Vacuum aspiration: an efficient outpatient screening technic for endometrial disease

In an effort to find a safe, efficient, and inexpensive means of ruling out the existence of a neoplastic process causing abnormal vaginal bleeding form the uterine cavity, 103 patients over 34 years of age had preoperative aspiration (Vabra aspirator) of the endometrial cavity. The tissue obtained at the time of D&C and hysterectomy was correlated with that obtained by the outpatient diagnostic procedure. In this pilot study, the aspirator was 98% accurate in evaluating high-risk women with abnormal uterine bleeding for malignant disease. In the two neoplasms missed, both women had had a recent D&C.     

Incidence of leukemia in Krakow in the period 1980-1990]

OBJECTIVE: This study was done to compare costs, operating and recovery times, safety, and patient acceptance between (a) minimally invasive laparoscopic tubal ligation under sedation and local anesthesia and (b) conventional laparoscopic operating-room-based tubal ligations under general anesthesia. METHODS: Fourteen women desiring sterilization were randomized between tubal ligation under sedation/local analgesia versus general anesthesia. Procedures were performed by supervised residents previously unfamiliar with the minimally invasive technique. Hospital charges were used as a surrogate for cost. Operating or procedure room times, surgical complications, and recovery times were recorded. Patient acceptance was assessed using satisfaction surveys administered in the recovery room and again 1 week postoperatively. RESULTS: The cost of minimally invasive tubal ligation was significantly lower than for the conventional technique ($1,615+/-$134 vs $2,820+/-$110, p < 0.001). Surgical times were not different between the two procedures: 40.4+/-15 min for the conventional technique versus 32.9+/-10 min for minimally invasive surgery. However, the total in-room time required in the operating room significantly exceeded that for the procedure room technique (84+/-10 min vs 60+/-2 min, p < 0.05). Likewise, recovery time for the general anesthesia technique was longer (48+/-6 min vs 14+/-7 min, p < 0.03). No complications were encountered with either surgical method. Patient satisfaction for pain, fatigue, and days of missed work was similar between the two groups. CONCLUSIONS: The use of minimally invasive surgery to perform tubal ligation is advantageous over conventional laparoscopic tubal ligation under general anesthesia with regard to cost and time utilization. The minimally invasive technique appears to be easy to learn, safe, and well tolerated.     

Human endometrial perfusion after tubal occlusion

We examined variations in human endometrial microvascular perfusion across one menstrual cycle in women who had undergone tubal ligation and did not report unusual menstruation. Endometrial red blood cell flux was monitored by laser Doppler fluxmetry via a fibreoptic probe atraumatically inserted transvaginally into the uterus of each of 13 conscious volunteers. The observations obtained have been compared with those previously reported from a matched control group of women [B.J. Gannon et al., Hum. Reprod., 12, 132-139 (1997)]. Women who had undergone tubal occlusion for sterilization exhibited greater endometrial perfusion during menstruation (cycle days 0-5), at the time of ovulation (cycle days 13-16) and in the late secretory phase (cycle days 23-28) than occurred in controls. In addition, vasomotion in the study group was lower than that in controls in the early and late secretory phase (cycle days 17-22 and 23-28). Tubal occlusion appeared to alter endometrial perfusion. It is possible that the reported menstrual changes in women following tubal ligation are a consequence of altered endometrial perfusion; a possible causative relationship is discussed.     

Diagnostic value of hysterosalpingography and laparoscopy in infertile women

Tubal pathology with tubal blockage due to the pelvic inflammatory diseases is one of the most frequent causes of infertility in a woman [1]. The two most important diagnostic procedures which are used for evaluation of tubal patency are hysterosalpingography and laparoscopic hydrotubation [4]. SUBJECT: The aim of the study was the comparison of hysterosalpingographic and laparoscopic findings and determination of accuracy of these two procedures in the diagnosis of tubal patency. MATERIAL AND METHODS: We studied and compared the results of hysterosalpingography and laparoscopy in 102 infertile women who were operated on at the Narodni Front Hospital of Gynaecology and Obstetrics in Belgrade during 1993 and 1994. Of 102 operated women 47 women were with primary infertility and 55 with secondary infertility. The patients were from 20 to 41 years of age, the average 28 +/- 2.4 years. RESULTS: Of one hundred and two operated women tubal blockage was found in 94 (92.1%) patients. Unilateral hydrosalpinx was found by hysterosalpingography in 16 (15.7%) subjects and bilateral hydrosalpinx in 30 (29.4%) women. Unilateral hydrosalpinx was found by laparoscopy in 17 (16.1%) patients and bilateral hydrosalpinx in 32 (31.4%) subjects. The concordant findings by hysterosalpingography and laparoscopy in the diagnostics of unilateral hydrosalpinx were found in 76.5% of cases, and in bilateral hydrosalpinx in 70.4%. This difference was not statistically significant. Unilateral tubal blockage was identified by laparoscopy in 26 (25.5%) patients and bilateral in 27 (26.5%) subjects. The concordant findings by hysterosalpingography and laparoscopy in unilateral tubal blockage were found in 61.5% of cases, and in bilateral tubal blockage in 70.4% of women. The total concordant findings by hysterosalpingography and laparoscopy in tubal blockage were found in 65.7 of cases, and concordant findings after hysterosalpingography and surgery were noted in 61.7% cases. The findings by laparoscopy and surgery were in harmony in 86.3% patients. Ovarian abnormalities were found by laparoscopy and surgery in 22 (21.6%) women. Pelvic adhesions were found by laparoscopy in 42 women of 49 patients in whom pelvic adhesions were found during the operation. Uterine congenital anomalies were found by laparoscopy in 3 (2.9%), women and by hysterosalpingography in 6 (5.9%) patients. DISCUSSION: Of 102 operated women tubal blockage was found in 94 (92.2%) women. Unilateral tubal blockage was found in 38 (40.4%) patients, and bilateral tubal blockage in 56 (59.6%) subjects. Hysterosalpingographic and laparoscopic hydrotubation findings in the diagnosis of tubal patency were concordant in 65% of cases, hysterosalpingographic and operative findings in 61.7% of patients, and laparoscopic and operative findings in 86.3% of subjects. Although concordant findings of 65.7% were noted in this study, which were similar to findings of other authors, the percentage of 62.5% [4], and 76% was observed [5]. During the operation pelvic adhesions were found in 49 patients, and laparoscopic in 42 women only. Ovarian abnormalities were found by laparoscopy in 22 (21.6%) patients, while uterine fibroid was found in 10 (9.8%) subjects. Uterine congenital anomalies were found by hysterosalpingography in 6 (5.9%) cases and by laparoscopy only in 3 (2.9%) patients. The advantage of visual hysterosalpingography seems to be in identification of some congenital uterine anomalies. However, the advantage of laparoscopy is identified by the possibility of visualisation of some other pelvic abnormalities which may be the cause of infertility. CONCLUSION: There are some hysterosalpingographic and laparoscopic advantages and disadvantages in the diagnosis of infertility in women. Only by using both procedures accurate results can be achieved in the tubes, the uterus and the ovary, that can be a cause of infertility in women.     

Assessment with transvaginal ultrasonography of endometrial thickness in women with postmenopausal bleeding

OBJECTIVE: The aim of this study was to assess the use of transvaginal ultrasonography in measuring endometrial thickness in postmenopausal women with bleeding, thus to determine the least invasive treatment. STUDY DESIGN: We evaluated 168 women with postmenopausal bleeding by transvaginal ultrasonography and histological study of the endometrium. RESULTS: No cancerous or precancerous lesions were found when endometrial thickness was under 10 mm. The mean endometrial thickness in women with cancerous and precancerous lesions was 10.75 +/- 1.63 mm, while in non-pathological lesions it was 1.36 +/- 1.18 mm. CONCLUSIONS: To diagnose endometrial pathology, an endometrial thickness over 6 mm yields a sensitivity of 88.6%, a specificity of 90.6%, a positive predictive value of 92%, with 4.6% of false-positives and 4.6% of false-negatives (six small polyps and one irregular maturation). Although we are waiting for other prospective and multicentric studies, our present experience leads us to believe that Dilatation and Curettage (D&C) can be avoided in postmenopausal bleeding with endometrial thickness under or equal to 6 mm.     

Influenza-like episodes in HIV-positive patients: the role of viral and ''atypical'' infections

AIMS: To assess possible endometrial pathology and other factors influencing the presence of uterine cavity fluid in postmenopausal women. STUDY DESIGN: A random sample of 559 asymptomatic postmenopausal women, recruited from the total population, were examined by transvaginal sonography (TVS) for the presence of uterine cavity fluid. Women with uterine cavity fluid who had an endometrial thickness of > or = 8 mm (including fluid) were admitted for hysteroscopy and a dilatation and curettage (D & C), and those with <8 mm underwent a new TVS examination one year later. A medical history, including details regarding previous minor gynecological surgery, was taken from the women and from an age-matched control-group of women from the same population. RESULTS: Uterine cavity fluid was found in 8.9% (50/559) of the women. In four women with an endometrium measuring > or = 8 mm, curettage revealed polyps in three women and atrophy with a pyometra in one woman. At the one-year follow-up, 22 women who originally had an endometrial thickness<8 mm had an endometrial thickness of<5 mm; 11 women had no cavity fluid and in the remaining 11 the cavity fluid had decreased. In 17 women, endometrial thickness measured > or = 5 mm and subsequent histology showed 11 endometrial biopsies with atrophy, four endometrial polyps and two cervical polyps. The prevalence of uterine cavity fluid increased with increasing age (p<0.0001) and was increased in smokers (p<0.013) but was unaltered by the presence or absence of hormone replacement therapy (HRT). CONCLUSION: There were no indications that uterine cavity fluid was associated with malignancy. The prevalence of uterine cavity fluid increased with increasing age and was higher in smokers. We could not demonstrate an increased prevalence of fluid in HRT-users.     

Distortion of Palmaz-Schatz stent geometry following side-branch balloon dilation through the stent in a rabbit model

In this prospective study, we have compared women undergoing laparoscopic cholecystectomy, laparoscopic gynaecological surgery and laparoscopic minor gynaecological procedures (diagnostic, tubal, ligation) (n = 10 in each group) to determine if lower abdominal laparoscopy results in less postoperative pulmonary dysfunction than upper abdominal laparoscopy. Pulmonary testing was performed before operation, and 3 and 6 h after operation, on the first and second days after surgery. After operation, a significant reduction in forced vital capacity, forced expiratory volume in 1 s and peak expiratory flow rate occurred after laparoscopic cholecystectomy at each time. There were no significant changes after minor gynaecologic laparoscopy, whereas laparoscopic gynaecological surgery resulted in minor pulmonary dysfunction on the day of surgery only. We conclude that postoperative pulmonary function was less impaired after gynaecological laparoscopy than after laparoscopic cholecystectomy. This study suggests that the site of surgery is an important determinant of lung dysfunction after laparoscopy.     

Transvaginal ultrasonography and hysteroscopy in the diagnosis of endometrial abnormalities

STUDY OBJECTIVE: To investigate the value of transvaginal ultrasonography, aspiration biopsy, and hysteroscopy combined with curettage or directed biopsy in detecting endometrial pathology in women with abnormal uterine bleeding. DESIGN: Prospective, nonrandomized study. SETTING: A university-affiliated hospital. PATIENTS: One hundred twenty-two premenopausal and 78 postmenopausal women with abnormal uterine bleeding. INTERVENTIONS: The women underwent transvaginal ultrasonography (TVS) combined with aspiration Pipelle biopsy. They were scheduled for hysteroscopy and endometrial sampling by curettage or directed biopsy within 4 weeks. MEASUREMENTS AND MAIN RESULTS: Ultrasonographic findings were evaluated on the basis of final diagnoses established by hysteroscopy and histologic examination. The endometrium was measured at its thickest part in the longitudinal plane. In premenopausal women, endometrial thickness was measured during the early proliferative phase of the cycle. Ultrasound examination was considered negative if single-layer thickness was less than 5 mm in the absence of endometrial projections. In all other cases it was classified as positive. For postmenopausal women the cutoff point was 4 mm (single layer). In postmenopausal women with endometrial thickness less than 4 mm, as well as in premenopausal patients with negative TVS, the combination of TVS and aspiration biopsy missed only one case of atypical hyperplasia. In premenopausal patients TVS clearly detected 73% of polyps and myomata, permitting diagnostic and surgical hysteroscopy to be performed at the same time. In postmenopausal women with endometrial thickness 4 mm or greater, aspiration biopsy failed to detect two cases of atypical hyperplasia and one of focal adenocarcinoma. Pipelle sampling was technically infeasible in a woman with endometrial cancer because of a stenotic cervix. It also missed the majority of benign lesions (polyps and myomas). CONCLUSIONS: Transvaginal ultrasound seems to be an excellent initial diagnostic method, with high sensitivity in diagnosing endometrial abnormalities. Its combination with aspiration biopsy seems to be safe in women with a thin endometrium. Hysteroscopy is necessary in postmenopausal women with an endometrium of 4 mm or more, as well as in premenopausal patients with endometrial thickness more than 5 mm (preovulatory phase of the cycle) and in those with suspected polyps or myomas.     

Chlamydial genital infections and laparoscopic findings in infertile women

Several studies have shown that previous chlamydial genital infection, reflected by serological markers, is strongly associated with tubal damage leading to tubal infertility. In 105 women undergoing laparoscopy, multiple samples were collected from the lower (urethra and cervix) and upper (endometrium, peritoneal fluid, tubal lumen) genital tract, in order to isolate Chlamydia trachomatis in cell culture. Chlamydia trachomatis was isolated from at least one site in 13 (30.9%) of 42 infertile women with tubal infertility, in 5 (12.1%) of 41 women with unexplained infertility, in 1 of 4 women affected by acute salpingitis and in 1 (5.5%) of 18 women with endometriosis or uterine malformations. The latter group was the control group. Thirteen (65%) of the 20 positive women harboured Chlamydia trachomatis in their upper genital tract alone and 16 women were positive in one or both tubes. Only one of the positive women showed laparoscopic signs of acute pelvic infection. Four of the 5 positive women with unexplained infertility harboured Chlamydia trachomatis in the tubal lumen. This study confirms that chlamydial infection is strongly associated with tubal damage. It suggests that cervical cultures are inadequate for excluding a tubal infection and that chlamydial colonization of the tubal mucosa is possible in the absence of symptoms and laparoscopic signs of active infection.     

Changes of lipid peroxidation parameters in children being treated for cancer

STUDY OBJECTIVE: To determine sensitivity, specificity, positive predictive value, negative predictive value, and global diagnostic precision of hysteroscopic exploration in the diagnosis of endometrial hyperplasia and adenocarcinoma in women with abnormal uterine bleeding. DESIGN: Retrospective analysis. SETTING: University-affiliated hospital. PATIENTS: One thousand three hundred ninety-eight patients with abnormal uterine bleeding, 57.3% premenopausal and 42.6% postmenopausal. INTERVENTIONS: Diagnostic hysteroscopy and subsequent dilatation and curettage. MEASUREMENTS AND MAIN RESULTS: Endometrium was classified hysteroscopically as normal, atrophic, endometrial hyperplasia, and endometrial carcinoma. Histopathologic diagnosis was performed to determine the efficacy of hysteroscopy in diagnosing endometrial hyperplasia and adenocarcinoma. For endometrial hyperplasia in premenopausal women, sensitivity was 71.8%, specificity 96.4%, and global diagnostic precision 92.5%; in postmenopausal women, respective figures were 85. 1%, 100%, and 97.3%. For diagnosing adenocarcinoma in premenopausal patients, hysteroscopy was 100% sensitive, with specificity 99.4% and global diagnostic precision 99.5%; in postmenopausal women, respective figures were 100%, 99.4%, and 99.5%. CONCLUSIONS: In women with abnormal uterine bleeding, diagnostic hysteroscopy is a basic tool that allows precise diagnosis of endouterine lesions such as polyps and submucous myomas. It also is highly accurate for evaluating endometrial adenocarcinoma and hyperplasia.     

Cystoscopic findings consistent with interstitial cystitis in normal women undergoing tubal ligation

PURPOSE: We test the hypothesis that women without chronic pelvic pain or irritative voiding symptoms do not demonstrate petechial hemorrhages known as glomerulations that are characteristic of patients with interstitial cystitis. MATERIALS AND METHODS: A prospective cohort design was used for examination with cystoscopy and bladder distention of 20 asymptomatic women undergoing tubal ligation. Cystoscopy with the patient under general anesthesia was performed to inspect the bladder mucosa before and after distention at 70 cm. of water pressure for 2 or 6 minutes. Photographs of the right, posterior and left of the bladder surfaces taken before and after the distention were scored on a scale of 1 to 5 using a panel of standards. Five urologists blinded to the source of individual photographs independently evaluated 120 research images interspersed with 46 other pictures from a library containing images from 19 symptomatic patients with and without interstitial cystitis. RESULTS: A total of 20 normal women with a mean age plus or minus standard deviation of 29+/-6 years consented to participate in this trial during laparoscopic tubal ligation. Photographs of bladder sites before and after distention with 890+/-140 ml. were scored as 1.4+/-0.3 (before distention) and 3.1+/-1.1 (after distention) on the scale of 1 to 5. The increase in scores following distention in normal subjects was seen to the same degree and in the same proportion as in patients with symptoms of interstitial cystitis (8 of 19 symptomatic patients in this series met current diagnostic criteria for interstitial cystitis). Slight but significant differences were seen among sites in the bladder but not between 2 and 6-minute distention durations. CONCLUSIONS: Bladder mucosal lesions characteristically associated with irritative voiding symptoms and pelvic pain in patients diagnosed with interstitial cystitis were observed in asymptomatic women.     

Recovery of cytomegalovirus and herpes simplex virus from upper and lower genital tract specimens obtained from women with pelvic inflammatory disease

Lower genital tract specimens and endometrial biopsies from 147 women with pelvic inflammatory disease (PID) and surgical specimens (fallopian tubes, ovaries, or both) from 22 women with PID and 37 women without PID were cultured for cytomegalovirus (CMV) and herpes simplex virus (HSV), as well as for organisms commonly associated with PID. CMV was isolated from 39 cervical or endometrial samples from 30 (20.4%) of 147 women with PID and from ovaries or fallopian tubes from 5 (22.7%) of 22 women with PID, but CMV was not recovered from surgical specimens obtained from 37 women undergoing surgery for tubal ligation, ectopic pregnancy, or other gynecologic conditions (P = .005). HSV was isolated from cervical samples obtained from 5 (3.4%) of 147 women with PID but not from any endometrial or surgical specimens. These data suggest that CMV, but not HSV, may contribute to the pathogenesis of PID in some patients.     

Uterine fluid irrigation and absorption in hysteroscopic endometrial ablation

OBJECTIVE: To compare two techniques of irrigation flow control with regard to risk of absorption of uterine irrigation fluid during operative hysteroscopy. METHODS: We compared two techniques of uterine irrigation fluid outflow management-passive gravity outflow and direct connection of the outflow to wall suction-in a randomized controlled trial involving 40 women undergoing hysteroscopic endometrial ablation. The amount of fluid absorbed by each subject was calculated, as were operating time, uterine size, and endometrial pharmacologic preparation. Endometrial thickness and operator view were graded visually by the surgeon. RESULTS: The median (range) amount of irrigation fluid absorbed was 450 mL (0-2300) in the group in which passive gravity outflow was used and 0 mL (700 mL excess outflow to 300 mL absorption) in the group in which direct connection of the outflow to wall suction was used (P < .001). None of the other variables that might have influenced uterine irrigation fluid absorption (operating time, uterine size, pharmacologic endometrial preparation, or endometrial thickness) differed between the two groups. CONCLUSION: Connecting the outflow of the uterine irrigation system to wall suction is a simple and effective method of reducing the risk of fluid absorption during endometrial ablation.     

Comparative study of diagnostic hysteroscopy and transvaginal ultrasonography in patients with abnormal uterine hemorrhage during the peri- and post-menopausal period

BACKGROUND: The aim of this study was to determine the diagnostic value of hysteroscopy and transvaginal ultrasonography in patients with abnormal uterine bleeding (AUB) in the peri and postmenopausal period. METHODS: 302 patients with AUB, underwent hysteroscopy and in 86 cases, also a transvaginal ultrasonography before hysteroscopy was performed. Results were compared with the histological diagnosis. RESULTS: The diagnostic accuracy of hysteroscopy was very high in the cases of endometrial carcinoma (sensibility 100%, specificity 99%), and lower in the cases of endometrial hyperplasia (sensibility 69%, specificity 72%) and endometrial atrophy (sensibility 29% and specificity 97%). Sonography proved to be less reliable in the diagnosis of endometrial pathology (carcinoma: sensibility 57%, specificity 100%, hyperplasia: sensibility 62.5% specificity 63%). The results of this study show that sonography may be used as a first choice diagnostic test in the investigation of women with AUB. CONCLUSIONS: Hysteroscopy represent a second diagnostic step for achieving a proper histologic diagnosis.     

Platelet transfusion practice: time for renewed consensus

BACKGROUND: Bilateral tubal pregnancies are rare and are usually confirmed simultaneously during the same operation. We report a case in which the right salpingectomy was performed seven weeks before the left salpingectomy. When the right salpingectomy was done, the left uterine tube appeared entirely normal. CASE: A 38-year-old woman underwent laparoscopic surgery for suspected right tubal pregnancy. A right tubal pregnancy was found to have partially aborted into the peritoneal cavity. The left uterine tube was carefully inspected and appeared normal. Histopathology of the right tube showed products of conception and chorionic tissue. Seven weeks after surgery, the woman presented in hemorrhagic shock necessitating emergency laparotomy and left salpingectomy. Histopathology of the left tube confirmed the presence of chronic tissue. The patient did not have coitus between the two salpingectomies. CONCLUSION: The explanation of the presentation is uncertain. However, this case underscores the importance of careful follow-up of patients after laparoscopic surgery for ectopic pregnancies.     

Elevated antitoxin titers in a man with generalized tetanus

STUDY OBJECTIVE: To compare the outcome of in vitro fertilization and embryo transfer (IVF-ET) after laparoscopic surgery in women with endometriosis with that of patients with tubal factor infertility. DESIGN: Retrospective survey of hospital and office charts using a computerized worksheet. SETTING: Lin-Kou medical center of Chang Gung Memorial Hospital. PATIENTS: Sixty-seven women with minimal to mild or moderate to severe endometriosis. Women with tubal factor infertility without other associated disorders (60 cycles) made up the control group. INTERVENTIONS: Seventy-five consecutive cycles of IVF-ET were performed in these patients who failed to conceive after laparoscopic conservative surgery. MEASUREMENTS AND MAIN RESULTS: The concentration of serum estradiol on the day of human chorionic gonadotropin (hCG) injection, the day of hCG injection, clinical pregnancy rates per transfer, number of follicles larger than 14 mm, number of embryos transferred, and implantation rate were not significantly different between women with endometriosis and those with tubal factor infertility. The number of oocytes retrieved and number fertilized were decreased, and the basal level of follicle-stimulating hormone on cycle day 3 was higher in women with both degrees of endometriosis. Women in both endometriosis groups received more follicle-stimulating hormone and human menopausal gonadotropin than those with tubal factor infertility. CONCLUSIONS: The outcome of IVF-ET in patients with endometriosis after laparoscopic surgery did not differ from that in the group with tubal factor infertility, but the former required more ampules of gonadotropin to achieve the same response. The advantages of laparoscopic surgery in women with endometriosis should be probably correlated with success of IVF-ET.     

Ataxia-telangiectasia in the Japanese population: identification of R1917X, W2491R, R2909G, IVS33+2T-->A, and 7883del5, the latter two being relatively common mutations

Postmenopausal uterine bleeding is an indication to sample the endometrium for diagnostic purposes. The endometrial brush cytologies of 20 advanced postmenopausal women collected at the time of hysterectomy in order to benchmark the expected morphology of postmenopausal endometrial brushings were reviewed. No women had symptoms or gross findings of primary endomyometrial disease. Endometrium was collected at the surgical pathology laboratory using the Tao Brush and CytoRich Fixative System. After formalin fixation of the uterus, the entire endometrium was embedded for routine histology. Sixteen endometrial brushings and matched endometrial sections showed endometrial atrophy, one brushing showed many ciliated epithelial cells, and three brushings showed focal (less than 10%) epithelial-cell atypia. In two atypias, abnormal endometrial epithelial-cell sheets contained enlarged, clear nuclei with nuclear notches and grooves resembling papillary thyroid cancer. One case showed no histological counterpart to this finding. The other case showed thickening of the pericornual fundic endometrium with cystic glands. The third case with epithelial atypia showed abnormal endometrial-cell sheets with nuclei resembling atypical hyperplasia or type I endometrial adenocarcinoma; corresponding endometrial tissue sections showed rare, irregular glands and back-to-back gland clusters with equivalent nuclear features. Atypical epithelium may be found in atrophic uteri in the absence of gross endometrial thickening. This may be a common event related either to de novo intraepithelial dysplasia in a noncycling endometrium or to hyperplasia that has partly regressed with estradiol withdrawal. This study shows that, in addition to endometrial intraepithelial carcinoma (EIC), isolated atypical glands with morphological and immunohistochemical features of atypical hyperplasia or type I endometrial adenocarcinoma may be found in grossly normal advanced postmenopausal endometrium of asymptomatic patients. This atypical epithelium is readily apparent in endometrial brush preparations, but requires serial sectioning of the endometrium to be demonstrated histologically. We have not established the natural history of this lesion, and in the absence of EIC or gross endometrial thickening indicative of atypical hyperplasia, we do not know whether this degree of epithelial atypia should be an indication for hysterectomy.     

Endometrial biopsy

Endometrial biopsy is an important diagnostic tool for the evaluation of infertility and abnormal uterine bleeding. The documented safety and accuracy of the plastic endometrial sampling devices have made them popular for use in the office. The procedure requires limited equipment and supplies, and it is generally well tolerated without anesthesia. The pathology report can guide the treatment of benign lesions, including simple hyperplasia. The finding of cytologic atypia indicates a significant risk of progression to carcinoma, and hysterectomy should be considered. If symptoms persist despite a normal endometrial biopsy, further evaluation is recommended.     

Risk factors for ectopic pregnancy: a meta-analysis

OBJECTIVE: To review current knowledge on the risk of ectopic pregnancy (EP), with the exception of contraceptive methods. DESIGN: Meta-analysis. SETTING: Case control and cohort studies published between 1978 and 1994 in English, French, German, or Dutch, retrieved by Medline search, crossover search from the papers obtained, and hand-search on recent medical journals. PATIENTS: A total number of 6,718 cases of EP in 27 case control studies and 13,049 exposed women in 9 cohort studies. MAIN OUTCOME MEASURES: Detected studies were tested for homogeneity. If homogeneity was not rejected, Mantel-Haenszel common odds ratios (OR) and 95% confidence intervals were calculated. RESULTS: Previous EP, previous tubal surgery, documented tubal pathology, and in utero diethylstilbestrol (DES) exposure were found to be associated strongly with the occurrence of EP. Previous genital infections (pelvic inflammatory disease [PID], chlamydia, gonorrhoea), infertility, and a lifetime number of sexual partners > 1 were associated with a mildly increased risk. For gonorrhoea, PID, previous EP, previous tubal surgery, and smoking, a higher common OR was calculated when using pregnant controls compared with using nonpregnant controls. CONCLUSIONS: The strong risk in women with a previous EP, previous tubal surgery, documented tubal pathology, or in utero DES exposure justifies the exploration of a screening policy for EP among these women. If a risk factor reduces fertility chances, the OR detected when using pregnant controls is higher than the OR calculated using nonpregnant controls.     

Comparison of the cumulative probability of pregnancy after in vitro fertilization-embryo transfer by infertility factor and age

OBJECTIVE: To compare the cumulative probability of pregnancy after multiple IVF cycles by age and cause of infertility. DESIGN: A prospective study was done in which patients were followed from the time they registered for their first IVF cycle until they achieved a clinical pregnancy, withdrew from treatment, or study was terminated. PATIENTS, SETTING, TREATMENTS: Infertile women undergoing IVF-ET at the Cooper Institute for In Vitro Fertilization were enrolled in this study if the luteal phase leuprolide acetate (LA) and hMG controlled ovarian hyperstimulation (COH) regimen was used. MAIN OUTCOME MEASURES: Clinical pregnancy, as determined by a positive beta-hCG level and ultrasonographic confirmation of a gestational sac, and delivery rates based on number of women with live births were compared by infertility factor and age. RESULTS: The 3-month cumulative probability of pregnancy based on life table analysis was 33% in women with tubal factor who were < or = 35 years of age, 25% in women with tubal factor who were > 35 years of age, 30% for women with multiple factors who were < or = 35 years of age, and 14% for women with multiple factors who were > 35 years of age. The rate for the older women with multiple factors was significantly lower than that for the other groups. The delivery rates were lower for the women with multiple factors than for women under 35 with tubal factor only. CONCLUSIONS: There is a significant effect of age and infertility factor on pregnancy and delivery rates. Physicians should consider these factors in evaluating their patients' prospects for success in IVF-ET.