Previous Myomectomy Research Articles

Surgical removal of multiple mesenteric fibroids (Kg 4,500) by abdominal spread of previous laparoscopic uterine myomectomy

Huge and multiple mesenteric fibroids (4,500 Kg weight) are very unusual. In many cases they are mistaken for subserosal fibroids of the womb due to the proximity with uterine walls. When they have a rapid growth, the risk of becoming malignant (sarcoma) has not to be underestimated. Surgery is challenging to remove abdominal nodes.A case of a 40-year old woman, admitted to the hospital with abdominal masses occupying the entire cavity was reported. Both computerized tomography (CT) and ultrasounds (US) were not diriment for belonging of tumours. Clinical history of patient reports a laparoscopic removal of uterine fibroids, using the morcellator. Laparoscopy was performed four years before. Open surgery by means of a large transversal suprapubic laparotomy according to Pfannestiel was carried out. Multiple and huge mesenteric, peritoneal and intestinal tumours spread in the whole abdominal cavity were found, removed and examined by frozen section histology; in addition a series of small conglomerated myomas in the site of previous laparoscopic transumbilical route was taken away as well (the largest fibroid weighed Kg 3.500 and the all tumors removed 4,500 Kg); the result was benign (fibroids) and genital apparatus was preserved. Operation was challenging. Postoperative course was uneventful; after five days patient was discharged.This case is very interesting for many factors: A) many extra-uterine fibroids spread throughout abdominal cavity; B) considerable weight of the masses C) intraoperative and postoperative danger. Finally, due to involvement of previous laparoscopic transumbilical incision together with other findings, the hypothesis of post laparoscopic dissemination has to be considered. A case of so large extragenital abdominal fibroids following laparoscopic uterine myomectomy has never been published so far.

When it is oportune to avoid cesarean myomectomy? An analysis of possible factors influencing duration of treatment in the intensive care unit

Background: Cesarean myomectomy (CM) is a controversial issue, even relatively contraindicated in obstetric practice. Recent reports showed that CM is not associated with increased morbidity, but those are lacking the data about risks of intensive care unit (ICU) treatment. Aim: The authors evaluated the factors affecting the duration of ICU treatment in patients after CM. Material and Methods: The study included 57 women who underwent CM and were postoperatively admitted and treated in ICU. Correlation analysis was used to estimate the effect of various parameters on the duration of ICU treatment. Results: There was a highly significant correlation between duration of ICU treatment and number of postoperative transfusions (p=0.001), duration of surgery (p=0.007), intraoprative hemorrhage (p=0.008) and myoma diameter (p=0.009). Duration of ICU treatment was also correlated with gestational age, hypertensive syndrome in pregnancy, preoperative hematocrit and hemoglobin values, number of intraoperative transfusions, postoperative hemorrhage and repeated myomectomy. Conclusions: In our report, longer ICU tretment was required in cases of perioperative hemorrhage, prolonged surgeries and those requiring perioperative transfusion. Patients who have had previous myomectomy, with lower preoperative hemoglobine and hematocrit vaues and bigger myomas are at risk of prolonged ICU treatment.

Analysis of clinical, biological and obstetric factors influencing the decision to perform cesarean myomectomy.

Myomas in pregnancy are associated with a significantly higher risk for cesarean section (CS). Cesarean myomectomy (CM), i.e. myomectomy during cesarean section, has been the source of much debate and was considered relatively contraindicated for many years. However, some authors advise to perform routine myomectomy during CS. The aim of our study was to determine factors influencing the intraoperative decision to perform CM. A total of 185 patients with uterine myomas, who delivered by caesarean section during a 5-year period, were included in the study--102 patients underwent CM (study group) and 83 women underwent CS without myomectomy (control group). Clinical and obstetric data were recorded and processed for analysis. Using non-parametric correlation methods, we investigated the influence of different variables on the decision to perform CM. No differences were recorded between the two groups in terms of parity fetal presentation, gestational age, number of previous laparotomies, and previous myomectomy presence of diabetes and hypertension, indications and type of CS. Significant differences were detected in type and location of the myomas, contrary to their number and size, where no significant differences were registered. The most significant predictors of CM included age, surgical experience and type of myomas. CM is generally performed by experienced surgeons and in younger women. Also, it is more often performed in patients affected by pedunculated and subserosal myomas, and less frequent in case of intramural and multiple myomas.

The risk of uterine rupture after myomectomy: a systematic review of the literature and meta-analysis

Fibroids may give rise to specific obstetrical complications such as pain due to degeneration, fetal malpresentation, or placenta previa. For all these reasons, surgical resection of the fibroid may be indicated before a pregnancy is pursued. The occurrence of a uterine rupture is a rare but severe complication of myomectomy. This study seeks to review the risk of uterine rupture during pregnancy and/or labor after laparoscopic myomectomy in comparison with laparotomic myomectomy. A systematic search of the literature through search strategies in MEDLINE (PubMed) and Embase (Embase.com) from January 1970 up to March 2013 was performed. We used the following MeSH terms and free text words: gynecologic surgical procedures, gynecologic surgery, leiomyoma, fibromyoma, fibroids, myoma, uterine tumors, and pregnancy complication. Our data show that the risk of uterine rupture during labor and delivery is low (0.75 %). Compared with traditional open myomectomy, the risk of uterine rupture during pregnancy is not significantly higher after a laparoscopic approach (P = 0.119). More elective cesarean sections are performed after laparoscopic myomectomy compared with the conventional open technique (P = 0.001). Our conclusions are supported by statistical pooling of observational studies of generally low methodological quality. The risk of uterine rupture after myomectomy is low (0.75 %). The available evidence in the literature does no allow discouraging attempts for childbirth per viam naturalem after previous myomectomy, regardless of the technique used. Randomized studies are needed before definitive evidence-based recommendations can be given.

Solitary Abdominal Wall Leiomyoma: 2 Cases Reports with Immunohistochemical Stain Confirmation and Literature Review

Background: Abdominal wall leiomyoma is extremely rare in the literature. However the information of the previous reported cases was incomplete. Even some cases which were diagnosed before were actually desmoid tumors, because these two diseases are very similar clinically, radiologically and pathologically. In this article we propose that, the definite diagnosis must be under immunohistochemical (IHC) stain. Method: Two 36-year-old female with the history of previous laparoscopic myomectomy suffered from palpable mass in the abdominal wall near the trocar site. Surgical intervention with excision biopsy of the mass was done. The specimen was sent for both conventional Hematoxylin and Eosin (H&E) a nd immunohistochemical (IHC) stain . Results: Both H&E a nd IHC stain confirmed leiomyoma . The two patients recovered well, without recurrence. Conclusions: Abdominal wall leiomyoma may relate to the previous myoma fragment retain at the trocar site of laparoscopic myomectomy and regenerate. However, the diagnosis of leiomoma should be under IHC stain confirmation, because it may easily get confused with desmoid tumors. Financial disclosure statement: None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript.

Primary Parasitic Leiomyoma in a Postmenopausal Woman With Neovascularisation From Omentum

Primary Parasitic Leiomyoma in a Postmenopausal Woman With Neovascularisation From Omentum Objective: We present a rare case of primary parasitic leiomyoma in a postmenopausal woman with neo-vascularization from blood vessels in the Omentum. The published literature on primary parasitic leiomyoma is very limited and is usually reported as an unexpected incidental finding, without mention of prevalence rate. The aim of presenting this case is to document the occurrence of rare primary parasitic leiomyoma, and to review the available literature. Materials and Methods: Case details and review of literature. Results: A 50 years old postmenopausal woman presented with complaints of one episode of postmenopausal bleeding, vague dyspeptic symptoms and occasional abdominal pain, of six months duration. There was no history of previous uterine myomectomy surgery. Patient was obese and had a well-defined suprapubic mass of 16 weeks gravid uterus size. Imaging studies were inconclusive about the origin of the mass and tumor markers were within normal range. With a provisional diagnosis of benign ovarian tumor, the patient underwent exploratory Laparotomy. A mass of size 12 x 11 cm was found impacted in the pouch of Douglas. It was attached to the uterus by a thin a vascular pedicle, and was adherent anteriorly to the Omentum and loops of small intestine. There were multiple blood vessels running from the Omentum to the mass. Histopathology confirmed the mass to be a leiomyoma. Conclusion: Parasitic myomas present with nonspecific symptoms. Their infrequent occurrence and unusual location pose a diagnostic and management dilemma. Imaging studies are usually inconclusive and the mass is usually mistaken for a solid ovarian or retroperitoneal tumor. A definitive diagnosis is made only at surgery and confirmed by histopathology.

Complications during cesarean delivery in a patient with two previous myomectomies

Myomas are associted with numerous pregnancy-related maternal and fetal complications, including high rate of cesarean deliveries. We present a woman with huge posterior myoma who had two previous myomectomies. During the cesarean section, the anatomy was found to be grossly distorted. Thus it was necessary to make an inverted T-incision on the uterus, which facilitated delivery of the fetus. The patients postoperative recovery was uneventful. This case illustrates the difficulties that may arise during cesarean section in the presence of uterine myomas in women with previous myomectomies. Clinicians should be prepared to manage those difficulties with inverted T-incision in order to prevent fetal injuries. Such operations should be performed by an experienced obstetrician.

Placenta accreta : dépistage, prise en charge et complications

Abnormal placental invasion can result in major obstetric haemorrhage during delivery. The most important risk factors are the following: previous caesarean delivery, placenta praevia maternal age over 35, smoking, previous myomectomy, dilatation and curettage. When placenta accreta is suspected on ultrasound, an RMI can complete the diagnostic. Therefore, patients must be managed, as far as possible, in a reference centre, by a trained medical team. Birth must be planned in order to decrease complications rate. Treatment can consist in radical management (caesarean-hysterectomy) or conservative management (preservation of both uterus and placenta). Conservative management allows patients to keep fertility but can also decrease blood loss during delivery. Side effects of this therapy are secondary haemorrhage, sepsis, long-term follow-up and vaginal loss. There are few studies describing fertility after conservative management, but it seems to be a secure treatment for future pregnancies. Embolization can be a very useful, already demonstrated, help when massive haemorrhage occurs. Management of placenta accreta is multidisciplinary and patients must be informed of all options. Treatment is decided regarding history of the patients, operative findings and peri-partum blood loss.

Incidence and Risk Factors for Clinical Failure of Uterine Leiomyoma Embolization

RESULTS: Overall, there were 18 failures at a median of 36 months (range 3–84 months). The cumulative failure rate increased steadily over time, 3% at 1 year, 7% at 3 years, 14% at 5 years, and 18% at 7 years. Of the 18 failures, 11 had reintervention, including six hysterectomies, four myomectomies, and one repeat uterine leiomyoma embolization, at a median of 56 months (range 15–84 months). The cumulative reintervention rate was 0 at 1 year, 3% at 3 years, 7% at 5 years, and 15% at 7 years. Women aged 40 years or younger had a higher failure risk (hazard ratio [HR] 5.89, 95% confidence interval [CI] 2.50–20.02, P.023) compared with older women. A history of previous myomectomy was also associated with an increased failure risk (HR 3.79, 95% CI 2.07–13.23, P.037). CONCLUSION: The 7-year cumulative rates of clinical failure and reintervention after uterine leiomyoma embolization were 18% (95% CI 8.2–27.8) and 15% (95% CI 5.2–24.8), respectively. The failure risk was higher for younger patients and for those with a prior myomectomy. LEVEL OF EVIDENCE: III

Incidence and Risk Factors for Clinical Failure of Uterine Leiomyoma Embolization

To estimate the incidence of clinical failure after uterine leiomyoma embolization and identify possible risk factors. One hundred seventy-six consecutive women undergoing uterine leiomyoma embolization were followed prospectively for a median of 48 months (range 12-84 months) to estimate the occurrence of clinical failure, defined as persistence or recurrence of leiomyoma symptoms, and any subsequent invasive treatment. Cumulative failure and reintervention rates were estimated by survival analysis and log-rank tests according to baseline patient characteristics. Multivariable Cox proportional hazards analysis was performed to adjust for confounders. Overall, there were 18 failures at a median of 36 months (range 3-84 months). The cumulative failure rate increased steadily over time, 3% at 1 year, 7% at 3 years, 14% at 5 years, and 18% at 7 years. Of the 18 failures, 11 had reintervention, including six hysterectomies, four myomectomies, and one repeat uterine leiomyoma embolization, at a median of 56 months (range 15-84 months). The cumulative reintervention rate was 0 at 1 year, 3% at 3 years, 7% at 5 years, and 15% at 7 years. Women aged 40 years or younger had a higher failure risk (hazard ratio [HR] 5.89, 95% confidence interval [CI] 2.50-20.02, P=.023) compared with older women. A history of previous myomectomy was also associated with an increased failure risk (HR 3.79, 95% CI 2.07-13.23, P=.037). The 7-year cumulative rates of clinical failure and reintervention after uterine leiomyoma embolization were 18% (95% CI 8.2-27.8) and 15% (95% CI 5.2-24.8), respectively. The failure risk was higher for younger patients and for those with a prior myomectomy. III.

Adenomyosis reduces pregnancy rates in infertile women undergoing IVF

High-resolution transvaginal ultrasound has facilitated the diagnosis of adenomyosis. This study determined the prevalence of this finding in infertile women and its effect on the outcome of IVF/intracytoplasmic sperm injection (ICSI). This prospective study evaluated 275 consecutive women, commencing IVF/ICSI for the first time. Inclusion criteria were adequate ovarian reserve. Women with fibroids or a previous myomectomy were excluded. All women were screened for adenomyosis by transvaginal ultrasound on three separate occasions. The control group included 256 women and the adenomyosis group included 19 women. There was no significant difference in the ages of women, FSH, cause of infertility, body mass index, total dose of gonadotrophin used and number of oocytes collected between the two groups. However, women with adenomyosis had a higher mean antral follicle count (P=0.006). The clinical pregnancy rate (22.2% versus 47.2%) and ongoing pregnancy rate (11.1% versus 45.9%) were significantly lower in women with adenomyosis and the miscarriage rate (50.0% versus 2.8%) was significantly higher in women with adenomyosis (all P<0.001). Ultrasound evidence of adenomyosis is found in a significant number of women presenting with infertility and has a negative impact on the outcome of IVF/ICSI.This paper suggests that a common condition known as adenomyosis is associated with a reduced success following fertility treatment such as IVF. The diagnosis of adenomyosis has been greatly facilitated by the advent of high-resolution transvaginal ultrasound. This was a study including 275 consecutive women who were commencing IVF for the first time. Comparing women who did not have adenomyosis and those that did, the clinical and ongoing pregnancy rates were both lower in women with adenomyosis (22.2% versus 47.2% and 11.1% versus 45.9%, respectively). So, fewer women with adenomyosis became pregnant and had an ongoing pregnancy. The miscarriage rate was higher in women with adenomyosis compared with those without (50.0% versus 2.8%). We conclude that ultrasound evidence of adenomyosis is found in a significant number of women presenting with infertility and has a negative impact on the outcome of IVF.

Factors associated with complications and conversion to laparotomy in women undergoing laparoscopically assisted vaginal hysterectomy

To identify risk factors for complications and conversion to laparotomy in women undergoing laparoscopically assisted vaginal hysterectomy (LAVH). Retrospective study. Tertiary referral hospital. All 2012 consecutive women who underwent LAVH for non-malignant diseases in a single institution. Retrospective study. Operative complications and conversion to laparotomy. Most of the LAVHs were successful, but conversion to laparotomy was required in 97 women (4.8%) because of pelvic adhesion (n= 71), large uterine size (n= 18) or bowel injury (n= 8). There were 45 women (2.2%) with complications (bladder injury, 26; bowel injury, 9; vascular injury, 9; and ureteral injury, 1). A history of previous cesarean section (twice or more) was a significant risk factor for complications [odds ratio (OR) 3.38]. A body mass index ≥30 kg/m(2) (OR 2.98), history of previous myomectomy (OR 6.19) and uterine weight ≥500 g (OR 3.24) independently influenced the risk of conversion to laparotomy. Risk factors identified in this study include a history of previous cesarean section (twice or more) and myomectomy, body mass index ≥30 kg/m(2) and uterine weight ≥500 g. The findings may be useful in counseling women preoperatively about the potential complications of LAVH.

Large parasitic myomas in abdominal subcutaneous adipose tissue along a previous myomectomy scar

The incidence of iatrogenic parasitic uterine myomas associated with the use of a laparoscopic morcellator has been increasing over the past decade. Recently, we encountered a very rare case with a large parasitic myoma measuring 12 cm in diameter in the abdominal subcutaneous adipose tissue along an abdominal longitudinal surgical scar. The patient had twice undergone abdominal myomectomy for multiple fundal myomas. This is the first report describing a case with as large a parasitic myoma presenting in the suprafascial adipose tissue under the surgical scar after laparotomy. In such a case demonstrating a solid tumor of unknown cause after a gynecologic surgical procedure, a parasitic myoma must be included in the differential diagnosis.

Placenta Accreta - Still a Dilemma

Objectives: To determine the etiological risk factors and outcomes of placenta accreta. Study Design: Descriptive study. Setting: Gynae Unit III Jinnah Hospital, Lahore. Duration of Study: Two years from 1 st Sept 2009 to 31 st Aug 2011. Materials and Methods: All the patients who pre-sented with suspected placenta previa, previous cesa-rean section or myomectomy scar and previous D&C in OPD and emergency department were included in the study. Trans-abdominal ultrasound was carried out in all the patients when diagnosed or had suspicion of placenta accrete it was confirmed by color Doppler. MRI was carried out in those patients who had anterior placenta previa along with placenta accreta. Data regarding age, parity, booking status and previ-ous obstetric history were recorded and analyzed. Results: During the study period there were 9046 deliveries and 13 patients presented with placenta acc-reta giving the incidence of 1 in 695 deliveries. Majo-rity of all patients (84.61%) with placenta accreta were between 31 – 35 years of age. Seventy seven percent were multi gravidae and 23% were grand multi gravi-dae. More than 2/3 rd of the patients were booked. Forty six percent of the patients had previous 2 C/S, 38.5% had previous 3 C/S and 15.5% had H/O D&C. In 77% placenta previa was present along with placenta acc-reta. All the patients with placenta accreta were opera-ted under General anaesthesia and had hysterectomy. There was no maternal deaths. Conclusion: Placenta accreta is an obstetric catastro-phe associated with high maternal and perinatal morbi-dity and mortality in developing countries. Antenatal care should be improved and all patients with previous C/S should have USG to diagnose placenta previa and accreta. This study showed a strong association of pla-centa accrete with previous C/S, placenta previa and previous D&C.

Uterine Artery Embolization Complicated by Uterine Perforation at the Site of Previous Myomectomy

A 46-year-old woman had an unusual complication from uterine myoma embolization by development of extensive necrosis with subsequent uterine perforation at the location of a previous myomectomy. We suggest that a scarred uterus may be a risk factor for uterine fibroid embolization complications, such as uterine necrosis.

Intestinal adhesion due to previous uterine surgery as a risk factor for delayed diagnosis of uterine rupture: a case report

IntroductionUterine rupture is a life-threatening condition both to mothers and fetuses. Its early diagnosis and treatment may save their lives. Previous myomectomy is a high risk factor for uterine rupture. Intestinal adhesion due to previous myomectomy may also prevent early diagnosis of uterine rupture.Case presentationA 38-year-old primiparous non-laboring Japanese woman with a history of myomectomy was admitted in her 34th week due to lower abdominal pain. Although the pain was slight and her vital signs were stable, computed tomography revealed massive fluid collection in her abdominal cavity, which led us to perform a laparotomy. Uterine rupture had occurred at the site of the previous myomectomy; however, the small intestine was adhered tightly to the rupture, thus masking it. The baby was delivered through a low uterine segment transverse incision. The ruptured uterine wall was reconstructed.ConclusionIntestinal adhesion due to a prior myomectomy occluded a uterine rupture, possibly masking its symptoms and signs, which may have prevented early diagnosis.

LESS Lysis of Abdominal Wall Adhesion before Hysterectomy

Single port surgery has been feasible for hysterectomy with less pain and good cosmetic result. But some criticize that LESS hysterectomy case was highly selective. In those cases VTH is enough. No port is needed. We present a 42 y/o woman with symptomatic recurrent myoma. She had previous laparotomy myomectomy and mini-lapatotomy appendectomy. There are two incision over Pfannestiel and appendectomy site. There are no scar over the umbilicus. After checking her intra-abdminal adhesion status, we decided to perform LESS lysis and hysterectomy with Chuang port and 10mm 0 angle laparotomy and some curved instrument.

Single layer uterine closure in laparoscopic myomectomy

ObjectiveOur goal was to assess uterine rupture in subsequent pregnancy following single layer closure during laparoscopic myomectomy (LM).DesignData was collected from Reproductive Associates of Delaware/RAD for those patients who underwent LM from December 2003 to August 2009. At this practice, single layer myometrial closure is uniformly performed by an experienced laparoscopist. Women were included if they had undergone LM requiring the use of suture and had a subsequent viable pregnancy (greater than 24 weeks).Materials and MethodsBilling records were searched for the diagnostic code for LM. Operative reports were reviewed to confirm the use of suture, and pregnancy outcome data was collected.ResultsOf 164 women who had myomectomies which met inclusion criteria, outcome data on 76 pregnancies was collected. Ten women had undergone previous myomectomy. The mean size of myoma removed was 40.4mm. The mean number of myoma removed was 3.83; 46 patients underwent removal of multiple myoma. Of 76 pregnancies, 19 were delivered vaginally and 57 were delivered by cesarean section. No uterine ruptures were reported.ConclusionBased on our case series and other data in the literature, we believe that appropriate and complete myometrial closure can be safely achieved through a single layer, when done by an experienced laparoscopist.Reproductive Associates of Delaware/RAD ObjectiveOur goal was to assess uterine rupture in subsequent pregnancy following single layer closure during laparoscopic myomectomy (LM). Our goal was to assess uterine rupture in subsequent pregnancy following single layer closure during laparoscopic myomectomy (LM). DesignData was collected from Reproductive Associates of Delaware/RAD for those patients who underwent LM from December 2003 to August 2009. At this practice, single layer myometrial closure is uniformly performed by an experienced laparoscopist. Women were included if they had undergone LM requiring the use of suture and had a subsequent viable pregnancy (greater than 24 weeks). Data was collected from Reproductive Associates of Delaware/RAD for those patients who underwent LM from December 2003 to August 2009. At this practice, single layer myometrial closure is uniformly performed by an experienced laparoscopist. Women were included if they had undergone LM requiring the use of suture and had a subsequent viable pregnancy (greater than 24 weeks). Materials and MethodsBilling records were searched for the diagnostic code for LM. Operative reports were reviewed to confirm the use of suture, and pregnancy outcome data was collected. Billing records were searched for the diagnostic code for LM. Operative reports were reviewed to confirm the use of suture, and pregnancy outcome data was collected. ResultsOf 164 women who had myomectomies which met inclusion criteria, outcome data on 76 pregnancies was collected. Ten women had undergone previous myomectomy. The mean size of myoma removed was 40.4mm. The mean number of myoma removed was 3.83; 46 patients underwent removal of multiple myoma. Of 76 pregnancies, 19 were delivered vaginally and 57 were delivered by cesarean section. No uterine ruptures were reported. Of 164 women who had myomectomies which met inclusion criteria, outcome data on 76 pregnancies was collected. Ten women had undergone previous myomectomy. The mean size of myoma removed was 40.4mm. The mean number of myoma removed was 3.83; 46 patients underwent removal of multiple myoma. Of 76 pregnancies, 19 were delivered vaginally and 57 were delivered by cesarean section. No uterine ruptures were reported. ConclusionBased on our case series and other data in the literature, we believe that appropriate and complete myometrial closure can be safely achieved through a single layer, when done by an experienced laparoscopist.Reproductive Associates of Delaware/RAD Based on our case series and other data in the literature, we believe that appropriate and complete myometrial closure can be safely achieved through a single layer, when done by an experienced laparoscopist.

Evaluation of sFas in serum and follicular fluid during ovarian stimulation for assisted reproduction

To measure the level of sFas in serum and follicular fluid (FF) from infertile women undergoing exogenous gonadotropin stimulation as a part of IVF/ICSI cycles and to study its correlation with oocyte maturation, fertilization, and embryo quality. Serum and FF samples were obtained from 55 patients at the time of transvaginal oocyte retrieval after ovulation induction for assisted reproduction. sFas levels in the serum and FF were measured in duplicate by a solid phase enzyme-linked immunosorbent assay (ELISA). E2 levels were measured by an enzyme immunoassay. There was no statistically significant correlation between age and sFas levels in serum ( p =0.84, r =−0.35) or follicular fluid ( p =0.75, r =−0.36). It was observed that the levels of sFas in serum and FF vary with different patients’ diagnosis. There was a statistically significant increase in sFas levels in both serum ( p =0.023, r =0.08) and FF ( p =0.014, r =0.01) in patients with uterine causes of infertility (subseptate uterus and previous myomectomy) compared with those having other causes of infertility. sFas were detected in low concentration in serum and FF in patients with male factor and idiopathic causes of infertility ( Fig. 1 ). A positive correlation was found between the sFas levels in the serum and those in the FF ( p =0.01, r =0.91) ( Fig. 2 ). However, no correlation was found between the levels of sFas and the levels of estradiol in the serum ( p =0.427, r =−0.03). There was a significant correlation between the number of fertilized oocytes and the level of sFas in the serum ( p =0.013, r =−0.42) ( Fig. 3 ). There was no correlation between the number of fertilized oocytes and the level of sFas in FF ( p =0.168, r =−0.40). However, a significant correlation between the levels of sFas in the serum of pregnant ( n =11) and non-pregnant women ( n =44) was observed ( p =0.045, r =0.90) ( Fig. 4 ). A lower level of sFas in serum was associated with a higher pregnancy rates. This may be attributed to the presence of good fertilized oocytes. The above phenomena may suggest that low levels of sFas in serum may be associated with improved implantation of fertilized oocytes or may prevent damage to the embryo. Lower levels of sFas seem to support embryo implantation.

A Large Submucous Myoma Missed during Previous Hysteroscopic Submucous Myomectomy – Retrospective Video Analysis

A 38-year old P2L2 presented with complaints of severe menorrhagia since 3 months.Ultrasound scan showed a large submucous myoma measuring 7×5cms and thickening of the posterior uterine wall. She had undergone hysteroscopic resection of a large submucous myoma only 7 months back. We requested for the procedure video from the previous surgeon and reviewed the video. The analysis showed that while the surgeon performed a complete resection of a submucous myoma, a second submucous myoma was missed during the procedure. We performed a diagnostic hysteroscopy and noted a large submucous myoma just near the internal os. Laparoscopic myomectomy was performed. This video intends to underscore the importance of meticulousness and diligence while performing surgical procedures so that findings beyond the diagnosis are not missed.