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A Randomized Trial on the Effects of Local Installation of Bupivacaine on Postoperative Pain after Operative Laparoscopy
oocyte-degeneration rates and abnormal fertilization rates especially when the zona pellucida is particularly thick and/or hard to be penetrated and when the oolemma is more fragile. This laser assisted ICSI procedure could be the method of choice in case of fragile oocytes or when only very few oocytes are obtained.
Wednesday, October 25, 2000 4:45 P.M. O-223 Pronuclear Formation of Human Oocytes Excluded from IVF-ET Program in an Oocyte Microsurgery Program.* 1S. H. Jun, 1,2J. M. Lim, 1 S. E. Park, 1,2H. M. Chung, 1,2H. Shim, 1,2K. Y. Cha. 1Infertility Medical Center of CHA General Hospital, 2College of Medicine, Pochon CHA University, Seoul, Korea. Objective: We have attempted to develop a pronuclear transfer system for rescuing unfertilized oocytes (UFOs) and developmentally incompetent oocytes (IOs) that excluded from IVF-ET program. This study was undertaken to establish an effective method for pronucleus (PN) formation of UFOs and IOs in the system. Design: Randomized, prospective study using human oocytes retrieved from stimulated cycle. Materials and Methods: Oocytes were retrieved from consenting patients stimulated with a long protocol using GnRHa and gonadotropins. In Experiment 1, mature oocytes with a first polar body (PB) were fertilized in vitro by our conventional IVF program and UFOs collected at 24 h after IVF were activated by one of following methods: 1) no treatment (control), 2) 10% ethanol, 5 min (ET), 3) 5 mg/ml calcium ionophore, 5 min (CI) and 4) a single electrical DC pulse of 1.5 kV/cm, 30 msec (EP). Treated UFOs were subsequently cultured in 100 ml droplets of TCM-199 medium at 37°C, 5% CO2 in air atmosphere and PN formation was evaluated by staining with Hoechst 33342 at 24 h after the treatments. In Experiment 2, IOs either arrested at the germinal vesicle (GV), GV breakdown (GVBD) to metaphase-I (MI) stage or classified as a mature oocyte with abnormal morphology at the time of retrieval were further cultured for 24 –28, 8 –15 and 0 h, respectively. IOs were then activated by the optimal protocol of Experiment 1 and PN formation was observed at 24 h after the treatment. Data from these experiments were analyzed by ANOVA and the least square method in PLOC-GLM of SAS. Results: In Experiment 1, there was a significant (P50.0001) treatment effect on PN formation in UFOs. No spontaneous activation was occurred in the control, but activation treatments induced PN formation with various efficacy (table 1). More UFOs formed PN after ET or EP treatment than after CI treatment and a highest proportion (64.3%) was obtained by ET. EP was as effective (63.5%) as ET, but fragmentation was observed in 20% of UFOs activated by EP. Proportion of UFOs that formed presumptive haploid PN (2 PNs 1 1 PB or 1 PN 1 2 PBs) was 33.3, 0 and 28.6% after ET, CI and EP treatments, respectively. In Experiment 2, a great (P50.0362) effect of IOs’ status on PN formation was found. IOs at the GVBD-MI oocytes had higher potential to form PN than those at the GV stage or with abnormal morphology (25 vs. 77.8%). Conclusion: The results of this study clearly demonstrated that the treatment of 10% ethanol for 5 min effectively induced PN formation of UFOs. IOs could form pronucleus with high efficacy by this ethanol treatment, as long as they grew beyond the GVBD stage and maintained morphological normality under the hormonal stimulation before oocyte retrieval. * Supported by a grant from the Interdisciplinary Research Program of the KOSEF (1999-2-205-002-5).
and Infertility, Department of Obstetrics and Gynecology, McGill University, Montreal, Quebec, Canada. Objectives: To evaluate insulin response to oral glucose tolerance test (OGTT) and adrenal steroid responses to ACTH stimulation in clomipheneresistant anovulatory women with polycystic ovary syndrome (PCOS) before and after laparoscopic ovarian drilling. Design: Prospective study. Materials and Methods: 20 clomiphene-resistant anovulatory women with PCOS underwent OGTT and ACTH tests before and after ovarian drilling. Results: Of a total 20 patients, 15 patients completed the study. 10 patients with the body mass index of .24 kg/m2 revealed evidence of insulin resistance. Positive correlation was found between serum insulin and body weight (r:0.6, P5.04). Insulin responses to OGTT before ovarian drilling at 215, 0, 30, 60 and 120 minutes were 192 6 108, 182 6 102, 863 6 534, 1074 6 713 and 1200 6 901 pmol/L and after drilling were 162 6 99, 158 6 98, 742 6 470, 963 6 660 and 1085 6 917 pmol/L respectively (P:NS). 17 a-OH progesterone responses to ACTH before and after ovarian drilling at 215, 0, 30 and 60 minutes were 2.9 6 1.3, 2.7 6 1.3, 8.9 6 9.4 and 10.4 6 4.4 nmol/L and 3.0 6 2.2, 2.7 6 2.9, 6.3 6 2.8 and 6.6 6 3.0 nmol/L respectively (P:NS). Conclusions: laparoscopic ovarian drilling does not influence insulin and adrenal steroids dynamics.
Wednesday, October 25, 2000 2:15 P.M. O-225 The Effect of Glucose on the Expression of Type I Collagen and Transforming Growth Factor-Beta 1 (TGF-b1) in Human Peritoneal Fibroblast Cells in Culture. G. Saed, W. Zhang, M. P. Diamond. Departments of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI. Objective: Since high glucose levels contribute to the pathogenesis of fibrosis in organs in diabetics, we hypothesized that high glucose may also stimulate extracellular matrix accumulation following peritoneal injury, thereby leading to adhesion development. A potential mediator for these effects is TGF-b1, a major profibrogenic factor produced by peritoneal tissues. Design: To test this hypothesis, we utilized the multiplex RT/PCR technique to determine the effect of increasing glucose concentrations on the mRNA levels of type I collagen and TGF-b1 in human peritoneal fibroblasts in culture (HPF). Materials and Methods: Primary cultures of HPF were incubated with varying amounts of glucose (0 –5 mg/L) for 24 hours in DMEM. Total RNA was extracted from HPF and converted to cDNA by reverse transcriptase. Multiplex RT/PCR simultaneously amplifying b-actin with TGF-b1 or type I collagen mRNAs in the same tube was developed in our laboratory to quantitate type I collagen and TGF-b1 mRNA levels in response to increasing glucose concentrations. PCR products were analyzed by agarose gel electrophoresis and density of each ethidium bromide stained band was measured by a scanning densitometer. Results: Multiplex RT/PCR showed that there was a significant increase in the mRNA for type I collagen and TGF-b1 in response to increasing glucose concentration. Conclusion: Increasing glucose concentration stimulated type I collagen expression in peritoneal fibroblasts in culture. A potential mediator for this effect may be TGF-b1. Our results suggest that individuals with diabetes mellitus may be at risk for greater levels of postoperative adhesions.
Wednesday, October 25, 2000 2:30 P.M.
THE SOCIETY OF REPRODUCTIVE SURGEONS Wednesday, October 25, 2000 2:00 P.M. O-224 Effects of Laparoscopic Ovarian Drilling on Serum Insulin and Adrenal Steroids in Women with Polycystic Ovary Syndrome. A. Saleh, D. Morris, S. Lin Tan, T. Tulandi. Division of Reproductive Endocrinology
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Abstracts
O-226 A Randomized Trial on the Effects of Local Installation of Bupivacaine on Postoperative Pain after Operative Laparoscopy. A. Saleh, G. Fox, A. Felemban, C. Guerra, T. Tulandi. Department of Obstetrics and Gynecology, and Department of Anesthesia. McGill University, Royal Victoria Hospital, Montreal, Quebec, Canada.
Vol. 74, No. 3, Suppl. 1, September 2000
Objectives: To evaluate the effects of local bupivacaine administration on immediate and late postoperative pain in women undergoing operative laparoscopy. Design: One hundred twenty participants undergoing laparoscopy for various gynecological indications were prospectively randomized into two groups: Group I, instillation of 10ml (25mg) of 0.5% bupivacaine into the trocar sites before incision, and 10ml of bupivacaine in 100ml of normal saline intraperitoneally at the completion of the procedure. Group II: instillation of equal volume of sterile saline into the trocar sites before incision, and intraperitoneally at the completion of the procedure (controls). Materials and Methods: A standard protocol for general anesthesia was used for all patients. All laparoscopic procedures were performed by the same surgeon using three-puncture techniques. After surgery, patients were observed in the recovery room for three hours. The recovery room personnel who were blinded to the study recorded return of consciousness, Modified McGill Pain Intensity scores, presence of nausea or vomiting, frequency and the dose of analgesic given. 24-hours after discharge each patient underwent a telephone interview for the presence of nausea and vomiting, pain intensity score, time and the amount of analgesic used. Results: A total of 112 patients completed the study (55 patients in group I and 57 patients in group II). There were no significant differences between the two groups in age, body mass index, surgical procedure performed, duration of surgery, return of consciousness, nausea or vomiting, Modified McGill Pain Intensity scores, time to first analgesic and mean analgesic medication used in the recovery room during the 3-hours observation and at 4, 8, 16, 20 and 24 hours after discharge. Conclusions: Local installation of bupivacaine is ineffective in reducing post laparoscopic pain.
Wednesday, October 25, 2000 2:45 P.M. O-227 Laparoscopic Management of Hydrosalpinges (HYDRO) Prior to In Vitro Fertilization-Embryo Transfer (IVF-ET): Salpingectomy vs. Proximal Tubal Occlusion (PTO)? E. S. Surrey, W. B. Schoolcraft. Colorado Center for Reproductive Medicine, Englewood, CO. Objectives: Several investigators have demonstrated that HYDRO may exert a deleterious effect on IVF-ET cycle outcome with improved results after surgical correction (Fertil Steril 1998;69:373– 84). The relative effects of different surgical interventions on ovarian blood supply and endometrial receptivity have not been demonstrated. The objectives of this study were to compare ovarian response and IVF-ET cycle outcome in patients with HYDRO managed by laparoscopic salpingectomy or PTO. Design: Retrospective chart review of all patients with a diagnosis of tubal factor infertility undergoing IVF-ET during a 12 month period in a tertiary care assisted reproductive technology program. Materials and Methods: All patients with a diagnosis of tubal factor infertility with early follicular phase FSH levels ,10 mIU/mL, E2 levels ,80 pg/mL, and hysteroscopically normal uterine cavities who were candidates for autologous IVF-ET were included (104 cycles). Patients were divided into 4 groups—Group I: HYDRO managed by laparoscopic salpingectomy (35 cycles); Group II: HYDRO managed by laparoscopic bipolar cautery PTO (17 cycles); Group III (Control): Tubal factor without HYDRO or prior bilateral tubal ligation (BTL) (37 cycles); Group IV (Control): Prior BTL for sterilization (15 cycles). There were no differences in HYDRO size or extent of adhesions between Grs. I and II. Response to controlled ovarian hyperstimulation (COH) and IVF-ET cycle outcome were evaluated. Pregnancy (PR) and implantation (IR) rates were defined as cardiac activity per ET procedure. Data analysis: Student’s grouped t-tests and chi square analysis as appropriate.
Group Cycles I II III IV
35 17 37 15
Age 35.1 6 0.7* 35.4 6 1.0†‡ 35.6 6 0.7 38.2 6 1.0
U.A. P.I.
COH days
3.1 6 0.3‡ 9.5 6 0.2‡ 3.4 6 0.4†‡ 10.1 6 0.4†‡ 2.9 6 0.2 9.8 6 0.2 2.6 6 0.1 9.3 6 0.3
FERTILITY & STERILITYt
COH ampules
Cancellation (%)
41.0 6 2.5‡ 51.1 6 3.9†‡ 43.5 6 2.7 43.3 6 3.4
17.1‡ 5.9†‡ 5.4 20
E2 day of hCG (pg/mL)
Oocytes
Embryos transferred
PR (%)
IR/ET (%)
2555 6 219‡ 2366 6 282†‡ 2925 6 259 2479 6 281
16.2 6 1.2‡ 14.4 6 1.8†‡ 17.5 6 1.8 12.2 6 1.3
2.8 6 0.2‡ 3.5 6 0.4†‡ 3.2 6 0.2 3.0 6 0.3
57.1‡ 46.7†‡ 52.9 58.3
29.2 6 5.9‡ 19.4 6 6.1†‡ 25.4 6 5.6 36.1 6 11.3
Conclusion: 1) Pre-IVF cycle management of HYDRO by laparoscopic salpingectomy or bipolar PTO yielded similar responses to COH and cycle outcome which were not significantly different from controls; 2) PTO may therefore be preferable in patients with HYDRO and dense pelvic adhesions with easy access only to the proximal portion of the fallopian tube.
Wednesday, October 25, 2000 3:00 P.M. SRS Prize Paper O-228 Assessment of Pelvic Adhesions: Statistical Validation, Reliability and Inter-Observer Correlation Using a Modification of the More Comprehensive Adhesion Scoring Method (MCASM). 1A. E. Bacevice, 2E. J. Bieber, 3R. C. Dunn, 4S. M. Rosenberg, 5K. M. Silverberg, 6A. Strandell. 1 St. John West Shore Hospital, Westlake, OH ; 2University of Chicago, Chicago, IL ; 3Texas Gynecologic Associates, Houston, TX ; 4Richmond Center for Fertility and Endocrinology, Richmond, VA ; 5Texas Fertility Center, Austin, TX ; 6Sahlgrenska Hospital, Go¨teborg, Sweden; 7Physicians Research Options, Salt Lake City; UT ; 8Gliatech Inc., Cleveland, OH ; 9 Boston Biostatistics, Inc., Framingham, MA ; 10Wayne State University, Detroit, MI. Objective: The MCASM (Fertil Steril, 62:984 – 88, 1994) is a method of scoring adhesions during pelvic surgery, and is based on the incidence of adhesions at 23 predetermined anatomical sites. A modified scoring system was developed by collapsing the 23 anatomical sites to 16 sites. The objective of this study was to test whether the less cumbersome 16 site modified scoring system provides a valid, reliable method for surgeons to assess adhesions at the time of laparoscopic pelvic surgery. Design: Eight gynecological surgeons independently reviewed the same eight videotapes of laparoscopic adhesiolysis surgeries. Outcomes measured were number of adhesions per patient, number of anatomical sites with adhesions for each patient, and estimated surface area of adhesions. Materials and Methods: Surgeons were trained as a group by an independent principal investigator surgeon on the standardized method for recording adhesions. The tapes were masked as to the identity of the operating surgeon, and reviewed by each surgeon in a randomized order (8 3 8 Latin Square design). Interobserver variability was evaluated using analysis of variance (ANOVA). Surgeon effect was tested using the F-statistic, and the intraclass correlation coefficient (r) and 95% confidence intervals (CI) were calculated as measures of reliability. Results: High reliability was observed for the number of adhesions, and the number of anatomical sites with adhesions (r50.728 [95% CI: 0.532, 0.925] and 0.721 [95% CI: 0.515, 0.927] respectively). Reliability was also positive for surface area of adhesions (r50.573, 95% CI: 0.356, 0.790). These positive reliability results were obtained despite some significant interobserver variability, indicating that variability among videotapes was greater than among surgeons. No differences in reliability were observed between the 16 and 23 site methods for sites or number of adhesions (both r.0.7), indicating validity of the modified scoring method. Conclusion: This modified 16-site MCASM provides a less cumbersome, yet comprehensive, valid and reliable method for surgeons to evaluate pelvic adhesions. (This project was supported by Gliatech Inc.)
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Wednesday, October 25, 2000 4:45 P.M. O-223 Pronuclear Formation of Human Oocytes Excluded from IVF-ET Program in an Oocyte Microsurgery Program.* 1S. H. Jun, 1,2J. M. Lim, 1 S. E. Park, 1,2H. M. Chung, 1,2H. Shim, 1,2K. Y. Cha. 1Infertility Medical Center of CHA General Hospital, 2College of Medicine, Pochon CHA University, Seoul, Korea. Objective: We have attempted to develop a pronuclear transfer system for rescuing unfertilized oocytes (UFOs) and developmentally incompetent oocytes (IOs) that excluded from IVF-ET program. This study was undertaken to establish an effective method for pronucleus (PN) formation of UFOs and IOs in the system. Design: Randomized, prospective study using human oocytes retrieved from stimulated cycle. Materials and Methods: Oocytes were retrieved from consenting patients stimulated with a long protocol using GnRHa and gonadotropins. In Experiment 1, mature oocytes with a first polar body (PB) were fertilized in vitro by our conventional IVF program and UFOs collected at 24 h after IVF were activated by one of following methods: 1) no treatment (control), 2) 10% ethanol, 5 min (ET), 3) 5 mg/ml calcium ionophore, 5 min (CI) and 4) a single electrical DC pulse of 1.5 kV/cm, 30 msec (EP). Treated UFOs were subsequently cultured in 100 ml droplets of TCM-199 medium at 37°C, 5% CO2 in air atmosphere and PN formation was evaluated by staining with Hoechst 33342 at 24 h after the treatments. In Experiment 2, IOs either arrested at the germinal vesicle (GV), GV breakdown (GVBD) to metaphase-I (MI) stage or classified as a mature oocyte with abnormal morphology at the time of retrieval were further cultured for 24 –28, 8 –15 and 0 h, respectively. IOs were then activated by the optimal protocol of Experiment 1 and PN formation was observed at 24 h after the treatment. Data from these experiments were analyzed by ANOVA and the least square method in PLOC-GLM of SAS. Results: In Experiment 1, there was a significant (P50.0001) treatment effect on PN formation in UFOs. No spontaneous activation was occurred in the control, but activation treatments induced PN formation with various efficacy (table 1). More UFOs formed PN after ET or EP treatment than after CI treatment and a highest proportion (64.3%) was obtained by ET. EP was as effective (63.5%) as ET, but fragmentation was observed in 20% of UFOs activated by EP. Proportion of UFOs that formed presumptive haploid PN (2 PNs 1 1 PB or 1 PN 1 2 PBs) was 33.3, 0 and 28.6% after ET, CI and EP treatments, respectively. In Experiment 2, a great (P50.0362) effect of IOs’ status on PN formation was found. IOs at the GVBD-MI oocytes had higher potential to form PN than those at the GV stage or with abnormal morphology (25 vs. 77.8%). Conclusion: The results of this study clearly demonstrated that the treatment of 10% ethanol for 5 min effectively induced PN formation of UFOs. IOs could form pronucleus with high efficacy by this ethanol treatment, as long as they grew beyond the GVBD stage and maintained morphological normality under the hormonal stimulation before oocyte retrieval. * Supported by a grant from the Interdisciplinary Research Program of the KOSEF (1999-2-205-002-5).
and Infertility, Department of Obstetrics and Gynecology, McGill University, Montreal, Quebec, Canada. Objectives: To evaluate insulin response to oral glucose tolerance test (OGTT) and adrenal steroid responses to ACTH stimulation in clomipheneresistant anovulatory women with polycystic ovary syndrome (PCOS) before and after laparoscopic ovarian drilling. Design: Prospective study. Materials and Methods: 20 clomiphene-resistant anovulatory women with PCOS underwent OGTT and ACTH tests before and after ovarian drilling. Results: Of a total 20 patients, 15 patients completed the study. 10 patients with the body mass index of .24 kg/m2 revealed evidence of insulin resistance. Positive correlation was found between serum insulin and body weight (r:0.6, P5.04). Insulin responses to OGTT before ovarian drilling at 215, 0, 30, 60 and 120 minutes were 192 6 108, 182 6 102, 863 6 534, 1074 6 713 and 1200 6 901 pmol/L and after drilling were 162 6 99, 158 6 98, 742 6 470, 963 6 660 and 1085 6 917 pmol/L respectively (P:NS). 17 a-OH progesterone responses to ACTH before and after ovarian drilling at 215, 0, 30 and 60 minutes were 2.9 6 1.3, 2.7 6 1.3, 8.9 6 9.4 and 10.4 6 4.4 nmol/L and 3.0 6 2.2, 2.7 6 2.9, 6.3 6 2.8 and 6.6 6 3.0 nmol/L respectively (P:NS). Conclusions: laparoscopic ovarian drilling does not influence insulin and adrenal steroids dynamics.
Wednesday, October 25, 2000 2:15 P.M. O-225 The Effect of Glucose on the Expression of Type I Collagen and Transforming Growth Factor-Beta 1 (TGF-b1) in Human Peritoneal Fibroblast Cells in Culture. G. Saed, W. Zhang, M. P. Diamond. Departments of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI. Objective: Since high glucose levels contribute to the pathogenesis of fibrosis in organs in diabetics, we hypothesized that high glucose may also stimulate extracellular matrix accumulation following peritoneal injury, thereby leading to adhesion development. A potential mediator for these effects is TGF-b1, a major profibrogenic factor produced by peritoneal tissues. Design: To test this hypothesis, we utilized the multiplex RT/PCR technique to determine the effect of increasing glucose concentrations on the mRNA levels of type I collagen and TGF-b1 in human peritoneal fibroblasts in culture (HPF). Materials and Methods: Primary cultures of HPF were incubated with varying amounts of glucose (0 –5 mg/L) for 24 hours in DMEM. Total RNA was extracted from HPF and converted to cDNA by reverse transcriptase. Multiplex RT/PCR simultaneously amplifying b-actin with TGF-b1 or type I collagen mRNAs in the same tube was developed in our laboratory to quantitate type I collagen and TGF-b1 mRNA levels in response to increasing glucose concentrations. PCR products were analyzed by agarose gel electrophoresis and density of each ethidium bromide stained band was measured by a scanning densitometer. Results: Multiplex RT/PCR showed that there was a significant increase in the mRNA for type I collagen and TGF-b1 in response to increasing glucose concentration. Conclusion: Increasing glucose concentration stimulated type I collagen expression in peritoneal fibroblasts in culture. A potential mediator for this effect may be TGF-b1. Our results suggest that individuals with diabetes mellitus may be at risk for greater levels of postoperative adhesions.
Wednesday, October 25, 2000 2:30 P.M.
THE SOCIETY OF REPRODUCTIVE SURGEONS Wednesday, October 25, 2000 2:00 P.M. O-224 Effects of Laparoscopic Ovarian Drilling on Serum Insulin and Adrenal Steroids in Women with Polycystic Ovary Syndrome. A. Saleh, D. Morris, S. Lin Tan, T. Tulandi. Division of Reproductive Endocrinology
S84
Abstracts
O-226 A Randomized Trial on the Effects of Local Installation of Bupivacaine on Postoperative Pain after Operative Laparoscopy. A. Saleh, G. Fox, A. Felemban, C. Guerra, T. Tulandi. Department of Obstetrics and Gynecology, and Department of Anesthesia. McGill University, Royal Victoria Hospital, Montreal, Quebec, Canada.
Vol. 74, No. 3, Suppl. 1, September 2000
Objectives: To evaluate the effects of local bupivacaine administration on immediate and late postoperative pain in women undergoing operative laparoscopy. Design: One hundred twenty participants undergoing laparoscopy for various gynecological indications were prospectively randomized into two groups: Group I, instillation of 10ml (25mg) of 0.5% bupivacaine into the trocar sites before incision, and 10ml of bupivacaine in 100ml of normal saline intraperitoneally at the completion of the procedure. Group II: instillation of equal volume of sterile saline into the trocar sites before incision, and intraperitoneally at the completion of the procedure (controls). Materials and Methods: A standard protocol for general anesthesia was used for all patients. All laparoscopic procedures were performed by the same surgeon using three-puncture techniques. After surgery, patients were observed in the recovery room for three hours. The recovery room personnel who were blinded to the study recorded return of consciousness, Modified McGill Pain Intensity scores, presence of nausea or vomiting, frequency and the dose of analgesic given. 24-hours after discharge each patient underwent a telephone interview for the presence of nausea and vomiting, pain intensity score, time and the amount of analgesic used. Results: A total of 112 patients completed the study (55 patients in group I and 57 patients in group II). There were no significant differences between the two groups in age, body mass index, surgical procedure performed, duration of surgery, return of consciousness, nausea or vomiting, Modified McGill Pain Intensity scores, time to first analgesic and mean analgesic medication used in the recovery room during the 3-hours observation and at 4, 8, 16, 20 and 24 hours after discharge. Conclusions: Local installation of bupivacaine is ineffective in reducing post laparoscopic pain.
Wednesday, October 25, 2000 2:45 P.M. O-227 Laparoscopic Management of Hydrosalpinges (HYDRO) Prior to In Vitro Fertilization-Embryo Transfer (IVF-ET): Salpingectomy vs. Proximal Tubal Occlusion (PTO)? E. S. Surrey, W. B. Schoolcraft. Colorado Center for Reproductive Medicine, Englewood, CO. Objectives: Several investigators have demonstrated that HYDRO may exert a deleterious effect on IVF-ET cycle outcome with improved results after surgical correction (Fertil Steril 1998;69:373– 84). The relative effects of different surgical interventions on ovarian blood supply and endometrial receptivity have not been demonstrated. The objectives of this study were to compare ovarian response and IVF-ET cycle outcome in patients with HYDRO managed by laparoscopic salpingectomy or PTO. Design: Retrospective chart review of all patients with a diagnosis of tubal factor infertility undergoing IVF-ET during a 12 month period in a tertiary care assisted reproductive technology program. Materials and Methods: All patients with a diagnosis of tubal factor infertility with early follicular phase FSH levels ,10 mIU/mL, E2 levels ,80 pg/mL, and hysteroscopically normal uterine cavities who were candidates for autologous IVF-ET were included (104 cycles). Patients were divided into 4 groups—Group I: HYDRO managed by laparoscopic salpingectomy (35 cycles); Group II: HYDRO managed by laparoscopic bipolar cautery PTO (17 cycles); Group III (Control): Tubal factor without HYDRO or prior bilateral tubal ligation (BTL) (37 cycles); Group IV (Control): Prior BTL for sterilization (15 cycles). There were no differences in HYDRO size or extent of adhesions between Grs. I and II. Response to controlled ovarian hyperstimulation (COH) and IVF-ET cycle outcome were evaluated. Pregnancy (PR) and implantation (IR) rates were defined as cardiac activity per ET procedure. Data analysis: Student’s grouped t-tests and chi square analysis as appropriate.
Group Cycles I II III IV
35 17 37 15
Age 35.1 6 0.7* 35.4 6 1.0†‡ 35.6 6 0.7 38.2 6 1.0
U.A. P.I.
COH days
3.1 6 0.3‡ 9.5 6 0.2‡ 3.4 6 0.4†‡ 10.1 6 0.4†‡ 2.9 6 0.2 9.8 6 0.2 2.6 6 0.1 9.3 6 0.3
FERTILITY & STERILITYt
COH ampules
Cancellation (%)
41.0 6 2.5‡ 51.1 6 3.9†‡ 43.5 6 2.7 43.3 6 3.4
17.1‡ 5.9†‡ 5.4 20
E2 day of hCG (pg/mL)
Oocytes
Embryos transferred
PR (%)
IR/ET (%)
2555 6 219‡ 2366 6 282†‡ 2925 6 259 2479 6 281
16.2 6 1.2‡ 14.4 6 1.8†‡ 17.5 6 1.8 12.2 6 1.3
2.8 6 0.2‡ 3.5 6 0.4†‡ 3.2 6 0.2 3.0 6 0.3
57.1‡ 46.7†‡ 52.9 58.3
29.2 6 5.9‡ 19.4 6 6.1†‡ 25.4 6 5.6 36.1 6 11.3
Conclusion: 1) Pre-IVF cycle management of HYDRO by laparoscopic salpingectomy or bipolar PTO yielded similar responses to COH and cycle outcome which were not significantly different from controls; 2) PTO may therefore be preferable in patients with HYDRO and dense pelvic adhesions with easy access only to the proximal portion of the fallopian tube.
Wednesday, October 25, 2000 3:00 P.M. SRS Prize Paper O-228 Assessment of Pelvic Adhesions: Statistical Validation, Reliability and Inter-Observer Correlation Using a Modification of the More Comprehensive Adhesion Scoring Method (MCASM). 1A. E. Bacevice, 2E. J. Bieber, 3R. C. Dunn, 4S. M. Rosenberg, 5K. M. Silverberg, 6A. Strandell. 1 St. John West Shore Hospital, Westlake, OH ; 2University of Chicago, Chicago, IL ; 3Texas Gynecologic Associates, Houston, TX ; 4Richmond Center for Fertility and Endocrinology, Richmond, VA ; 5Texas Fertility Center, Austin, TX ; 6Sahlgrenska Hospital, Go¨teborg, Sweden; 7Physicians Research Options, Salt Lake City; UT ; 8Gliatech Inc., Cleveland, OH ; 9 Boston Biostatistics, Inc., Framingham, MA ; 10Wayne State University, Detroit, MI. Objective: The MCASM (Fertil Steril, 62:984 – 88, 1994) is a method of scoring adhesions during pelvic surgery, and is based on the incidence of adhesions at 23 predetermined anatomical sites. A modified scoring system was developed by collapsing the 23 anatomical sites to 16 sites. The objective of this study was to test whether the less cumbersome 16 site modified scoring system provides a valid, reliable method for surgeons to assess adhesions at the time of laparoscopic pelvic surgery. Design: Eight gynecological surgeons independently reviewed the same eight videotapes of laparoscopic adhesiolysis surgeries. Outcomes measured were number of adhesions per patient, number of anatomical sites with adhesions for each patient, and estimated surface area of adhesions. Materials and Methods: Surgeons were trained as a group by an independent principal investigator surgeon on the standardized method for recording adhesions. The tapes were masked as to the identity of the operating surgeon, and reviewed by each surgeon in a randomized order (8 3 8 Latin Square design). Interobserver variability was evaluated using analysis of variance (ANOVA). Surgeon effect was tested using the F-statistic, and the intraclass correlation coefficient (r) and 95% confidence intervals (CI) were calculated as measures of reliability. Results: High reliability was observed for the number of adhesions, and the number of anatomical sites with adhesions (r50.728 [95% CI: 0.532, 0.925] and 0.721 [95% CI: 0.515, 0.927] respectively). Reliability was also positive for surface area of adhesions (r50.573, 95% CI: 0.356, 0.790). These positive reliability results were obtained despite some significant interobserver variability, indicating that variability among videotapes was greater than among surgeons. No differences in reliability were observed between the 16 and 23 site methods for sites or number of adhesions (both r.0.7), indicating validity of the modified scoring method. Conclusion: This modified 16-site MCASM provides a less cumbersome, yet comprehensive, valid and reliable method for surgeons to evaluate pelvic adhesions. (This project was supported by Gliatech Inc.)
S85