Nulligravid Women Research Articles

Prolapse worsens with age, doesn't it?

Female pelvic organ prolapse is common and generally thought to worsen over time. This assumption has recently become less plausible, as the author and others have been able to show that mild to moderate pelvic organ descent is common in young, nulligravid women. To investigate the relationship between age and pelvic organ prolapse. The records of 1110 women seen for interview, clinical examination, urodynamics and ultrasound were evaluated in a retrospective study. Data were analysed to investigate the relationship between patient age at presentation and pelvic organ descent on clinical examination and ultrasound imaging. After removal of 139 datasets of women with previous incontinence or prolapse surgery, 971 datasets remained. Mean age was 54 years (17-90), mean vaginal parity was 2.4 (0-12), with 31% complaining of prolapse. We found weak complex relationships between age and cystocele/rectocele staging, with a positive correlation to menopause and a negative relationship thereafter. This was confirmed on imaging findings, with regression showing an almost parabolic fitted line plot for cystocele and rectocele, but a near-linear curve for uterine prolapse. In nulliparous women, the positive relationship between age and cystocele in premenopausal women was still significant (P = 0.028), indicating that it is not explained by the confounding effect of child bearing. Ageing seems to play a complex role in the aetiology and pathogenesis of pelvic organ prolapse. Our results contradict epidemiological studies showing age to be a major risk factor for pelvic reconstructive surgery and pelvic organ prolapse.

When do involuntarily infertile couples choose to seek medical help?

To estimate the probability of medical consultation for infertility during the course of a pregnancy attempt and to study its determinants. Pregnancy-based retrospective telephone survey analyzed with a discrete time Cox model. Two rural counties in Brittany and Normandy, France. A random sample of 901 women from the general population aged 18-60 years reporting 1,460 pregnancy attempts resulting in a live birth between 1985 and 2000 (participation rate, 73%). None. Probability of medical consultation for involuntary infertility cumulated over time. The cumulative probability of medical consultation for involuntary infertility among nulligravid women was 45% after 12 months of involuntary infertility and 75% after 24 months. The probability of medical consultation at any time was half that for parous women (odds ratio 0.4, 95% confidence interval 0.2-0.6). More highly educated women were more likely to have sought medical help for infertility. Only 45% of women who had sought medical advice received infertility treatment. Our survival approach provides a description of infertility service use during the course of a pregnancy attempt, and confirms that parity and educational level are strong predictors of medical help-seeking behaviors.

Intrauterine Contraceptive Device in the Bladder

In Brief A 23-year-old nulligravid woman presented to our hospital with a misplaced copper T380 intrauterine contraceptive device (IUD) that was placed 2 months previously. The only symptom was pelvic pain and a history of severe pain at the time of insertion. She denied bladder or bowel symptoms. Diagnostic laparoscopy failed to identify the IUD and a laparotomy was performed at which time the IUD was palpable in the bladder and removed via a cystotomy at the dome of the bladder. This case emphasizes the bladder as one of the possible extrauterine locations that should be considered when looking for an IUD that has perforated the uterus. Ultrasonography to specifically examine the bladder or cystoscopy should be considered when other imaging fails locate the IUD in the endometrial cavity. A 23-year-old nulligravid woman presented with a misplaced copper T380 IUD placed 2 months previously. The IUD was found in the bladder.

Evaluation of office hysteroscopy in pre-menopausal and post-menopausal women: experience with 2,255 cases

To assess whether outpatient hysteroscopy without anesthesia confers any advantages over the traditional technique, we conducted a retrospective study. Participants consisted of 2,255 women who were referred to outpatient hysteroscopy at Alexandra Hospital from October 1991 to July 2007. The procedure was done without general or any other form of anesthesia; only in some cases was local anesthetic used. Diagnostic hysteroscopy was performed by means of a 2.7-mm hysteroscope and a 3.2-mm diagnostic sheath. The mean age was 36.37 years, 78.89% were nulliparous, and 94.01% were pre-menopausal. Hysteroscopy was successful in 98.40% of the participants. The morbidity ratio of the procedure was 0.13%. Cervical dilation was required in 10.15%. Local anesthesia was used in 7.36% of the participants. Indications included control of intrauterine cavity (36.49%), repeated failure of IVF infertility (27.45%), abnormal bleeding (4.1%), ultrasound indications (4.64%), amenorrhea (2.4%) oligomenorrhea (1.3%), monitoring of the endometrium because of tamoxifen therapy (1.46%), and a history of abortions (0.86%). Nulligravid women suffer significantly more often from endometrial atrophy and endometrial hyperplasia. The use of a 3.2-mm diameter hysteroscope proves that hysteroscopy without local anesthesia is a safe, well-tolerated method of assessing endometrial functional status in order to choose the most effective therapy.

Endometrial carcinoma in a patient having 45,X Turner syndrome with gonadal mosaicism

Only three cases of endometrial carcinoma in women with possibly pure 45,X Turner syndrome without previous unopposed estrogen therapy have been reported. A 46-year-old single nulligravid woman with Turner syndrome phenotype, spontaneous menstruation, and well-differentiated adenocarcinoma of the endometrium was diagnosed as having the 45,X karyotype from peripheral blood, skin, buccal cells, and endometrium, which was confirmed using fluorescence in situ hybridization (FISH). Analysis of the ovarian tissue using FISH confirmed 45,X/46,XX mosaicism. Gonadal mosaicism may help to interpret spontaneous menstruation and endometrial carcinoma in possibly pure 45,X Turner syndrome. We conclude that a molecular analysis of lymphocytes and various tissues is necessary for detecting low-level mosaicism in apparently homogeneous 45,X women.

Primary ovarian pregnancy after the empty follicle syndrome: A case report

A 32-year-old nulligravida woman underwent in vitro fertilization treatment because of 6 years of unexplained infertility. On the day of ovum pick-up, no eggs were retrieved and the patient was diagnosed to have empty follicle syndrome. Six weeks later, she presented with left lower abdominal pain and mild vaginal bleeding. Laboratory tests and diagnostic laparoscopy revealed left ovarian pregnancy. Left oophorectomy was performed and the histopathological examination confirmed the diagnosis.

Pregnancy and birth history influence women's experience of menopause

The determinants of experiencing menopausal symptoms are complex, representing biological, psychological, and social factors. We report the impact of one such factor, fertility, on the experience of menopausal symptoms. We hypothesize that nulliparous women will have more dissatisfaction with childbearing choices and more negative attitudes toward menopause but will experience fewer menopausal symptoms. Women aged 40 to 65 years were recruited from a single internal medicine practice to participate in a 5-year longitudinal study of the impact of menopause on health-related quality of life. Women completed questionnaires including the RAND-36, attitudes toward menopause, menopausal symptoms, and fertility and childbearing. Based on self-reported pregnancy and birth history, we categorized women as parous (one or more live births), nulligravida (no pregnancies or births), and nulliparous (one or more pregnancies and no live births). Categorical variables were analyzed using univariable and multivariable ordered logistic and logistic regression. Continuous variables were analyzed using Student's t test and multivariable linear regression techniques. The 728 participants were, on average, 50.8 years old with 2.4 pregnancies and 1.7 live births. Compared with parous women, nulligravida and nulliparous women were more likely to report being very dissatisfied with childbearing choices (odds ratio [OR] [95% CI]: 3.3 [2.3-4.6] and 4.0 [2.5-6.4], respectively). Nulliparous, but not nulligravida, women expressed more negative attitudes toward menopause compared with parous women (P<0.001). Nulligravida and nulliparous women were half as likely to report hot flashes as parous women (OR [95% CI]: 0.6 [0.4-0.9] and 0.5 [0.3-0.9], respectively). Compared with parous women, nulligravida women were less likely to report vaginal dryness (OR [95% CI]: 0.5 [0.3-0.7]). Our study examined the impact of pregnancy and birth history on menopausal symptoms, and the findings support the hypothesis that women who experience infertility may find menopause to be a time of normalcy and experience fewer hot flashes. Both physiologic and psychosocial mechanisms deserve further study.

Resectoscope or Versapoint for hysteroscopic metroplasty

ObjectiveTo assess the feasibility, safety, and reproductive outcome of hysteroscopic metroplasty using the Versapoint device compared with the resectoscope using the Collins loop. MethodsSixty-three women diagnosed with partial septate uterus were included in the study. Forty-two women underwent hysteroscopic metroplasty using Versapoint and 21 women had the procedure using the resectoscope. Operating time, complications, pregnancy rate, and mode of delivery were recorded. Data were analyzed with the Mann–Whitney test. ResultsOperating time was 20.5 min for the resectoscope group and 15.4 min for the Versapoint group (P<0.05). Pregnancy rate, delivery rate, and spontaneous abortions were similar in both groups. ConclusionOperative hysteroscopy with Versapoint does not require cervical dilation, thus avoiding cervical incompetence, cervical lacerations, and uterine perforation. The Versapoint technique is a safe and effective alternative to the resectoscope. It could be used predominantly in nulligravida women, especially in those with cervical canal stenosis.

Vaginal distribution of Replens® and K-Y® Jelly using three imaging techniques

Background Determination of vaginal distribution is important to the development of potential vaginal microbicidal or spermicidal products. Study Design This was a descriptive study of three imaging techniques with a randomized crossover assignment of two gels and activity status within each technique. Method Each of three sites utilized one technique. Three nulligravid women and three parous women were to be enrolled at each site. We studied the effects of time, ambulation, parity and body mass index on vaginal spreading of two commonly used gels, K-Y® Jelly and Replens®. Imaging by magnetic resonance imaging and gamma scintigraphy was performed at 5, 20, 35 and 50 min after insertion of 3.5 mL of gel. Imaging with a fiberoptic probe was performed at 5 and 20 min after insertion. Results Initial application of the gel resulted in approximately two thirds of maximum coverage possible, both in linear extent along the vaginal axis and in surface area covered. Over the next 45 min, spreading increased to about three quarters of the maximum possible. Ambulation generally increased linear spreading and the proportions of women with gel at the introitus and os. Effects of parity and body mass index (BMI) were similar on most measures of gel spreading, with nulligravid women tending toward greater spread than parous women and women of high BMI usually showing somewhat greater spread than women of normal weight. Differences between the two gels were not seen when all conditions of application were considered together. Conclusion In vivo imaging of gel distribution demonstrated that ambulation, parity and BMI affect vaginal gel spreading. The three imaging techniques have advantages and disadvantages and provide complementary information for microbicide development.

Increased rate of endometriosis and spontaneous abortion in an in vitro fertilization program: No correlation with epidemiological factors

Background. There are conflicting data concerning endometriosis and spontaneous abortion (SAB). The aim of the present study was to evaluate if there was any association between endometriosis and SAB. Moreover, we investigated risk factors in women with endometriosis and SAB.Methods. The medical files of 457 married women with endometriosis and 200 infertile women without endometriosis were studied retrospectively. All cases were diagnosed by laparoscopy. Data concerning demographic variables and menstrual characteristics were recorded from 226 women with endometriosis, which were divided into two groups. Group 1 included 126 cases with endometriosis and SAB, and Group 2 comprised 100 parous women with endometriosis and without SAB. Statistical comparisons between groups were made using the χ2 test and odds ratios (OR) and 95% confidence intervals (CI).Results. The proportion of SAB was significantly higher in women with endometriosis than in infertile women without endometriosis (126/457 (27.6%) vs. 36/200 (18.0% ); OR = 1.7, 95% CI 1.1 = 2.6; p = 0.01). The frequency of nulligravid women was significantly higher in women with endometriosis than in the control group (OR = 1.9, 95% CI 1.4 – 2.81; p = 0.001). Mean age, age at onset of endometriosis, race, height, weight, body mass index, medical history of allergies, and family histories of endometriosis and cancer were similar in women with endometriosis and SAB and in parous women with endometriosis but without SAB. Moreover, the two groups were similar in age at menarche, length of cycle, duration and amount of flow, and the severity of disease. The incidence of infertility was significantly higher in women with SAB (p < 0.001).Conclusion. These data suggest but do not prove that the risk of SAB is increased in women with endometriosis. The epidemiological risk factors of endometriosis are not associated with an increase in the abortion rate.

Unusual case of adenocarcinoma arising in endometriosis mimicking colorectal cancer in a young woman with a Müllerian anomaly

To report a case of endometrioid adenocarcinoma that arose in endometriosis mimicking colorectal cancer in a young woman with a Müllerian anomaly. A case report. A university hospital. A 31-year-old, white nulligravida woman with a history of two previous laparoscopies for infertility and chronic pelvic pain. A solid rectosigmoid mass adherent to the left pelvic sidewall was found in this patient. The patient was subjected to an exploratory laparotomy followed by adjuvant chemotherapy. Surgical findings and histopathological observations are included in this report. Intraoperative and histologic examinations revealed endometriosis-associated colorectal cancer. Although a rare event, this condition should be considered in the diagnosis of women with a previous history of pelvic endometriosis, Müllerian malformation, abdominal pain, constipation, or rectal bleeding.

Von Willebrand disease presenting as recurrent hemorrhage after transvaginal oocyte retrieval

A 34-year-old nulligravid woman experienced hemorrhage after each of 2 oocyte retrievals. Initial coagulopathy screening was negative. Treatments used during in vitro fertilization likely interfered with assay performance. Reevaluation remote from medications confirmed the diagnosis of von Willebrand disease. Treatments used during in vitro fertilization may increase bleeding risk and confound coagulopathy evaluation.

The non-communicating rudimentary horn: diagnostic and therapeutic challenges

We describe the case of a 23-year-old nulligravid woman who complained of increasing post-menstrual lower abdominal pain. She used contraceptives permanently for three months and was referred with a sub-mucosal lesion suspicious for a type 2 fibroid to be resected. During hysteroscopy, no fibroid mass could be confirmed. A post-operatively performed ultrasound including hydrosonography demonstrated a lesion highly suspicious for a uterus unicollis with a non-communicating uterine horn and a haematometra. Laparoscopy confirmed a normal outer lining of the uterus with hypoplastic tube on the right side. Referring to pre-operative findings, a broadly based uterine horn including a large haematometra was diagnosed. We performed a laparoscopic resection of the rudimentary horn and a right salpingectomy. The patient could be discharged without any complications three days later.

Long-term effects of ovulation-stimulating drugs on cancer risk

Although nulliparity has been extensively related to the risk of ovarian, breast and endometrial cancers, with many studies showing the relationship largely attributable to infertility, treatment effects on cancer risk are poorly understood. Two early studies raised substantial concern when ovulation-stimulating drugs were linked with large increases in ovarian cancer, supporting the notion of an important aetiological role of incessant ovulation. Subsequent studies have been mainly reassuring, although some have suggested possible risk increases among nulligravid women, those with extensive follow-up, and those developing borderline tumours. Results regarding effects of fertility drugs on breast cancer risk are conflicting, with some showing no associations and others demonstrating possible risk increases, although for varying subgroups. In contrast, endometrial cancer results are more consistent, with two recent studies showing increased risks related to clomiphene usage. This is of interest given that clomiphene is structurally similar to tamoxifen, a drug extensively linked with this cancer. Given the recent marketing of fertility drugs and the fact that exposed women are only beginning to reach the cancer age range, further follow-up is necessary. This will also be important to fully resolve effects of exposures such as gonadotrophins, used more recently in conjunction with IVF.

Are IUDs OK When STD Risk Is High

Recommendations concerning intrauterine device (IUD) use have changed during recent years, and the American College of Obstetricians and Gynecologists now states that “nulligravid or multiparous women at low risk for sexually transmitted diseases” (STDs) are appropriate candidates. In a study of almost 200 women in an urban university-based clinic population who (based on their STD risk) traditionally might not have been considered good candidates …

Ovarian cryopreservation with transposition of a contralateral ovary: a combined approach for fertility preservation in women receiving pelvic radiation

To describe a technique of fertility preservation by ovarian transposition combined with ovarian cryopreservation in the setting of oncologic pelvic radiation for a reproductive age woman. Case report. IVF center at a tertiary care hospital. Thirty-year-old nulligravid women who previously underwent lumbar spinal cord tumor debulking requested fertility preservation before pelvic radiation. Laparoscopic ovarian transposition with cryopreservation of the contralateral ovary. New technique in fertility preservation. Laparoscopic surgery was used to evaluate, select, and remove a single ovary that then underwent cryopreservation. Transposition of the remaining ovary was subsequently successfully performed, placing it of out of the pelvis. The combination of ovarian cryopreservation and ovarian transposition may maximize future fertility options for women facing pelvic irradiation. This combined approach should be included among the options offered to reproductive age women before pelvic radiation.

Pure non‐gestational choriocarcinoma of the ovary diagnosed by DNA polymorphism analysis

Pure primary ovarian choriocarcinoma is a rare condition that can be of gestational or non-gestational origin. Non-gestational choriocarcinoma has been found to be resistant to single-agent chemotherapy and has a worse prognosis than gestational choriocarcinoma, but it is difficult to distinguish the two types by routine histological examination. Herein is reported a case of primary pure non-gestational choriocarcinoma of the ovary in a 33-year-old nulligravid woman, as confirmed by DNA polymorphism analysis. All tested microsatellite markers had identical DNA profiles with the same allelic sizes between the tumor and the myometrium of the patient, who was homozygous for three markers (BAT26, BAT25 and D17S250) and heterozygous for four (D2S123, D18S57, DCC and D18S58), supporting non-gestational origin. The patient has no evidence of disease 17 months after surgery and four cycles of combination chemotherapy. This case demonstrates the usefulness of DNA polymorphism analysis for the determination of the origin of extrauterine choriocarcinoma. Clinical relevance of this method needs to be further studied and substantiated.

Menstrual Abnormalities in a Woman with Acth-Dependent Pituitary Macroadenoma Mimicking Polycystic Ovary Syndrome

Here, we present a case of ACTH-dependent pituitary macroadenoma (Cushing's disease) resulting in secondary amenorrhea mimicking polycystic ovary syndrome (PCOS). A 20-year-old nulligravid woman had been suffering from oligomenorrhea, amenorrhea, and moderate hirsutism since the age of 18 years. She visited a gynecologic clinic where PCOS was impressed according to the clinical manifestation and ultrasound finding. The patient responded to medication in the 1st year, but gradually failed to induce menses. She was advised to visit the endocrinology department for secondary amenorrhea and endocrine survey. Physical examination revealed central obesity, supraclavicle fatpad, abdominal striae, and myopathy of four limbs. Endocrine studies revealed: serum prolactin 21 ng/mL (3.0-20 ng/mL), FSH 5.69 mIU/mL (3.4-10.0 mIU/mL), LH 1.01 mIU/mL (1.1-11.6 mIU/mL), E2 < 20 pg/mL (follicular phase 53-258 pg/mL), ACTH 110 pg/mL (0-46.0 pg/mL), cortisol 26.7 microg/dL at 8 a.m. (5.0-25 microg/dL), cortisol 21.3 microg/dL at 11 p.m. (half of normal morning value). Right pituitary macroadenoma was diagnosed through a series of dexamethasone tests and MRI. The patient received staging surgery including transsphenoidal adenomectomy and right frontotemporal craniotomy. As a result, the patient's physical condition gradually improved, and her menstrual cycle became regular with medication after the operation in the outpatient follow-up. PCOS is a common disease resulting in secondary amenorrhea. However, Cushing's syndrome resulting from pituitary macroadenoma should also be considered. Therefore, a careful history, observation, physical examination, and endocrine studies can differentiate between patients with PCOS and Cushing's disease.

Failure of Laparoscopy to Relieve Ureteral Obstruction Secondary to Endometriosis

To present a case of hydronephrosis and hydroureter secondary to pelvic endometriosis and to discuss the pitfalls in laparoscopic management. A 37-year-old nulligravida woman had mild elevation of blood pressure for about 1 year without abdominal pain, dyspareunia, or dysmenorrhea. Renal ultrasound revealed left hydronephrosis and a 4-cm pelvic cyst. Intravenous pyelogram showed distal ureteral obstruction. An MRI with fat saturation disclosed a left ovarian endometrioma and a lesion in the uterosacral ligament causing periureteral compression. Laparoscopic findings included a dilated left ureter above the uterosacral ligament, left uterosacral ligament endometriosis with adhesions, and a 4-cm left ovarian endometrioma. Cystoureteroscopy showed external ureteral compression 2 cm above the ureteral orifice. A ureteral catheter was placed. The left endometrioma was enucleated and ureterolysis was performed. The latter procedure had to be discontinued because of bleeding from descending uterine vessels. The ureteral catheter was removed 2 months later and her blood pressure gradually returned to normal. However, after 1 year, she was found to have recurrent hydronephrosis and underwent segmental resection of the distal ureter and reconstruction by end-to-end reanastomosis. In women of reproductive age, hydronephrosis and hypertension may be the only symptoms of endometriosis. While laparoscopic treatment is useful in endometriosis, it may fail in the presence of chronic inflammation and severe fibrosis.

Leukemia inhibitory factor gene mutations in the population of infertile women are not restricted to nulligravid patients

Objective Leukemia inhibitory factor (LIF) is one of the key cytokines in the embryo implantation regulation. We investigated the prevalence of the LIF gene mutations in the population of infertile women that consisted of nulligravid and secondary infertile patients. Study design We designed a LIF gene mutation screening method that is based on the Temperature Gradient Gel Electrophoresis (TGGE). The population to screen consisted of 176 infertile women including group A of 147 nulligravid women and group B of 29 women with secondary infertility that had a history of either miscarriage or an ectopic pregnancy but no live births. The control population was comprised of 75 healthy fertile subjects. The groups of fertile controls and infertile patients were compared for statistically significant differences using the t-test. Results Six potentially functional LIF gene mutations, the G to A transitions at the position 3400 leading to the valin to methionin exchange at codon 64 (V64M) in the AB loop region of the LIF protein, were detected. All of the six positive women were infertile. Four of them were nulligravid and two of them had history of spontaneous conception followed by early miscarriage. No positive TGGE samples were identified in the control group, which means that the frequency of functionally relevant mutations of the LIF gene in infertile women is significantly enhanced in comparison with controls ( P < 0.05, t-test). Conclusion The results suggest that the LIF gene mutations affect fertility. Even though they occur infrequently, their impact on molecular events during early phases of pregnancy should be further established.