Laparoscopic intra-ovarian platelet rich plasma injection for ovarian rejuvenation: a new hope for infertile women

This case report was presented to show the outcome of bilateral laparoscopic platelet rich plasma intra-ovarian injection for 34-year old woman who had primary infertility secondary to premature ovarian insufficiency and had two previously failed attempts of ICSI. One month after the procedure, the patient had menses and her hormonal profile was improved with increased serum AMH and E2 and decreased serum FSH and LH. On the eleventh day of the menstrual cycle, folliculometry detected good follicle measuring 18×20 mm, on the fifteenth day, trans-vaginal ultrasonography assured ovulation and timed intercourse was ordered, and she got pregnant. At the thirty fifth gestational week, she had premature preterm rupture of membrane and urgent cesarean delivery was performed and the newborn was admitted to neonatal intensive care unit. As conclusion, intra-ovarian PRP injections could be safe, productive, and a natural treatment for women with POI. Laparoscopic injection allowed perfect under-vision intra-ovarian injection and can be conducted as one-day procedure and this can be considered a novelty of the applied procedure.

Hysteroscopy: an effective tool in post-menopausal bleeding

Background: Postmenopausal bleeding is a condition where endometrial carcinoma is to be ruled out. Traditionally, D and C is the preferred method for diagnosis in such condition. Other diagnostic modalities like trans vaginal ultrasonography (TVS) and hysteroscopy are being used for diagnosis in the cases of PMB. The objective of this study is to evaluate the efficacy and accuracy of TVS and hysteroscopy in women with postmenopausal bleeding (PMB).Methods: One hundred postmenopausal women with vaginal bleeding underwent TVS and hysteroscopy. Endometrial tissue was obtained by curettage and sent for histopathology examination. The results of TVS and Hysteroscopy were compared against HP report.Results: Hysteroscopy was successful in 98 patients. Endometrial histopathology revealed proliferative, secretory and atrophic endometrium in 26, 7 and 23 patients respectively. Polyp was diagnosed in 13 patients. Endometrial hyperplasia was detected in 11 patients and endometrial malignancy in 14 patients. All patients with endometrial hyperplasia and malignancy had ET (endometrial thickness) more than 4 mm, except one patient with endometrial malignancy who had 4 mm ET. The sensitivity and specificity of TVS for suspecting endometrial pathology at ET 4mm were 93% and 69.6%, respectively. Hysteroscopy had sensitivity of 95.2%, specificity of 92.8%, with diagnostic accuracy of 93.8%.Conclusions: Hysteroscopy was found to be the more sensitive and specific than Transvaginal sonography for diagnosing endometrial pathologies. Hysteroscopy is safe and effective for detecting endometrial pathologies in patients with PMB.

Daily Vaginal Application of Dienogest (Visanne©) for 3 Months in Symptomatic Deeply Infiltrating Rectovaginal Endometriosis: A Possible New Treatment Approach?

A 27-year-old patient suffering from deeply infiltrating rectovaginal endometriosis was treated with 2 mg/day dienogest vaginally for 3 months. The therapy was tolerated very well. The patient reported less side effects compared to the oral use of dienogest. After 3 months of dienogest treatment, the rectovaginal gynecological examination identified the visible vaginal part of endometriosis in remission. The firm endometriosis node approximately 3 cm in size and approximately 10 cm ab ano was still palpable, but it was much less painful. The laboratory values for luteinizing hormone (LH) and follicle-stimulating hormone (FSH) were unremarkable, with an LH/FSH quotient of 0.7 during dienogest treatment, while 17-β estradiol and progesterone were suppressed. At palpation and vaginal ultrasonography, there was no change in the findings before and after 3 months of dienogest treatment, but the patient was now de facto asymptomatic. To the best of our knowledge, this is the first report of a vaginal dienogest treatment in symptomatic deeply infiltrating rectovaginal endometriosis. Vaginal administration of dienogest should receive further investigation in pharmacokinetic and clinical studies.

Synergistic approach in diagnosing endometrial disease in women with postmenopausal bleeding

Background: All women with postmenopausal uterine bleeding mandate examination for endometrial diseases especially endometrial carcinoma. In current scenario, hysteroscopy has replaced traditional Dilatation and Curettage as diagnostic procedure of choice. However, office endometrial sampling with pipelle combined with vaginal ultrasonography being easier and less expensive is recommended. Aim and objectives of the study was to evaluate the combined use of vaginal ultrasonography and office endometrial sampling for the diagnosis of endometrial disease in postmenopausal women with uterine bleeding.Methods: One hundred consecutive postmenopausal women presenting with uterine bleeding were enrolled in the study. Vaginal ultrasonography was used to measure the endometrial thickness. Endometrial sampling was done using endometrial biopsy pipelle, as office procedure, in the OPD examination room. The sample was sent for Histopathological Examination (HPE), The accuracy of vaginal ultrasound and pipelle was measured.Results: In 21% patients, endometrial carcinoma was found, endometrial hyperplasia in 26%, atrophic endometrium in 18%, endometrial polyp in 10% and no specific pathology in 20%. Endometrial thickness measured by Transvaginal ultrasound ranged from 1mm to 28mm with mean of 10.16mm and median of 11.5mm. The mean endometrial thickness in subgroup without disease was 5.26±3.8mm, with benign disease 12.8±3.1mm and in carcinoma 16.97±5.6mm. All cases with carcinoma had endometrial thickness exceeding 5mm (range 5.7mm to 28mm).Conclusions: The study illustrates that by combined use of Trans Vaginal Sonography (TVS) and office endometrial sampling, sufficient diagnostic information was obtained for women with postmenopausal bleeding, obviating the need for more invasive diagnostic procedures.

Predicting onset of labor from echogenicity of the cervical gland area on vaginal ultrasonography at term

On vaginal ultrasonography, cervical gland area (CGA) gradually disappears with advancing gestation. This is attributed in part to the echogenicity of the CGA becoming equal to that of the cervical stroma. The present study aimed to assess the usefulness of echogenicity in the CGA at term for predicting the time of spontaneous onset of labor.The ratio of mean grayscale level (MGL) in the CGA to that in the cervical stroma (CGA/stroma MGL ratio) was estimated as an index of echogenicity in the CGA in women after 36 weeks of gestation (n=190). Using this ratio, time until onset of labor was predicted among women between 37 and 38 weeks (n=104).CGA/stroma MGL ratio increased with advancing gestation, decreasing cervical length (CL), and increasing Bishop score. Univariate logistic analysis indicated that a combination of CL<20 mm and CGA/stroma MGL ratio ≥100% predicted onset of labor within a week [odds ratio (OR), 22.2; 95% confidence interval (CI), 2.4–202.0] was even better than short CL alone (OR, 6.8; 95%CI, 1.7–26.7; P=0.006). Stepwise logistic analysis identified that this combination was an only independent predictor (OR, 20.8; 95%CI, 2.3–188.5; P=0.007).The combination of CGA/stroma MGL ratio ≥100% and short CL may offer a useful predictor of onset of labor.

Impact of Vaginal-Rectal Ultrasound Examinations with Covered and Low-Level Disinfected Transducers on Infectious Transmissions in France

Background.The risk of cross-infection from shared ultrasound probes in endorectal and vaginal ultrasonography due to low-level disinfection (LLD) is difficult to estimate because potential infections are also sexually transmitted diseases, and route of contamination is often difficult to establish. In France, the widely used standard for prevention of infections is through the use of probe covers and LLD of the ultrasound transducer by disinfectant wipes. We performed an in silico simulation based on a systematic review to estimate the number of patients infected after endorectal or vaginal ultrasonography examination using LLD for probes.Study design.We performed a stochastic Monte Carlo computer simulation to produce hypothetical cohorts for a population of 4 million annual ultrasound examinations performed in France, and we estimated the number of infected patients for human immunodeficiency virus (HIV), herpes simplex virus, hepatitis B virus, hepatitis C virus, human papilloma virus, cytomegalovirus, and Chlamydia trachomatis. Modeling parameters were estimated by meta-analysis when possible.Results.The probability of infection from a contaminated probe ranged from 1% to 6%, depending on the pathogen. For cases of HIV infection, this would result in approximately 60 infected patients per year. For other common viral infections, the number of new cases ranged from 1,600 to 15,000 per year that could be attributable directly to ultrasound and LLD procedures.Conclusions.Our simulation results showed that, despite cumulative use of probe cover and LLD, there were still some cases of de novo infection that may be attributable to ultrasound procedures. These cases are preventable by reviewing the currently used LLD and/or upgrading LLD to high-level disinfection, as recommended by the US Centers for Disease Control and Prevention.