Extensive Excision of Deep Infiltrative Endometriosis before In Vitro Fertilization Significantly Improves Pregnancy Rates

Abstracts / Journal of Minimally Invasive Gynecology 15 (2008) S1eS159 a vaginal route with laparoscopic pelvic lymphadenectomy. Abdominal radical trachelectomy has also been performed, but does not have the reproductive success. Robotic approach to the abdominal technique permits more precise surgery, preservation of the vasculature to the uterus, and minimal manipulation of the reproductive organs. This is the first report of this procedure and describes the technique.

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Conclusion: Newer studies indicate that interstitial (cornual) ectopic pregnancies deserve more conservative management than previously employed. Design of an algorithm for evaluation and treatment of interstitial (cornual) ectopic pregnancy will serve as a model for future decision-making and provide a testable hypothesis for refinement of management criteria. Medical treatment (either systemic or local) and laparoscopic cornual or endo-loop resection have replaced exploratory laparotomy as first line approach; hysteroscopic approaches still remain investigational.

FRIDAY, OCTOBER 31, 2008 122

Plenary Session 10dPregnancy Issues (10:30 AM d 10:40 AM)

Clinical Algorithm for Evaluation and Management of Interstitial (Cornual) Ectopic Pregnancies Krotz SP, Frishman GN. Obstetrics & Gynecology, Brown University, Providence, Rhode Island Study Objective: To design a clinical algorithm for the evaluation and treatment of interstitial (cornual) pregnancies based on clinical studies and recent medical literature. Design: A Medline Search was performed using the search terms ‘‘interstitial’’ and ‘‘cornual’’ pregnancy to identify a total of 336 studies. We define interstitial (cornual) pregnancy as a pregnancy in the proximal portion of the fallopian tube surrounded by myometrium. Studies with larger patient cohorts and clinically useful findings were incorporated into the algorithm design. Setting: University Hospital. Intervention: Clinical algorithm design.

Measurements and Main Results: Of the 336 studies, data from 38 studies inclusive of 144 patients were used to construct a clinically useful management algorithm for interstitial (cornual) ectopic pregnancies. Risk factors include in vitro fertilization, previous ectopic pregnancy, previous salpingectomy and sexually transmitted infections. Symptomatic patients with BhCG valuesO2000 mIU/mL should undergo transvaginal ultrasound evaluation for the Interstitial Sign or criteria outlined by Timor-Tritsch, and if inconclusive, undergo MR evaluation. Surgical diagnosis is last resort. Patients with a cornual pregnancy!23 mm are good candidates for multi-dose systemic or local methotrexate administration with success rates of 79% and 91% respectively. Those with BhCG valuesO12,000 mIU/mL, a gestational sac O23 mm orO8 weeks gestational age may be at greater risk for methotrexate failure and should be considered for endoscopic management if appropriate candidates.

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Plenary Session 10dPregnancy Issues (10:41 AM d 10:51 AM)

Three-Dimensional (3D) Coded Contrast Imaging: A New Ultrasound Approach to Evaluate Tubal Patency Excaoustos C,1 Zupi E,1 Szabolcs B,1 Romanini ME,1 Falkensammer P,2 Gabardi C,2 Arduini D.1 1Department of Obstetrics and Gynecology, Universita` degli Studi di Roma ‘‘Tor Vergata,’’ Rome, Italy; 2GE Healthcare, Zipf, Austria Study Objective: Transvaginal hystero-salpingo-contrast-sonography (TVS HyCoSy) with air-saline mix solution appears to be an accurate and inexpensive screening tool to assess tubal patency. However, HyCoSy with saline-air mix solution has some limitations. Since the surrounding bowel and the fimbrial ends have similar echogenicity, is not easy to visualize spillage of the saline-air mix at the distal portion of the tubes. The aim of this study is to assess the validity of a new dedicated contrastenhanced ultrasound technology in the evaluation of tubal patency and in the visualization of tubal course. Design: TVS HyCoSy with the 3D ‘‘Coded Contrast Imaging’’ (CCI) technology was performed before laparoscopic chromoperturbation. Setting: University hospital. Patients: Twenty infertile patients scheduled for laparoscopy. Intervention: TVS HyCoSy with the 3D CCI technology (GE Healthcare) was performed during intrauterine injection of the second-generation contrast agent. The CCI allows the detection of contrast in the tube by discriminating the harmonic answer of contrast microbubbles from ultrasound echoes coming from other tissues and organs. We used laparoscopic chromoperturbation as our gold standard for determine tubal patency and tubal morphology. Measurements and Main Results: Of the 20 patient that underwent 3D HyCoSy, 5 showed a tubal occlusion. 3D HyCoSy with this new software demonstrated a high concordance for tubal status with laparoscopic dye test (96%). Conclusion: The major advantages of 3D HyCoSy with CCI are: 1. The imaging of the tube is produced only by contrast microbubbles and the broadband ultrasonic signals from surrounding tissue are filtered out completely. 2. The view of hyperechoic contrast media inside the tube in a completely anechoic pelvic cavity, make this diagnostic method easier for even an inexperienced sonographer. 3. The visualization for few minutes of the contrast media makes possible the use of 3D examination showing the tubal course in different planes and in the space.

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Plenary Session 10dPregnancy Issues (10:52 AM d 11:02 AM)

Extensive Excision of Deep Infiltrative Endometriosis before In Vitro Fertilization Significantly Improves Pregnancy Rates Bianchi PHM, Zanatta A, Hassun PA, Alegretti JR, Motta ELA, Serafini PC. Huntington Medicina Reprodutiva, Sa˜o Paulo, Brazil Study Objective: To compare the outcomes of in vitro fertilization treatments in women that choose to or declined to underwent laparoscopic extensive excision of deep infiltrative endometriosis. Design: Patient self-randomized, prospective study. Setting: Infertility clinic and private hospital in Sao Paulo, Brazil.

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Abstracts / Journal of Minimally Invasive Gynecology 15 (2008) S1eS159

Patients: 179 infertile patients (age < 38 years) with symptoms or signs of endometriosis and sonographic images suggestive of infiltrative disease. Intervention: After thorough counseling women were allowed to choose between 2 options: group A e proceeded directly to in vitro fertilization (n 5 64) or group B - underwent laparoscopic confirmation and excision of infiltrative endometriosis followed by in vitro fertilization (n 5 105). Ten women were lost to follow. Comparisons of in vitro fertilization outcomes were made between the groups. Measurements and Main Results: All patients had at least one infiltrative endometriotic lesion excised during laparoscopy (5  2, average  standard deviation). Patient’s characteristics on groups A and B were: age (32  3 vs. 32  3 years, p 5 0.94), infertility duration (29  20 vs. 27  17 months, p 5 0.45), day 3 follicle stimulating hormone levels (5.6  2.5 vs. 5.9  2.5 mUI/mL, p 5 0.50) and previous in vitro fertilization attempts (1  1 vs. 2  1, p 5 0.01). In vitro fertilization outcomes on group A and B were as follows: total dose of follicle stimulating hormone required during ovulation induction per patient (2380  911 vs. 2542  1012 IU, p 5 0.01), number of oocytes retrieved per patient (10  5 vs. 9  5, p 5 0.04), number of embryos transferred per patient (3  1 vs. 3  1, p 5 1) and pregnancy rates (24% vs. 41%, p 5 0.004).The odds to achieve a pregnancy were 2.45 times higher in group B. Conclusion: Women younger than 38 years had significantly higher pregnancy rates if in vitro fertilization treatments were performed after laparoscopic extensive excision of infiltrative endometriosis.

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Plenary Session 10dPregnancy Issues (11:03 AM d 11:13 AM)

Efficacy of Ovarian Drilling by Transvaginal Hydrolaparoscopy for Infertility Due to Polycystic Ovarian Syndrome Poujade O, Kane A, Deffieux X, Gervaise A, Faivre E, Frydman R, Fernandez H. Obstetrics and Gynecology, Hopital Antoine Beclere, Clamart, France Study Objective: To evaluate the fertility and the pregnancy outcome in women with Polycystic ovarian syndrome (PCOS) after bilateral ovarian drilling under fertiloscopy. Design: Retrospective study. Setting: University hospital. Patients: Seventy-four women with PCOS resistant to citrate clomiphene (CC) who underwent ovarian drilling under transvaginal hydrolaparoscopy (fertiloscopy) were retrospectively reviewed. Mean follow-up was 23.37 months (SD 16.53). Intervention: The ovarian drilling was performed using bipolar energy under fertiloscopy (except when laparoscopic conversion was required). Measurements and Main Results: After ovarian drilling, pregnancy occurred in 47 women (63%). The pregnancy occured spontaneously in 20 cases (27%), after ovarian stimulation in 5 cases (6.7%) and after in vitro fertilization in 22 cases (29.7%). In 5 cases (6.7%) multiple pregnancies were observed. In 5 cases (6.7%) a conversion to laparoscopy was required, due to failure to perform the fertiloscopy (4%), pelvic adhesions (1.3%), or uterine haemorrhage (1.3%). The average delay to pregnancy was 11.09 months (SD 8.5). Conclusion: Ovarian drilling under fertiloscopy represents an efficient alternative ovulation induction method in case of PCOS resistant to medical stimulations and to intrauterine inseminations. The minimally invasive procedure and the use of bipolar energy minimize the comorbidities.

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Plenary Session 10dPregnancy Issues (11:14 AM d 11:24 AM)

Modified Uterine Transplant Procedure in the Sheep Model Ramirez ER,1 Ramirez HA,5 Nessetti DK Ramirez,5 Nessetti MBr,4 Pillari VT,2 Khatamee M.3 1Obstetrics and Gynecology, St. John’s Hospital, Marina Del Rey, California; 2Obstetrics and Gynecology, New York Methodist Hospital, Brooklyn, New York; 3Obstetrics and Gynecology, New York University, New York, New York; 4Family Practice,

Creighton University, Omaha, Nebraska; 5Obstetrics and Gynecology, Universidad de la Salle, Pasadena, Texas Study Objective: The purpose of this project is to develop a uterine transplant procedure in the sheep model that may be suitable for human uterine transplant. Design: Pilot Study. Setting: University De La Salle Bogota, Colombia. Patients: A total of 10 sexually matured sheep undergoing uterine allotransplantation were studied. Intervention: Uterine transplantation through a mini-laparotomy incision with the application of a 900e500 modified Mobius retractor device. Measurements and Main Results: The short-term effects of warm and cold tissue ischemia were quantified and uterine tissue reperfusion was analyzed after vascular reanastomosis. The ovine model was preferred since the anatomical landmarks and vascular anatomy are comparable to human with the exception of a bicornuate uterus in the sub-primate model. A modified surgical procedure was applied to our uterine allo-transplanted sheep (n-10) and tissue rejection was managed with cyclosporine therapy. A total abdominal hysterectomy without oophorectomy was performed and a cold ischemic time of 45 minutes was recorded. The uterine arteries and veins were reapproximated using a continuous end-to-end noninterlocking approach. Vascular patency and uterine tissue viability were assessed by histological studies. Complete tissue reperfusion of blood was achieved in our 10 animals within 30 seconds after vascular reanastomosis without evidence of arterial or venous thrombosis. At six months postuterine transplantation, hysterectomies were performed documenting viable uterine tissue and vascular patency in six out of the ten uterine allotransplants. The site of uterine vessel reanastomosis was patent and histological studies indicated neovascularization with presence of smooth muscle and glandular endometrial tissue. Conclusion: We have developed a modified procedure that has allowed us to perform successful uterine transplants in the sheep model. This is the first reported case in the literature documenting a successful procedure of uterine allo-transplantation in the ewe.

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Plenary Session 11dEndometriosis (10:30 AM d 10:40 AM)

Different Sonographic Approaches Are Able to Assess Accurately the Extension of Deep Pelvic Endometriosis Exacoustos C, Zupi E, Amadio A, Szabolcs B, Concetta A, Romanini ME, Arduini D. Department of Obstetrics and Gynecology, Universita` degli Studi di Roma ‘‘Tor Vergata’’ Italy, Rome, Italy Study Objective: Magnetic Resonance Imaging (MRI) has emerged to be the best diagnostic imaging to evaluate the extent pelvic deep infiltrating endometriosis (DIE). Transvaginal sonography (TVS) is very accurate in diagnosing ovarian endometriomas but shows some diagnostic limits in the evaluation of the detection and extension of DIE. The aim of this study was to evaluate the accuracy of different sonographic approaches in the assessment of posterior DIE compared to laparoscopical and histological findings. Design: Patients with pelvic DIE underwent sonographic evaluation prior to laparoscopic surgery, using a transvaginal sectorial probe, first transvaginally (TVS) then transrectally (TRS). Furthermore vaginosonography was associated to the transrectal examination. Setting: University hospital. Patients: Fifty patients with pelvic DIE scheduled for laparoscopic surgery. Intervention: An accurate mapping of the extension of the disease was performed at sonographic examinations (TVS, TRS, vaginosonography) and during laparoscopy. The mapping was based on a detailed list of locations which described the endometriotic/fibrotic infiltrating tissue in terms of presence or absence on different sides of the posterior and anterior pelvis: pouch of Douglas, rectovaginal septum (RVS), uterosacral ligaments (USL), vaginal walls, rectal-sigmoid wall and bladder. Measurements and Main Results: The sensitivity in the diagnosis of endometriotic nodules of the USL and of the distal rectal and sigmoid wall was similar for TVS alone (88%, 90%) and after TRS and vaginography (89%, 90%). Whereas the accuracy in the diagnosis of