Between 2008 and 2010, four patients were treated for leiomyomatosis peritonealis disseminata, three were symptomatic and in one pelvic tumor was found during a routine pelvic examination. All four ...patients were in reproductive age and had never used any hormonal medication. Possible etiological factors were analyzed. The only common feature we found in these patients was laparoscopic myomectomy (in one additional laparoscopic supracervical hysterectomy 1 year after the first procedure) performed 3–11 years previously. Laparoscopy confirmed multiple myoma-like tumors and was converted to laparotomy in two patients; in the two patients, the tumors were removed laparoscopically. Laparoscopic myomectomy with morcellation could be an etiological factor for leiomyomatosis peritonealis disseminata. In selected cases and in experienced hands, the disease can be treated laparoscopically.
BACKGROUND
Advances in the diagnosis and treatment of malignancies in girls and young women had significantly increased survival rates, but surgical removal of the ovaries, potentially sterilizing ...radiotherapy or chemotherapy often result in premature ovarian failure, infertility and premature menopause. The degree of ovarian damage depends on the gonadotoxicity of chemotherapeutic agent and radiation dose, while surgical removal of the ovaries results in irreversible loss of ovarian function. Recently, with the purpose of fertility preservation, on one side, less radical surgical procedures in early stages of cancer are performed while on the other, advances in laboratory techniques in in vitro fertilization enable cryopreservation of own genetic material.CONCLUSIONS
While cryopreservation of embryos and oocytes is already an established and successful procedure, ovarian transplantation - despite reports of livebirths following the transplantation - still remains at experimental stage. The indication for fertility preservation should take into account type of cancer, prognosis of the disease, age (≤ 38 let), planned therapy, such as type of surgical procedure, gonadotoxicity of chemotherapeutic agents and irradiation dose, and therefore cooperation of oncologists, reproductive gynecologists and embryologists is mandatory, because each indication must be carefully taken into consideration.
Background. Endometriosis is an estrogen dependent disease that affects 5 − 20 % of women of reproductive age. Course of the disease is progressive and leads to a variety of symptoms that range from ...pain complaints to infertility. Some symptoms depend on the location of the break out. The most frequent symptoms are dysmenorrhea, dyspareunia, chronic pelvic pain and infertility. Endometriosis is also found in asymptomatic women. Clinical signs and symptoms with extrapelvic endometriosis are based on the involved organ system. Dysmenorhea may progress and begin prior to the onset of menses or become chronic and be noted throughout most of the menstrual cycle. Pain during menstrual cycle is estimated on 60–80 % of women with endometriosis. Dyspareunia is estimated on 25–50 % of women with endometriosis. It is frequently associated with rectovaginal and uterosacral ligament disease. It was established that advanced endometriosis is more frequently related to dysmenorrhea and deep dyspareunia in comparison with early disease. Chronic pelvic pain is defined as the pain that lasts 6 months and is not cyclic. In women being evaluated for pelvic pain, the diagnosis of endometriosis is made in 40–60 %, especially when it comes to deep infiltrative endometriosis. Infertility can be the only presenting symptom. The incidence of infertility in women with endometriosis is hard to establish. Some women with mild endometriosis are able to conceive, however this mild endometriosis can cause infertility. There is estimation that 20–30 % of women with endometriosis are infertile. Conclusions. Medical history is very important in recognizing the disease. Endometriosis does not threaten life but is associated with significant morbidity of women. It has a major impact on women’s health and life quality and represents a significant public health issue. Because the clinical signs and symptoms are complex and there is sometimes lack of the association between the stage of the disease and intensivity of symptoms, the disease can be diagnosed too late.
Background. Endometriosis is a comon, complex gynecological syndrom defined as the growth of endometrial glands and stroma in an extra-uterine location. It affects 5 – 20 % of women of reproductive ...age.1 Nowadays, prevailing opinion about endometriosis is based on presumption, that endometriosis is a result of changed immune system, according to autoimmune theory.2, 3 Characteristics of autoimmune disease that are also found in endometriosis are female preponderance, multiorgan involvement, family occurence, possible genetic basis, response to hormonal manipulation, tissue damage, polyclonal B lymphocite activation, immunological abnormalities in T lymphocite and B lymphocite function and associated autoimmune disease. Women with endometriosis are more frequently affected by asthma, rheumatoid arthritis, systemic lupus erythematosus, Sjögren syndrom and Hashimoto’s thyroiditis. Autoimmune disease is characterized by the production of autoantibodies against components of apoptotic cells. Anti-endometrial antibodies of IgG and IgM classes could be detected in 60 % of endometriosis patients. They show reactivity in glandular epithelium and stroma. Anti-endothelial antibodies specifically react with vascular endothelium and might be with anti-endometrial antibodies partially responsible for failure of implantation leading to infertility, wich is common in endometriosis patients. Anti-nuclear antibodies are frequent serological findings in patients with autoimmune disease, and could be detected in 29–47 % of women with endometriosis.4 Generation of anti-nuclear antibodies is a risk factor for development of other autoimmune disease in women of reproductive age. Studies have shown conflicting results on the presence of anti-ovarian antibodies in the serum of endometriosis patients and in the peritoneal fluid. Their presence is one of the possible causes of infertility. Conclusions. Ethiopathogenesis of endometriosis still remains uncelar but currently available data suggest that there are many similarites between endometriosis and such autoimmune diseases as rheumathoid arthritis, systemic lupus erythematosus, Sjögren syndrom etc. Important similarity is the presence of auto-antibodies. Autoimmune theory represents a challenge and at the same time opens the possibility of a new mode of treatement of endometriosis with immunomodulators.
Background. Many studies have shown significant reduction of fertility in endometriosis. Mechanisms of infertility are still not completely clear. The aim of our study is to obtain the effectiveness ...of laparoscopic treatment of infertility for different stages of endometriosis. Methods. The effectiveness of laparoscopic treatment of infertility in endometriosis was observed through a questionnaire that was sent to 281 patients (pts), who had laparoscopic treatment at the Department of Obstetrics and Gynecology Ljubljana during the period from 1999 to 2006 due to endometriosis as the only cause of infertility. 53.4 % (150/281) pts, who answered the questionnaire, were divided into group I (minimal and mild endometriosis) and group II (moderate and severe endometriosis). We established the rate of pregnancy (in total, spontaneous and ART) and compared the results between two groups. Relatively small percentage of answered questionnaires was most likely due to the fact that the questionnaires were sent to pts who were operated several years ago and did not respond or have changed their address. Because the study is still ongoing, we present partial results. Results. For 132 pts wanting to get pregnant the overall pregnancy rate was 76.5 % (101/132). The rate of pregnant pts depended on the stage of endometriosis. In group I 86.8 % (79/91) pts became pregnant – 58. 2 % (46/79) spontaneously, 41.8 % (33/79) with ART. In group II 53.6 % (22/41) pts became pregnant – 68.2 % (15/22) spontaneously, 31.8 % (7/22) with ART. The difference between groups was statistically significant (p < 0.05). Conclusions. Our results are comparable to the results found in the literature. Laparoscopic treatment of infertility is effective in all four stages of endometriosis. According to our results laparoscopic treatment has the primary role in the treatment of endometriosis-associated infertility
Abstract Background: Deep inltrating endometriosis (DIE) aects rectosigmoid in up to one third of patients. In these cases bowel resection with endto-end anastomosis is indicated. Our aim was to ...determine sensitivity, specicity, positive and negative predictive value and accuracy of rectal endoscopic ultrasound (REUS) for preoperative assessment of bowel in patients with DIE. Methods: In this retrospective study we included 72 patients who underwent surgery for DIE between 2004 and 2010 in University Medical Centre Ljubljana, Slovenia and had REUS preoperatively. REUS ndings were compared with intraoperative ndings and in case of bowel re-section also with patohistological ndings. Results: Bowel inltration was found in 29/72 (40 %) of patients during surgery. Bowel resection was performed in 23 patientsin all cases patohistological examination conrmed endometriosis. REUS correctly conrmed or excluded endometriosis in 60/72 (83 %) of patients, in one patient (1,4 %) it was false positive and in 11 patients (15 %) it was false negative. Sensitivity and specicity of REUS were 62 % and 98 %, respectively. Coefficient Kappa between REUS and surgery was 0,63. Conclusions: REUS should be used during pre-operative workup of patients with DIE as it can accurately diagnose bowel lesions in approximately 80 % of patients. The positive result of REUS is very reliable (specicity 98 %), however, negative result should be interpreted with caution due to limited sensitivity (62 %) of the examination. Indeed, REUS is false negative in approximately one third of patients. Therefore, additional preoperative examinations should be performed in case of negative result of REUS when bowel endometriosis is suspected.
To analyze the indications, surgical approach and pregnancy outcome in women undergoing surgical treatment of adnexal masses in pregnancy.
In this retrospective study, 51 women were enrolled. ...Preoperative sonographic appearance, the size of the tumor, patient's age, gestational age at the time of surgery and pregnancy outcome following a laparoscopic and/or laparotomy approach were evaluated. The data were obtained from the National Perinatal Informational System, National Cancer Registry, inpatient records, operative reports and pathology records, and responses to a questionnaire on pregnancy outcome mailed to all the patients.
Of the 51 pregnant women with adnexal masses, 27 were treated laparoscopically and 24 through laparotomy. Acute symptoms were the indication in 14 (27.4%) and tumor > 5 cm or sonographic appearance in 37 (72.6%). There were 44 (86.4%) benign and 7 (13.6%) malignant masses (4 borderline and 3 cancers). There were no differences in pregnancy outcome between emergency and planned surgery or between laparoscopy and laparotomy.
Surgical treatment of persistent adnexal masses in pregnancy, particularly those with a sonographic appearance of a complex tumor, is justified because of the high risk of torsion, rupture and malignancy. Immediate treatment of symptomatic masses permits conservative, fertility-preserving surgery and has no adverse effect on pregnancy outcome. Laparoscopic surgery and surgery in the first trimester do not impair pregnancy outcome.
Background: Endometriosis is often defined as heterogeneous immune abnormality. In accordance with the data, women with endometriosis are more frequently affected by Hashimoto’s thyroiditis, systemic ...lupus erythematosus, Sjögren syndrome, rheumatoid arhritis, asthma, eczema and have increased activity of policlonal B-cells, abnormal acitvity of T- and B-lymphocytes, decreased activity of natural killer cells and presence of antiendometrial antibodies. In our study, we tried to define the disease in the context of other autoimmune diseases and determine the type of immune abnormality. Methods: In the prospective study 60 females with endometriosis were inluded in the study group and 49 healthy females in the control group. The presence of endometriosis in the complex of other autoimmune diseases was evaluated by targeted family, personal and reendomeproductive history. The type of immune abnormality was evaluated by immunological analysis on the cell level: subtypisation of lymphocytes, cytotoxic and regulatory T cells and NK cells. On the humoral level, we defined antiovary, antiendometrial and antiendothelial antibodies. The results were statistically evaluated using the Pearson’s Chi-square test and Mann – Whitney test. Results: Patients with endometriosis are more frequently affected by allergies (p = 0.039). Five serums of endometriosis patients were positive for antiendothelial antibodies specifically reacting with vascular endothelium. There was statistically significant diference between the study and the control group in the proportion of regulated T lymphocytes (CD3+ CD25++) in the pherypheral blood (p = 0.025). Conclusions: We have not fully confirmed the hypothesis that women with endomeriosis have alterations in the immune response. However, the present study supports and adds important infomation to the views that immune abnormality plays an important role in the etiopathogenesis of endometriosis. On the humoral level, we showed the presence of antiendothelial antibodies reacting with vascular endothelium.
Background: Deep infiltrating endometriosis (DIE) affects rectosigmoid in up to one third of patients. In these cases bowel resection with end-to-end anastomosis is indicated. Our aim was to ...determine sensitivity, specificity, positive and negative predictive value and accuracy of rectal endoscopic ultrasound (REUS) for preoperative assessment of bowel in patients with DIE. Methods: In this retrospective study we included 72 patients who underwent surgery for DIE between 2004 and 2010 in University Medical Centre Ljubljana, Slovenia and had REUS preoperatively. REUS findings were compared with intraoperative findings and in case of bowel resection also with patohistological findings. Results: Bowel infiltration was found in 29/72 (40%) of patients during surgery. Bowel resection was performed in 23 patients - in all cases patohistological examination confirmed endometriosis. REUS correctly confirmed or excluded endometriosis in 60/72 (83%) of patients, in one patient (1,4%) it was false positive and in 11 patients (15%) it was false negative. Sensitivity and specificity of REUS were 62% and 98%, respectively. Coefficient Kappa between REUS and surgery was 0,63. Conclusions: REUS should be used during preoperative workup of patients with DIE as it can accurately diagnose bowel lesions in approximately 80% of patients. The positive result of REUS is very reliable (specificity 98%), however, negative result should be interpreted with caution due to limited sensitivity (62%) of the examination. Indeed, REUS is false negative in approximately one third of patients. Therefore, additional preoperative examinations should be performed in case of negative result of REUS when bowel endometriosis is suspected.
To find the incidence of ectopic pregnancy (EP) in patients who conceived in the IVF-ET program, and risk factors affecting the occurrence of EP.
We analyzed the effects of the indication for IVF, ...type of ovarian stimulation (hMG + hCG vs. GnRH + hMG + hCG), type of embryo transfer (transcervical intratubal, intrauterine in chest-knee position and intrauterine in lithotomy position) and number of embryos transferred on the occurrence of EP. EP was treated by laparotomy, prostaglandin E2 or laparoscopic surgery.
In 7991 stimulated and 92 natural cycles treated in the Ljubljana IVF-ET program between May 1983 and June 1994 we achieved 1059 pregnancies, of which 44 were ectopic (incidence 4.1%), the main risk being tubal factor infertility. There were 38 (86.3%) tubal, 3 (6.8%) heterotopic, 1 (2.4%) ovarian, and 2 (4.5%) cornual EP. In two patients multiple tubal EP occurred (1 twin, 1 triplet). Forty-two patients (95.4%) had tubal factor infertility, 1 (2.3%) unexplained, and 1 (2.3%) patient had male factor. The incidence of EP in patients with tubal infertility was 5.4%, in patients with unexplained infertility 2.0% and in those with male factor 0.9%. There appeared to be no correlation between the two superovulatory methods. With transcervical intrauterine ET the incidence of EP was 0 of 5 clinical pregnancies (CP); with intrauterine in chest-knee position it was 26 (3.5%) of 738 CP; with intrauterine in lithotomy position it was 17 (5.4%) of 316 CP. The difference between the two types of intrauterine ET is not statistically significant. The incidence of EP did not correlate with the number of embryos transferred. The average initial values of beta hCG performed 17 days after ET were significantly lower in patients with EP than in those with normal singleton pregnancy (157 +/- 143 mIU/ml vs. 408 +/- 148 mIU/ml).
EP can complicate the IVF procedure. The main risk factor is tubal infertility with or without previous tubal surgery. The low initial value of beta hCG has a strong predictive value in the diagnosis of EP.
