.8 and 59.5 +/- 14.8% respectively; P < 0.001). Immunoblotting was used to evaluate the following in proteins: poly (ADP-ribose) polymerase (PARP), caspases 8 and 3, Bcl-2, heat shock protein (HSP) 70, Bax, Bak and Stat-1 (a protein known to be inducible by IFN-gamma).

RESULTS

Based on densitometric analysis of immunoblots, the PARP 116 kDa bands were respectively 4.3- and 33.3-fold lower for treated groups 1 and 2. Caspase 8, caspase 3 and HSP70 were expressed slightly less in treated group 2 than treated group 1. Densitometric analysis of bands corresponding to Bcl-2 showed respectively for treated groups 1 and 2, 3.2- and 2.5-fold decreases. Bak expression was similar in both control groups, and comparably lower in the two treated groups. With regard to Stat-1, densitometry showed 3.3- and 1.3-fold increases respectively in treated groups 1 and 2.

CONCLUSIONS

These results suggested that Fas-mediated apoptosis of GC is accompanied by significant changes in proteins acting in apoptosis, and that this type of programmed cell death might play a potential prognostic role for women undergoing IVF.

Determinants of pregnancy rate and obstetric outcome after laparoscopic myomectomy for infertility

OBJECTIVE

To determine the effect of myomectomy on infertility and to assess the factors influencing reproductive outcome.

DESIGN

Retrospective study.

SETTING

Tertiary care center.

PATIENT(S)

One hundred and three infertile women with uterine leiomyoma who had had infertility >2 years and a follow-up time >12 months were enrolled. Follow-up was complete for 88 patients, including 28 (31.8%) with primary infertility and 44 (50%) with unexplained infertility. The mean (+/-SD) age of the patients was 36.1 +/- 2.1 years.

INTERVENTION(S)

Laparoscopic myomectomy.

MAIN OUTCOME MEASURE(S)

Pregnancy rate according to patient and fibroid characteristics.

RESULT(S)

Forty-two patients became pregnant (40.7%). The mean (+/-SD) delay in conception was 7.5 +/- 2.6 months. Nearly 80% of the women conceived spontaneously. Of 44 pregnancies in 42 women, 36 live newborns were delivered. No dehiscence of uterine scar occurred. The pregnancy rate was significantly higher in women <35 years of age or <3 years of infertility. Women with unexplained infertility had higher pregnancy rate than did women with multifactorial infertility (P<.001). No difference was noted in pregnancy rates according to fibroid characteristics.

CONCLUSION(S)

Fertility and pregnancy after laparoscopic myomectomy depend primarily on patient age, duration of infertility before myomectomy, and existence of associated infertility factors.

Vascular endothelial growth factor, platelet endothelial cell adhesion molecule-1 and vascular cell adhesion molecule-1 in the follicular fluid of patients undergoing IVF

BACKGROUND

The aim of our study was to measure concentrations of vascular endothelial growth factor (VEGF), platelet endothelial cell adhesion molecule-1 (PECAM-1) CD31 and vascular cell adhesion molecules (VCAM-1) in the follicular fluid of women treated with assisted reproduction technology to determine whether these proteins might be outcome markers.

METHODS

Follicular fluid was collected from 75 patients < or =40 years undergoing oocyte retrieval procedures at our tertiary hospital during 1997 and 1998: 50 with tubal disease, 12 with endometriosis, and 13 whose partners had been diagnosed with severe oligoasthenoteratozoospermia. This retrospective analysis considered age and information about treatment and outcome for all these women who had undergone fewer than three assisted reproduction attempts.

RESULTS

Nineteen women became pregnant (defined by human chorionic gonadotrophin concentrations and embryonic cardiac activity 1 month after follicular aspiration); 56 did not. Women did not differ significantly in their follicular fluid concentrations of VEGF, sCD31 and VCAM-1 according to cause of infertility, or assisted reproduction outcome, or age. Follicular fluid concentrations of VEGF were significantly correlated with the number of gonadotrophin ampoules administered (P < 0.012), and follicular fluid concentrations of sVCAM-1 with the fertilization rate (P < 0.01). Follicular fluid concentrations of VEGF and sVCAM-1 were also correlated (P < 0.007).

CONCLUSIONS

Our results do not suggest that VEGF, CD31, or sVCAM-1 in follicular fluid predict assisted reproduction outcome, especially among patients < or =40 years old. The correlation of a high fertilization rate and sVCAM-1 in follicular fluid suggests that sVCAM-1 might be a marker of fertilization.

[Myoma and infertility: analysis of the literature]

The influence of myomas on reproduction has been clearly demonstrated, however their effects on fertility remain debated. The aim of this review, between January 1988 and December 2000, was to clarify the relation between myoma and fertility, and to assess pregnancy rates after myomectomy in infertile patients. Spontaneously, 54 publications were selected and 40 eligible. No study compared pregnancy rates with or without myomas. Pregnancy rates after myomectomy varied between 9.6% and 76.9%, with descriptive series. In medically assisted procreation, five publications were eligible. Myoma presence was associated with decreased pregnancy rates. Hysteroscopic sub-mucous myoma resection increased pregnancy rates. Relation between myoma and sterility is probable, however no proof was obtained. Myomectomy efficacy has not been statistically proven, but spontaneously almost 60% of patients became pregnant 24 months after surgery. Decreased pregnancy rates are observed when other infertility factors are associated. Concerning myomectomy in medically assisted procreation, conflicting results are available. Prospective randomised studies are needed.

[Management of pregnant women infected with HIV at Bichat Hospital between 1990 and 1998: analysis of 202 pregnancies]

OBJECTIVE

To describe medical and obstetrical prenatal care of pregnant women infected by HIV-1 emphasizing the role of cesarean section.

DESIGN

A retrospective study of 202 pregnancies followed between 1990 and 1998 in a french hospital in Paris.

RESULTS

56.9% of the women were born in subsaharian Africa; 80.2% were infected by sexual intercourse and the seropositivity was discovered during the pregnancy in 51% of the cases. Viral coinfections by hepatitis B virus, hepatitis C virus and Human papillomavirus were found respectively in 14.7%, 16.5% and 13% of the pregnancies. Prematurity occurred in 15% of the deliveries. Efficacy of antiretroviral therapy was confirmed in this study: 5.7% of the children were infected despite the antiretrovial treatment versus 19.3% without treatment (p < 0.03). Prophylactic cesarean section was proposed to the patients since 1994; the morbidity of cesarean was 8.8% (69 cesarean sections).

CONCLUSION

The policy of the association of prophylactic cesarean section and monotherapy by Zidovudine is validated by recent studies. The extension of prophylatic cesarean section to all the pregnant women infected by HIV is proposed. However the evaluation of the morbidity of the cesarean section in HIV infected women needs a prospective case-control study.

APC resistance and third-generation oral contraceptives: Acquired resistance to activated protein C, oral contraceptives and the risk of thromboembolic disease

Using a newly-developed technique, a severe acquired plasma resistance to activated protein C has been described in women using third-generation (rather than second-generation) oral contraceptives. The following items are discussed: (i) the technical parameters used to appreciate the effect of activated protein C induce a bias of interpretation, the mean intrinsic effect of activated protein C, in plasmas from women on second or third-generation oral contraceptives being strictly identical; (ii) there are no data available to show that this assay can indicate a thromboembolic risk in asymptomatic women on oral contraceptives; and (iii) this assay is a global and non-specific test, basically sensitive to the plasma concentrations of many coagulation factors which are increased or decreased by oestrogens and progestogens. For instance protein S, in which oral contraceptive-induced modifications account for the differential effect of oral contraceptives on Rosing's assay, but which modifications are not related to the thromboembolic risk of oral contraceptives. The androgenic potential of the progestogen may counteract the effect of oestrogens in the test. More generally, in such a complex situation in which there is a 'modification of the modification', there is no haemostasis-related test which provides a risk indicator for thrombosis. Based on testing of the plasma response to activated protein C, it is impossible to state that third-generation oral contraceptives induce a more important thromboembolic risk than oral contraceptives containing a more androgenic progestogen.

Safety of cryopreservation straws for human gametes or embryos: a preliminary study with human immunodeficiency virus-1

The aim of this preliminary experimental study was to test the stability of cryopreservation straws to human immunodeficiency virus-1 (HIV-1). Three kinds of straws were tested: four polyvinyl chloride (PVC), four polyethylene terephthalate glycol (PETG) and 20 high-security ionomeric resin (IR). The PVC and PETG straws were sealed ultrasonically, and the IR straw by thermosoldering. Each sealed straw was cut in half to produce two demi-straws and then filled with 100 microl of HIV-1-containing supernatant (reverse transcriptase activity: 15 000 c.p.m./50 microl). The unsealed cotton end of PVC and PETG straws and the two halves of the IR straws (cotton and plastic plug ends) were tested. Each demi-straw was two- thirds submerged in RPMI medium at 37 degrees C, and RPMI samples were withdrawn on days 3, 7 and 11. Viral RNA was extracted from the medium and then amplified by reverse transcriptase-polymerase chain reaction (RT-PCR) followed by nested PCR using primers specific to HIV-1 protease. On day 7, no HIV-1 RNA was detected in any of the different samples of medium that had surrounded the unsealed PVC and PETG straws with cotton ends, but three IR specimens were positive. On day 11, PVC and PETG remained negative but HIV-1 RNA was detected in RPMI samples for two more IR demi-straws (n = 5). In conclusion, under these experimental conditions (at 37 degrees C), the unsealed cotton end PVC, PETG and thermosoldered cotton end IR demi-straws appeared to be safe for HIV-1, while IR straws, sealed or unsealed with a plastic plug and with unsealed cotton ends, leaked.

Are sphincter defects the cause of anal incontinence after vaginal delivery? Results of a prospective study

PURPOSE

Anal incontinence affects approximately 10 percent of adult females. Damage to the anal sphincters has been considered as the cause of anal incontinence after childbirth in the sole prospective study so far available. The aims of the present study were to determine prospectively the incidence of anal incontinence and anal sphincter damage after childbirth and their relationship with obstetric parameters.

METHODS

We studied 259 consecutive females six weeks before and eight weeks after delivery. They were asked to fill in a questionnaire assessing fecal incontinence. Anal endosonography (7-10 MHz) was then performed. Two independent observers analyzed internal and external anal sphincters.

RESULTS

A total of 233 patients (90 percent) were assessed, of whom 31 had cesarean section. De novo sphincter defects were observed in 16.7 percent (14 percent external, 1.7 percent internal, and 1 percent both) in the postpartum period only after vaginal delivery. These disruptions occurred with the same incidence after the first and the second childbirth. Independent risk factors (odds ratio; 95 percent confidence interval) for sphincter defect were forceps (12; 4-20), perineal tears (16; 9-25), episiotomy (6.6; 5-17), and parity (8.8; 4-19) as revealed by multivariate analyses. The overall rate of anal incontinence was 9 percent and independent risk factors (odds ratio; 95 percent confidence interval) involved forceps (4.5; 1.5-13), perineal tears (3.9; 1.4-10.9), sphincter defect (5.5; 5-15), and prolonged labor (3.4; 1-11). Among these patients only 45 percent had sphincter defects.

CONCLUSION

Anal incontinence after delivery is multifactorial, and anal sphincter defects account for only 45 percent of them. Primiparous and secundiparous patients have the same risk factors for sphincter disruption and anal incontinence. Because external anal sphincter disruptions are more frequent than internal anal sphincter damage, surgical repair should be discussed in symptomatic patients.

[Relationship between human immunodeficiency virus and sperm--implications in medically assisted procreation]

The number of HIV-sero-discordant couples (man HIV+, woman HIV-) asking for assisted reproductive technologies (ART) has been increasing more and more since the efficiency of antiretroviral therapy was clinically proven. Long-term survey and amelioration of life quality in treated HIV-seropositive patients have induced in these couples a strong wish to conceive but they expected the most reduced risk of viral contamination. Epidemiologic data concerning HIV transmission during episodic unprotected sexual acts showed an elevated annual seroconversion rate which justifies that since 1992, European biologists specialized in human reproduction have proposed to carry out ART using intrauterine insemination (IUI) with prepared sperm in the population of couples where the man is HIV-seropositive. In spite of adapted technologies of sperm preparation, presence of HIV nucleic acids was demonstrated in purified spermatozoon (SPZ) fractions, resulting from residual free virus or virus linked to SPZ or residual infected cells, not completely eliminated. However, approximatively 2000 IUI were carried out with an HIV-controlled sperm treatment and no female and newborn seroconversions were reported. Even if the total lack of risk is impossible to obtain, a strict method of infected sperm preparation associated with sensitive virological techniques should permit us to obtain a minimal risk of contamination of women after IUI. In vitro fertilization (IVF) with or without microinjection allowed us to obtain the same results but they should be confirmed by further studies to be more relevant. These European workings, associated to a clear legal regulation in France, permit us to considerate that carrying out ART in HIV-sero-discordant couples in which the man is HIV-seropositive is allowable regarding both the viral problem and eventual sterility.

Fertility after hysteroscopic myomectomy: effect of intramural myomas associated

OBJECTIVE

The aims of this retrospective study were to evaluate the subsequent fertility and outcome of pregnancies after hysteroscopic myomectomy according to (a) the characteristics of submucous myomas and (b) the association with intramural myomas.

MATERIALS AND METHODS

From July 1994 to June 1997, 119 patients had hysteroscopic myomectomy including 31 infertile women. Among these 31 patients, the mean number of removed myomas by hysteroscopy was 1.4 (range 1-4) and the mean diameter of fibroid was 20 mm (range 10 to 50).

RESULTS

Eleven out of 31 women (35.5%) became pregnant. Thirteen pregnancies were observed including nine term deliveries, three miscarriages and one premature labor at 24 weeks of amenorrhea. A difference in delivery rate was found between patients with one submucous myoma resected and those with two or more (p=0.02). No difference in pregnancy and in delivery rates was observed according to size and location of submucous myomas. In contrast, in patients without intramural myomas, the delivery rate (p<0.03) was significantly greater and the delay of conception (p=0.05) was significantly shorter than those found in patients with intramural myomas.

CONCLUSION

Our study suggest that fertility after hysteroscopic myomectomy depend on (a) the number of submucous myomas resected and (b) the association with intramural fibroids.

[Postpartum sphincter rupture and anal incontinence: prospective study with 259 patients]

AIMS

Damage to the anal sphincter has been considered as the cause of anal incontinence after childbirth. The aims of the present study were to determine prospectively the incidence of anal incontinence and anal sphincter damage after childbirth, and their relationship with obstetric parameters in France.

PATIENTS AND METHODS

We studied 259 consecutive women six weeks before and eight weeks after delivery. They were asked to fill out a questionnaire dealing with faecal and urinary incontinence. Anal endosonography (B&K 7-10 MHz) was then performed. Two independent observers analyzed internal and external anal sphincters.

RESULTS

Two hundred and thirty-three women (90%) were assessed, among whom 31 had had a caesarean section. De novo sphincter defects were observed in 19.3% (39 patients) in the postpartum period only after vaginal delivery (202 patients). These disruptions occurred with the same incidence after the first and second childbirth. Independent risk factors (odds ratio; 95% confidence interval) for sphincter defect were forceps (odds ratio 11.9; 4.8-33.3), perineal tears (odds ratio 16.1; 4.4-83.9), episiotomy (odds ratio 6.6; 1.7-34.2), and pauciparity < or = 2 (odds ratio 8.8; 1-78.3), as revealed by multivariate analyses. The overall rate of de novo anal incontinence was 9% (20 patients), and independent risk factors involved forceps (odds ratio 4.5; 1.5-13), perineal tears (odds ratio 3.9; 1.4-10.9), de novo sphincter defect (odds ratio 5.5; 5-15) and prolonged labor (odds ratio 3.4; 1-11). Among the 20 women who had de novo anal incontinence, only 45% (9 patients) had sphincter defects.

CONCLUSION

De novo anal incontinence after delivery is multifactorial and anal sphincter defects account only for 50% of them. Primiparous and secundiparous women have the same high-risk factor for sphincter disruption and anal incontinence. Since external anal sphincter disruptions are more frequent than internal anal sphincter damage, surgical repair should be discussed.

The role of selective prescribing in the increased risk of VTE associated with third-generation oral contraceptives

In the early 1960s, it became apparent that oral contraception (OC) with oestroprogestogens increased the cardiovascular, venous thromboembolic (VTE), myocardial infarction (MI) and cerebrovascular accident (CVA) risk. The change in medical prescribing patterns, the reduction in ethinyloestradiol dosage and the use of less androgenic progestogens made prescribers confident that the risks would subsequently decrease. At the end of 1995 and early 1996, four publications called into question that optimism by showing that third-generation pills induced a two-fold increase in VTE risk compared with second-generation pills. A biological rationale was due to be announced later. Since then, re-analysis of the data has shown that the thrombotic risk factors are increased in third-generation OC users but, more importantly, that those users (unlike those using second-generation pills) are the women who have not had the opportunity of revealing a latent thrombophilia and are, therefore, at a greater risk of expressing it during third-generation OC intake. When these data are considered, the difference between second- and third-generation OC users in terms of VTE risk is completely destroyed. In addition and although the risk factors (smoking in particular) are concentrated in third-generation OC users, the MI risk is less in those users than in second-generation pill users. This is particularly true in the presence of a risk factor such as smoking. No difference in risk has been observed for CVA in the general population between second- and third-generation OC users, but once more among smoking women the risk is lower with third-generation OC.