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Modified Uterine Transplant Procedure in the Sheep Model
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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.
125
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.
126
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.
127
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
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.
125
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.
126
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.
127
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