Transvaginal Scan Research Articles

Sonographic appearance of malignant deep endometriosis of the rectum

In a symptomatic, 47-year-old woman with dysmenorrhea, dyschezia, and rectal bleeding, a transvaginal ultrasound demonstrated adenomyosis and an irregular hypoechoic nodule of 31 mm×12 mm×24 mm that infiltrated the anterior rectal wall and caused a retraction compatible with deep infiltrating endometriosis (Figure 1). After an elastography was conducted, the nodule stiffness was observed to be high (Figures 2 and 3). After a transvaginal scan following the intrarectal introduction of a physiological solution (Video), the nodule appeared to infiltrate the submucosa for 3 mm and caused 50% lumen stenosis (Figure 4). Contrary to what is reported for endometriomas, no specific sonographic signs of malignant transformation were evident. Total hysterectomy and partial rectal resection were performed by laparoscopy. Histopathology confirmed adenomyosis and revealed a moderately differentiated endometrioid adenocarcinoma, developed on a deep endometriosis of the rectum. Malignant transformation of endometriosis occurs in 0.7% to 2.5% of women, mainly after 45 years of age. Seventy-five percent of cases involve the ovaries and 25% involve extragonadal sites, mostly the rectum-sigmoid. Figure 2Transvaginal elastography Show full caption The black-marked blue area represents the high-stiffness endometriosis nodule at transvaginal elastography. Xholli. Sonographic appearance of malignant deep endometriosis of the rectum. Am J Obstet Gynecol 2022. View Large Image Figure Viewer Download Hi-res image Figure 3Analysis of the transvaginal elastography Show full caption At elastography analysis the yellow circular area placed in the middle of the nodule proved the presence of high-stiffness tissue with an objective value of 0.05% (in the graphic), whereas the light blue circular area placed in the pericervical tissue showed the presence of soft tissue with an objective value of 0.47%. Xholli. Sonographic appearance of malignant deep endometriosis of the rectum. Am J Obstet Gynecol 2022. View Large Image Figure Viewer Download Hi-res image Figure 4Transvaginal scan Show full caption At transvaginal scan, the nodule marked by the yellow tract infiltrating the submucosa for 3 mm (yellow arrow) narrows the rectal lumen by about 50%. D1 represents the minimum lumen diameter of the affected rectal wall. D2 is the normal rectal lumen diameter. Xholli. Sonographic appearance of malignant deep endometriosis of the rectum. Am J Obstet Gynecol 2022. View Large Image Figure Viewer Download Hi-res image The black-marked blue area represents the high-stiffness endometriosis nodule at transvaginal elastography. Xholli. Sonographic appearance of malignant deep endometriosis of the rectum. Am J Obstet Gynecol 2022. At elastography analysis the yellow circular area placed in the middle of the nodule proved the presence of high-stiffness tissue with an objective value of 0.05% (in the graphic), whereas the light blue circular area placed in the pericervical tissue showed the presence of soft tissue with an objective value of 0.47%. Xholli. Sonographic appearance of malignant deep endometriosis of the rectum. Am J Obstet Gynecol 2022. At transvaginal scan, the nodule marked by the yellow tract infiltrating the submucosa for 3 mm (yellow arrow) narrows the rectal lumen by about 50%. D1 represents the minimum lumen diameter of the affected rectal wall. D2 is the normal rectal lumen diameter. Xholli. Sonographic appearance of malignant deep endometriosis of the rectum. Am J Obstet Gynecol 2022.

Corpus luteum number and the maternal renin-angiotensin-aldosterone system as determinants of utero-placental (vascular) development: the Rotterdam Periconceptional Cohort

BackgroundPregnancies with > 1 corpus luteum (CL) display a hyperdynamic circulation and an increased risk of small-for-gestational age deliveries. Among the factors released by the CL is prorenin, the inactive precursor of renin. Since the renin-angiotensin-aldosterone system (RAAS) is involved in early hemodynamic pregnancy adaptation, we linked both CL number and first-trimester concentrations of prorenin (as an indicator of RAAS activity) and the aldosterone/renin ratio (as an indicator of angiotensin-independent aldosterone effectiveness) to non-invasive markers of utero-placental (vascular) development, measured longitudinally from the first trimester onwards.MethodsA total of 201 women, who conceived naturally or after in-vitro fertilization treatment (with 0 (n = 8), 1 (n = 143), or > 1 (n = 51) CL), were selected from the Rotterdam Periconceptional Cohort. Maternal RAAS components were determined at 11 weeks gestation. Placental volume and utero-placental vascular volume were measured from transvaginal 3D ultrasound scans at 7, 9 and 11 weeks gestation, pulsatility and resistance indices of the uterine arteries were assessed by pulsed wave Doppler ultrasounds at 7, 9, 11, 13, 22 and 32 weeks gestation. At birth placental weight was obtained using standardized procedures.ResultsPregnancies without a CL show lower uterine artery indices throughout gestation than 1 CL and > 1 CL pregnancies, while parameters of placental development are comparable among the CL groups. After adjustment for patient- and treatment-related factors, first-trimester prorenin concentrations are positively associated with uterine artery pulsatility and resistance indices (β 0.06, 95% CI 0.01;0.12, p = 0.04 and β 0.10, 95% CI 0.01;0.20, p = 0.04, respectively), while high prorenin concentrations are negatively associated with first-trimester utero-placental vascular volume (β -0.23, 95% CI -0.44;-0.02, p = 0.04) and placental weight (β -93.8, 95%CI -160.3;-27.4, p = 0.006). In contrast, the aldosterone/renin ratio is positively associated with first-trimester placental volume (β 0.12, 95% CI 0.01;0.24, p = 0.04).ConclusionsThe absence of a CL, resulting in low prorenin concentrations, associates with low uterine artery pulsatility and resistance, while high prorenin concentrations associate with a low utero-placental vascular volume and weight. These data support a scenario in which excess prorenin, by upregulating angiotensin II, increases uterine resistance, thereby preventing normal placental (vascular) development, and increasing the risk of small-for-gestational age deliveries. Simultaneously, high aldosterone concentrations, by ensuring volume expansion, exert the opposite.

Isthmocele Endometriosis- the Relationship between Cesarean Section and Endometriosis.

<h3>Study Objective</h3> We present a unique case of diffuse peritoneal endometriosis following cesarean section, involving the cesarean scar isthmocele and associated with secondary infertility, failed embryo transfers, and progressive pelvic pain. <h3>Design</h3> Case report of endometriosis within an isthmocele membrane and concomitant peritoneal endometriosis. <h3>Setting</h3> A combined hysteroscopic and laparoscopic approach in lithotomy position. <h3>Patients or Participants</h3> A 44-year-old patient with three prior cesarean-sections and a laparoscopic appendectomy, in none of which, endometriosis was visualized. She presented with dysmenorrhea, dyspareunia, and recurrent embryo transfer failures. The progressively debilitating symptoms started 14 years ago, shortly after her last cesarean-section. MRI and ultrasound demonstrated a retroverted uterus and a prominent, thin, fluid filled, cesarean scar defect. <h3>Interventions</h3> A combined hysteroscopic and laparoscopic approach was performed. Indocyanine green dye was used to identify the bladder borders and methylene blue was added to the hysteroscopy irrigation solution to create contrast. A wide excision of the isthmocele was performed followed by a three-layer closure and excision of all apparent peritoneal lesions using the AquaBlue contrast technique (ABCt™). <h3>Measurements and Main Results</h3> In the pathological assessment, multiple foci of endometriosis were identified within the isthmocele membrane, clearly differentiated from intrauterine endometrial tissue. Additionally, all seven excised peritoneal specimens contained peritoneal endometriosis. Two weeks following the procedure, transvaginal sonographic scan confirmed thick anterior uterine wall, and the patient reported only minor discomfort with almost complete resolution of her symptoms. <h3>Conclusion</h3> This case demonstrates endometriosis within the isthmocele membrane, with concomitant symptomatic peritoneal endometriosis. We propose a laparoscopic isthmocele excision technique with three-layer reconstruction, and peritoneal endometriosis excision using methylene blue contrast. We suggest a possible link between isthmocele and endometriosis and emphasize the need for wide excision of the isthmocele margins and maintaining clean borders, given the possibility of endometriosis within the isthmocele, which might be a cause or a contributor to the tissue weakness and isthmocele formation.

Gynecological and Obstetrical Outcomes after Laparoscopic Repair of a Cesarean Scar Defect in a Series of 15 Women

<h3>Study Objective</h3> To evaluate gynecological and obstetrical outcomes, as well as remaining myometrial thickness, after laparoscopic repair of a cesarean scar. <h3>Design</h3> Observational study and retrospective evaluation of the remaining myometrium before and after repair. <h3>Setting</h3> Obstetrics and Gynecology Department in a University hospital. <h3>Patients or Participants</h3> A series of 15 symptomatic women with cesarean scar defects and remaining myometrial thickness of less than 3 mm, according to transvaginal ultrasound scan imaging. <h3>Interventions</h3> Laparoscopic repair of the cesarean scar defect. <h3>Measurements and Main Results</h3> Increase in myometrial thickness at the site of cesarean section, gynecological and obstetrical outcomes. The mean thickness of the myometrium increased significantly from 2mm before surgery to 7mm after surgery. Six months after surgery, all but two patients were free of symptoms. The persistence of intermenstrual bleeding in of one of them required a posterior hysteroscopic correction. Among the 7 women with infertility, 3 (42%) became pregnant and delivered healthy babies by cesarean section at 38–39 weeks of gestation. Two of these pregnancies were obtained spontaneously and the other one was an in vitro fertilization. <h3>Conclusion</h3> In symptomatic women with residual myometrial thickness of less than 3mm who wish to conceive, laparoscopic repair could be considered an appropriate approach.

Transvaginal Sonographic Evaluation of Cesarean Section Scar Niche in Pregnancy: A Prospective Longitudinal Study

Background and Objectives: To investigate the prevalence of a Cesarean section (CS) scar niche during pregnancy, assessed by transvaginal ultrasound imaging, and to relate scar measurements, demographic and obstetric variables to the niche evolution and final pregnancy outcome. Materials and Methods: In this prospective observational study, we used transvaginal sonography to examine the uterine scars of 122 women at 11+0–13+6, 18+0–20+6 and 32+0–35+6 weeks of gestation. A scar was defined as visible on pregnant status when the area of hypoechogenic myometrial discontinuity of the lower uterine segment was identified. The CS scar niche (“defect”) was defined as an indentation at the site of the CS scar with a depth of at least 2 mm in the sagittal plane. We measured the hypoechogenic part of the CS niche in two dimensions, as myometrial thickness adjacent to the niche and the residual myometrial thickness (RMT). In the second and third trimesters of pregnancy, the full lower uterine segment (LUS) thickness and the myometrial layer thickness were measured at the thinnest part of the scar area. Two independent examiners measured CS scars in a non-selected subset of patients (n = 24). Descriptive analysis was used to assess scar visibility, and the intraclass correlation coefficient (ICC) was calculated to show the strength of absolute agreement between two examiners for scar measurements. Factors associated with the CS scar niche, including maternal age, BMI, smoking status, previous vaginal delivery, obstetrics complications and a history of previous uterine curettage, were investigated. Clinical information about pregnancy outcomes and complications was obtained from the hospital’s electronic medical database. Results: The scar was visible in 77.9% of the women. Among those with a visible CS scar, the incidence of a CS scar niche was 51.6%. The intra- and interobserver agreement for CS scar niche measurements was excellent (ICC 0.98 and 0.89, respectively). Comparing subgroups of women in terms of CS scar niche (n = 49) and non-niche (n = 73), there was no statistically significant correlation between maternal age (p = 0.486), BMI (p = 0.529), gestational diabetes (p = 1.000), smoking status (p = 0.662), previous vaginal delivery after CS (p = 1.000) and niche development. Uterine scar niches were seen in 56.3% (18/48) of the women who had undergone uterine curettage, compared with 34.4% (31/74) without uterine curettage (p = 0.045). We observed an absence of correlation between the uterine scar niche at the first trimester of pregnancy and mode of delivery (p = 0.337). Two cases (4.7%) of uterine scar dehiscence were confirmed following a trial of vaginal delivery. Conclusions: Based on ultrasonography examination, the CS scar niche remained visible in half of the cases with a visible CS scar at the first trimester of pregnancy and could be reproducibly measured by a transvaginal scan. Previous uterine curettage was associated with an increased risk for uterine niche formation in a subsequent pregnancy. Uterine scar dehiscence might be potentially related to the CS scar niche.

OC01.06: Clinical utility of assessing the embryonic brain by ultrasound at 7–10 weeks of gestation

To assess the clinical utility of assessing the embryonic brain and cranium by ultrasound at 7–10 weeks of gestation. 1000 consecutive cases of clinically indicated scans at 7-10 weeks were evaluated prospectively to assess the clinical utility of evaluating cranial and brain morphology in cases with bleeding, pelvic pain, previous pregnancy losses, and those requesting for reassurance scans or an early scan. All embryos were assessed by transabdominal scans, supplemented by transvaginal scans. 3D studies were utilised routinely. The evaluation was part of a larger study of complete embryonic morphology. Observations were categorised into normal studies, conclusive abnormal morphology, need for follow up at 11-14 weeks to confirm an anomaly and early genetic consultation. All patients were followed up with an 11-14 weeks and an 18-22 weeks' study unless there was a fetal demise or termination of pregnancy. All pregnancies that went to term were assessed by a clinical neonatal evaluation. A total of 61 embryos had an abnormal morphology and 19 of these had a cranial/brain anomaly. Of the 19 cranial and brain anomalies, seven embryos were non-viable at the time of scanning. Seven embryos had acrania, four anencephaly, three holoprosencephaly, one occipital encephalocele and four ventriculomegaly. 21 embryos in the original cohort had gray zone findings, of which 11 were normal on follow up and 10 were abnormal, all at the 11-14 week window. Of these five had CNS anomalies. There is a significant number of embryos with brain/cranial anomalies recognisable in early pregnancy in patients with clinically indicated scans at 7-10 weeks. It is prudent to include embryonic morphology at this period of ultrasound evaluation to triage pregnancies towards definitive management, early follow up, initiation of genetic evaluation or follow up at 12-14 weeks. Importantly, a change in management direction from routine NIPT at 10-11 weeks to a genetic consultation is possible.

Effect of Sildenafil Citrate on Success Rate of Ovulation Induction by Clomiphene Citrate

Background: Disorders of ovulation are common causes of infertility, and polycystic ovary syndrome (PCOS) is by far the most frequent condition. Objetive: The aim of this work was to evaluate the effect of adding vaginal sildenafil citrate to clomophine citrate used as ovarian stimulant drug on both endometrial thickness and pregnancy rate in patient with polycystic ovary syndrome (PCO). Patients and Methods: This prospective Comparative study included a total of 58 patients with primary and secondary infertility aged between18 years to 35 years, attending at Outpatient Clinics, Obstetrics and Gynecology Department, Zagazig University Hospitals. Patients were divided into two equal groups; each were 29. 1st Group was given clomiphene, and 2nd group was given Clomophine citrate and Sildenafil. A transvaginal Scan for imaging the uterus and adnexa for any pathology and measuring the basic endometrial thickness was also done on Day 3. Results: This study shows that there was an increase in endometrial thickness in sildenafil group (13.4±1.814 mm) comparable with clomiphene citrate group only (8.52±2.081 mm) (P=0.01). The result was statistically significant with increase threshold regard for implantation with statistically significant in group B (P=0.018). Conclusions: It could be concluded that addition of sildenafil citrate to clomiphene citrate therapy for induction of ovulation in patients with PCOS resulted in significant increase of endometrial thickness and non-significant increase of pregnancy Rates.

Malignant Germ cell Tumor of Ovary: An Unusual Combination and An Irony of Fate

Malignant mixed ovarian germ cell tumors are very rare malignant ovarian germ cell tumors, with a very high degree of malignancy. They are aggressive cancers affecting young adolescent girls. The commonest combination reported in literature is dysgerminoma and endodermal sinus tumors. Fertility sparing surgery followed by combination chemotherapy is the treatment of choice. The objectives of this case report are the advanced age of presentation, unusual histopathological combination, and the irony of infertility treatment. We report a rare case of 40-year-old woman with Malignant mixed germ cell tumor comprising of components of endodermal sinus tumor, immature teratoma, dysgerminoma and embryonal carcinoma. Patient was on hormonal therapy for the cause of infertility, presented with complains of lower abdominal pain, constipation and incomplete evacuation of bladder for 2months. Transvaginal ultrasonography and CT scan showed a large multicystic space occupying lesion with predominant solid component in midline abdominopelvic location. Tumor markers i.e., AFP, Prolactin and CA125 were raised. Total abdominal hysterectomy and bilateral salpingoophorectomy, pelvic and retroperitoneal node resection, peritonectomy and omentectomy was performed.

P–727 Prevalence of ultrasound-detected gynaecological pathology in a One-Stop fertility clinic

Abstract Study question What is the prevalence of abnormal findings on transvaginal ultrasound scan (TVS) in a population of women presenting with subfertility to a One-Stop fertility clinic? Summary answer Two thirds of women in our population had ultrasound-detected pathology. The five commonest pathologies were uterine fibroids, polycystic ovaries, endometriosis, adenomyosis and benign ovarian cysts. What is known already Gynaecological pathology is common in women presenting with subfertility. However, their prevalence varies depending on the age, geography, background health of the population and study design. Few prevalence studies performed in the general female population show definitive associations with subfertility. As imaging techniques become increasingly sophisticated and patient demographics evolve over time, the prevalence of gynaecological pathology is anticipated to change. Understanding their prevalence in a subfertile population would shed light on the burden of disease, providing information about prevention strategies and service priorities. There are no published studies on the prevalence of ultrasound-detected gynaecological pathology in the subfertile population. Study design, size, duration This was a retrospective cross-sectional study of 1558 women presenting to a One-Stop fertility clinic of a university teaching hospital between January 2012 and December 2020. Participants/materials, setting, methods Women who attend the clinic routinely have their demographic data and a detailed clinical history taken prior to a transvaginal ultrasound scan. A clinical examiner trained in transvaginal ultrasonography performs the ultrasound examination in a standardized fashion. Ultrasound features and diagnoses are systematically recorded in an electronic database. We obtained demographic data and details of gynaecological diagnoses from the electronic database. We analysed the data using descriptive statistics and reported our results as proportions. Main results and the role of chance The median age of women at the time of scan was 35 years (range 21–46 years). The mean Body Mass Index was 24.8 kg/m2 (range 16.9–50.4 kg/ m2). The median duration of subfertility was 24 months (range 3–168 months). 472/1558 (30.3%, 95% CI 28.0–32.6) women had normal pelvic scans. The most frequent pathology seen in our population was uterine fibroids (410/1558, 26.3%; CI 24.1–28.6); 10.5% of these fibroids distorted the uterine cavity. Polycystic ovaries were the next most common pathology (363/1558, 23.3%; CI 21.2–25.4), followed by endometriosis (177/1558, 11.4%; CI 9.8–13.0), adenomyosis (160/1558, 10.3%; CI 8.8–11.9) and benign ovarian cysts (122/1558, 7.8%; CI 6.6–9.3). The other abnormalities seen on scan included congenital uterine anomalies (81/1558, 5.2%; CI 4.2–6.4), endometrial polyps (69/1558, 4.4%; CI 3.5–5.6), pelvic adhesions (44/1558, 2.8%; CI 2.1–3.8) and intrauterine adhesions (13/1558, 0.8%; CI 0.5–1.4). Of the 1086 women with abnormal scans, 832 (76.6%, CI 74.0–79.1) had one pathology detected on TVS and 254 (23.4%, CI 20.9–26.0) had more than one pathology detected. Limitations, reasons for caution A limitation of our study was the lack of histological confirmation of the ultrasound findings. Due to our smaller sample size, our prevalence could potentially be overestimated. Wider implications of the findings: The relevance of each pathology to chances of conception requires further examination to avoid under- or overtreating women in their fertility journey. Our findings may provide a background for future correlation studies. Furthermore, a scan quality assessment may be considered if the detection rate is substantially different in similar populations. Trial registration number Not applicable

O-050 Virtual reality applications in ultrasound

Abstract text Surgical simulation has been introduced in surgical training since 1920 following the example of airline and military industry. Recently, the Association of American Medical Colleges commented on the increased use of simulation in different medical specialties, recognizing its potential ability to improve patients safety and to enhance healthcare in general. Historically, graduating obstetrics and gynecology residents have been expected to learn following the adage ‘see one, do one, teach one’, which required a high volume experience. Nowadays, as the complexity of procedures increases and surgical volume decreases, in order to acquire surgical skills rapidly there is the need to integrate surgical and ultrasound virtual simulation into modern residency training alongside traditional teaching methods. In addition, recent changes in the field (e.g. workhours restrictions, decreased bedside teaching) have high lightened these necessities. Ultrasonography is a skill that requires a complex interplay of motor skills and visual-cognitive skill. The learning process include two steps: an initial global assessment followed by a focal search for pathology and key landmarks. Recently more attention has been paid to design increasingly sophisticated simulators for ultrasound in obstetrics and gynecology. These are broadly divided into to major categories: physical mannequins and virtual reality simulators. The physical mannequins practically consist in low cost silicon dummies that enable learners to discover basic anatomical and pathological findings using real ultrasound equipment. This type of simulators allows the trainees to learn haw to use the equipment in order to obtain proper scans. However, the case complexity is limited due to the low fidelity of the physical mannequins. In addition there is no automated feedback and a supervisor is always needed during the practice. The virtual reality simulators usually rely on haptic devices or physical mannequins that record probe movements during transabdominal or transvaginal scans and combined them with computer-animated/real ultrasound images. Instructions and automated feedback are provided during the practice. They often contains multiple cases allowing the trainees to be exposed to different clinical scenarios. In the field of Reproductive Endocrinology and Infertility some ultrasound and surgical skills are required for independent practice including transvaginal oocyte pick-up, hysterosalpingocontrastsonography (HyCoSy) and embryo-transfer. Considering advantages and disadvantages of both apprenticeship models (traditional training and simulator-based training), a blended approach which combines simulator-based training with didactic and more traditional training on real patients could be introduced. So far the use of simulation-based training has shown promising results in terms of moderate effects on patient outcomes and large effects on trainee behavior in the clinical setting. It could be useful especially in the initial part of a structured training for novices, enabling them to acquire basic skills and to reach a predefined level of performance in a safe and controlled environment, before applying the procedure to real patients.

P–747 Implementation of the ESHRE Congenital uterine anomaly classification into practice and clinical pregnancy outcomes at a Tertiary University Teaching Hospital Fertility department

Abstract Study question What’s the incidence of class U1-U6 CUAs in subfertile women? What’s the clinical pregnancy rate in women with the most common anomaly, a septate uterus? Summary answer The incidence of CUAs is 5.9% in our subfertile population, with a septate uterus (U2) being the most common abnormality in 4.2% of the population What is known already Congenital uterine anomalies (CUAs) are common. A systematic review suggested an estimated overall prevalence of 5.5% in an unselected population, 8.8% in the subfertile population, 13.3% in those with a history of recurrent miscarriage and 24.5% in those with a history of subfertility and recurrent miscarriage. A septate uterus (U2) is the most common CUA and is amenable to surgical intervention although at present there is a lack of evidence suggesting benefit in subfertile patients. Women with a septate uterus are known to have poorer reproductive outcomes, including reduced conception rate and increased first trimester loss. Study design, size, duration All patients referred to our department for subfertility had a 2D pelvic ultrasound scan as part of their baseline investigations. Since it was established in 2016, all patients with a suspected CUA based on clinical history and investigations, were referred to the clinic and data collected prospectively. Prior to this, women with suspected CUAs required a hysteroscopy or MRI scan for confirmation of diagnosis, often leading to long waiting lists and treatment delays. Participants/materials, setting, methods Out of the 4716 patients referred to the department for subfertility from 2016–2018, 302 women were referred to the 3D clinic due to suspicion of a CUA. Transvaginal 3D-ultrasound scan was performed and CUAs classified according to the ESHRE/ESGE working groups. Patients diagnosed with a septate uterus were given options of conservative versus surgical treatment, in the light of unclear benefits of hysteroscopic septum resection. Clinical pregnancy data were collected about this cohort. Main results and the role of chance Of the 302 women referred to the service, the uteri of 25 patients were unable to be assessed accurately, most commonly as the cavity was unclear due to a thin endometrium. The remaining 277 patients were classified as having the following CUAs; Normal (U0) 63 patients, Dysmorphic (U1) 5 patients, Septate (U2) 199 patients, Bicorporeal (U3) 6 patients and Hemi uterus (U4) 4 patients. No women were classified as having an aplastic uterus (U5) or unclassified (U6). Of the 199 women with a septate uterus, 15 women opted for surgical intervention, 143 women decided to have conservative management and 41 women were lost to follow up. The women who had hysteroscopic resection of the septum had a mean age of 35 years, 6/15 had primary subfertility and 6/15 had a history of recurrent miscarriage. The women who had conservative management had a mean age of 32.5 years, 100/143 had primary subfertility and 20/143 had a history of recurrent miscarriage. At present, 89/143 women who have had conservative management and 12/15 women who had surgical interventions have had a clinical pregnancy, 72/89 and 6/12 of these pregnancies were IVF/ICSI pregnancies respectively. Limitations, reasons for caution This is an observational study, these findings can be useful for patient counselling. However, ideally randomised controlled trials are needed as evidence for the different treatment options for the cohort of patients with septate uterus, which are largely lacking in the current literature, as their feasibility remains a challenge. Wider implications of the findings: Three-dimensional transvaginal ultrasonography clinics are cost-effective one-stop services, successfully providing a diagnosis and management plan in 92% of patients referred with a suspected CUA. They increase patient satisfaction by providing an opportunity to discuss risks in future pregnancies and reducing reliance on hysteroscopy and MRI scans. Trial registration number Not applicable

The Birth of first JIPMER “ICSI” Baby

Assisted reproductive techniques are becoming more and more essential for human life in the Society. Worldwide more than 5 million babies were born out of this technology after the birth of first baby Louis Brown and second Durga (India) in 1978. It is a boon for the couple in despair to have a child especially when it is provided by Govt Institutions for the less affordable people of the Society. It is essential to share provider’s experiences and expectations of the public in a fast growing biomedical field like ART. The techniques of IVF and ICSI have undergone a sea change since the initial technique of natural cycles to ovarian hyper stimulation and stem cell research. A 29 year old lady, Type I Diabetic with hirsutism, PCOS, failed IUI underwent ICSI following ovarian stimulation employing antagonist protocol after 8 years of married life. The husband is also diabetic for 13 years and suffered from post-polio residual paralysis and had asthenospermia. Frozen Embryo transfer of cleavage stage embryos was done on 31.7.2019 after endometrial preparation employing HRT. Her β HCG was HCG 387 on 14.8.2019 and intrauterine pregnancy was confirmed by transvaginal scan. Pregnancy and Diabetes were managed with progesterone support and Insulin therapy respectively. An alive male baby was delivered by emergency Caesarean section on 28.3.2020 at 12.34 PM for breech presentation in labour during lockdown for COVID 19. Both mother and baby were discharged home in healthy condition and the baby is one year old at the time of writing this report.

Evaluation of cervical length by transabdominal and transvaginal scans during early pregnancy.

Objective&#x0D; To compare the measurements and the client-preferences of transabdominal scan (TAS) and transvaginal scan (TVS) in assessing cervical length.&#x0D; Method &#x0D; A validation study with a cross sectional component on patient-preferences was conducted among 568 pregnant women with a period-of-amenorrahea between 11+0 to 22+6 weeks. Pre- and post-void TAS and a post-void TVS measurements were taken. Receiver Operating Characteristics (ROC) curves were generated to assess the detection of short cervix using pre and post-void TAS at different lengths of the cervix. &#x0D; Results &#x0D; The mean (SD) age of the participants was 28.4(5.7) years with a mean gestation age of 14+1 weeks. The mean (SD) cervical lengths detected by the pre-void TAS, post-void TAS and TVS were 32.2 (5.8)mm, 28.9 (5.8) mm and 34.4 (5.3) mm respectively. Factors with significant association with a higher TVS cervical length were; increasing age (p

Recurrent Cesarean scar pregnancy: case series and literature review.

To determine the rate of recurrent Cesarean scar pregnancy (CSP) in our clinical practices and to evaluate whether the mode of treatment of a CSP is associated with the risk of recurrent CSP, as well as to review the published literature on recurrent CSP. We performed a retrospective search of our six obstetric and gynecological departmental ultrasound databases for all CSPs and recurrent CSPs between 2010 and 2019. We extracted various data, including number of CSPs with follow-up, number of cases attempting and number achieving pregnancy following treatment of CSP and number of recurrent CSPs, as well as details of the treatment of the original CSP. After analyzing the clinical data, we evaluated whether the mode of treatment terminating the previous CSP was associated with the risk of recurrent CSP. We also performed a PubMed search for: 'recurrent Cesarean scar pregnancy' and 'recurrent Cesarean scar ectopic pregnancy'. Articles were reviewed for year of publication, and extraction and analysis of the same data as those obtained from our departmental databases were performed. Our database search identified 252 cases of CSP. The overall rate of clinical follow-up ranged between 71.4% and 100%, according to treatment site (mean, 90.9%). Among these, 105 women had another pregnancy after treatment of the previous CSP. Of these, 36 (34.3%) pregnancies were recurrent CSP, with 27 women having a single recurrence and three women having multiple recurrences, one with two, one with three and one with four. We did not find any particular single or combination treatment mode terminating the previous CSP to be associated with recurrent CSP. The literature search identified 17 articles that yielded sufficient information for us to evaluate their reported prevalence of recurrent CSP. These reported 1743 primary diagnoses of CSP, of which 944 had reliable follow-up. Data were available for 489 cases that attempted to conceive again after treatment of a previous CSP, and on the 327 pregnancies achieved. Of these, 67 (20.5%) were recurrent CSP. On the basis of our pooled clinical data and review of the literature, recurrent CSP is apparently more common than was previously assumed based upon mostly single-case reports or series with few cases. This should be borne in mind when counseling patients undergoing treatment for CSP regarding their risk of recurrence. We found no obvious causal relationship or association between the type of treatment of the previous CSP and recurrence of CSP. Patients who become pregnant after treatment of a CSP should be encouraged to have an early (5-7-week) first-trimester transvaginal scan to determine the location of the gestation. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Laparoscopic Management of Myomectomy Scar Pregnancy after a Cryopreserved Embryo Transfer

A 38-year-old nulligravida woman with previous history of hysteroscopic myomectomy underwent in vitro fertilization and became pregnant. Two cleavage stage embryos were transferred 3 days following oocyte retrieval. Twelve days later, serum β human chorionic gonadotropin was positive. The first transvaginal ultrasound scan at 4 weeks revealed a gestational sac in diverticulum at the anterior lateral fundus, communicated with the uterine cavity, the gestational sac was 25 mm in diameter (Fig. 1A).

Оцінка якості життя онкогінекологічних хворих після проведеної гістероваріектомії, асоційованої з тромботичними ускладненнями

Oncological treatment for post-operative patients is aimed to improve their symptomatic course and life prognosis. However, the subjection of a woman following radical intervention in her reproductive system has a devastating effect on the quality of life in this cohort of patients. Quality of life is one of the modern criteria for assessing the effectiveness of health care. The main tool for measuring quality of life is the standardized questionnaires produced by psychometric methods. European Organization for Research and Treatment of Cancer Quality of Life Questionnaire was used to assess the quality of life of women with cancer with post-operative thrombotic complications. The purpose of the study was to assess the indicators dynamics of the quality of life in oncological patients before and after a hysterovariectomy associated with thrombotic complications. Materials and methods. In accordance with the purpose of the study, a comprehensive examination of 34 women with oncological diseases of the uterus and appendages with postoperative deep vein thrombosis, who were in hospital, was done. The average age of patients was 51.4 士 3.5. All patients underwent hysterovariectomy. The control group consisted of 30 healthy women. The set of diagnostic and therapeutic measures included a thorough clinical examination with anamnesis, features of menstrual and reproductive functions, transvaginal ultrasound scanning, hysteroscopy and histological examination of macrodrugs removed during surgery. The groups were compared by age, volume of surgery and comorbidities. Results and discussion. Analysis of the initial results of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire in oncological patients showed a low statistically significant score in all its scales compared to practically healthy women (p &lt;0.05). In the group of patients with post-operative thrombotic complications, after a hysterovariectomy, there was an evident decrease by 46.5% in physical activity compared to the initial data (p &lt;0.05). In the context of therapy, there has been a decrease in social contacts and in the level of communication due to physical and emotional limitations (p &lt;0.05). The decline in quality of life was associated with an increase in sexual dysfunction in 100% of cases. Conclusion. The assessment of indicators of quality of life in patients with malignant neoplasia of the gynaecological sphere must be monitored before and after rapid treatment to determine the necessary social-medical algorithm of actions to adapt such patients during the rehabilitation period

The Effect of Venoactive Drug Therapy on the Development and Severity of Post-Embolization Syndrome in Endovascular Interventions on the Gonadal Veins.

Objective. To evaluate the incidence of post-embolization syndrome (PES) and the effect of venoactive therapy on its development, severity, and duration after endovascular embolization of gonadal veins (EEGV) with coils in patients with pelvic congestion syndrome (PCS). Materials and Methods. We analyzed the outcomes of EEGV with coils in 70 female patients who received (n = 38; group 1) or did not receive (n = 32; group 2) treatment with a venoactive drug (VAD) before and after the procedure. Assessments of the EEGV efficacy and for possible signs of PES were done on days 1, 5, 10, 15, 20, and 30 after the intervention. All patients underwent transvaginal and transabdominal duplex ultrasound scanning (DUS) after EEGV. In addition, patients with PES were examined using the computed tomography of the pelvic veins in the postprocedural period. Results. Technical success of EEGV was achieved in 100% of patients. Pelvic venous pain (PVP) reduction after EEGV was observed in 77.1% of patients. The PES was diagnosed in 18.6% of cases (10.5% in group 1 vs. 28.1% in group 2, p > 0.05). In three patients of group 1, the protrusion of coils was suspected and eventually verified during the resection of the left gonadal vein with coils. The group 1 patients had less severe post-embolization pain (6.2 ± 0.4 vs. 7.8 ± 0.3 scores in group 2; p = 0.009) and three times shorter duration of PES (5.0 ± 1.2 vs. 16.2 ± 2.7 days; p = 0.003). No significant differences in the diameters of gonadal veins, side of embolization, and number of coils were revealed between patients with and without PES. The rate of parametrium vein thrombosis was found to be significantly higher in patients with PES than in those without PES (30.7% vs. 18.5%, respectively; p < 0.05). Conclusion. The PES is a frequent complication of EEGV with coils and occurs in 18.6% of patients. Venoactive treatment does not effect the incidence of this complication but reduces the PES severity and duration.

Two novel mutations in exon 2 of bone morphogenetic protein (BMP) 15 gene in Pakistani infertile females.

ObjectiveTo determine the proportion of fertility in Pakistani infertile females and discover if there are considerable connection among BMP15 gene polymorphism, follicle maturation and hormonal regulation in Pakistani infertile females.MethodsAll selected participants were initially examined through follicle-stimulating hormones (FSH), luteinizing hormone (LH), thyroid-stimulating hormone (TSH), Prolactin, and Trans-vaginal scan (TVS). BMP15 gene polymorphism among infertile and fertile females was done by extracted Genomic DNA from whole blood. Sanger sequencing was performed for the identification of mutation in exons-intron boundaries of the BMP15 gene. Bioinformatics tools were used to assess the protein structure.ResultsThe total five mutations including two novel missense variants of BMP15 in exon 2, whereas three previously reported i.e. two cosmic mutations (c.615delC), (c.584InsG) and one frame shift mutations (c.635delA) were also observed. The first novel mutation was found at (c.1038InsGG) (p.346Gln < Gly) in which the insertion of GG at DNA position 1038 of exon 2 resulting in a substitution of glutamine into glycine at 346th amino acid of BMP15 protein. The second novel variant (c.1049delT) (p. Ser334Pro) was also observed in exon 2 of the BMP15 gene, which substituted serine into proline at 334th amino acid of the BMP15 protein.ConclusionIt is concluded that there are various missense mutations present in exon 2 of the BMP15 gene of Pakistani infertile females, consequently expected function of protein changes due to change in codons of amino acids. Provean and SIFT suggest the two novel variants as potentially deleterious. Although three other variants were also found in Pakistani infertile females which were previously reported. These mutations may result in early blockage of folliculogenesis and ovaries become streaky. Further research is required to resolve the actual allusion of these variations in the BMP15 gene.

The Effect of Ageing on Clinical, Hormonal and Sonographic Features Associated with PCOS-A Long-Term Follow-Up Study.

The knowledge of polycystic ovary syndrome (PCOS) natural history is limited. Our objective was to assess the effect of aging on clinical, hormonal and sonographic ovarian PCOS features and additionally to identify parameters that impact the course of PCOS. A secondary aim was to supply additional information on the reproductive outcome in women with previously diagnosed PCOS. A longitudinal cohort study with a median follow-up of 120.9 months was conducted, and 31 Caucasian women previously diagnosed with PCOS according to the Rotterdam criteria were re-examined at a median age of 35. Clinical examinations; transvaginal ultrasound scans; and lipid, E-selectin and sex hormone assessments were performed at the beginning and at the end of the follow-up. It was observed that menstrual cycles became regular and sonographic morphology of ovaries was normalized in 55% and 49% of the participants, respectively (all p < 0.05). At the final assessment, 55% of the women no longer met the criteria for PCOS (p < 0.05). The age, follicle-stimulating hormone (FSH) and E-selectin assessed at the baseline were the most important predictors of the PCOS persistence into later years (respectively, OR = 0.84, OR = 0.39, OR = 1.08, all p < 0.05). Ninety-five percent of the patients who had ever been trying to conceive became pregnant a minimum of once. The women with persistent PCOS had worse metabolic and reproductive parameters compared to the women with resolved PCOS. Positive correlations were found between the number of miscarriages and ovarian volume, LH, androstenedione, 17-hydroxyprogesterone and an increase in E-selectin during the follow-up (R = 0.46, R = 0.59, R = 0.54, R = 0.49, R = 0.47, all p < 0.05). In conclusion, progressing from the third to the fourth decade is connected with a reduction in PCOS features, which seems to have a great impact on fertility of women with a previous diagnosis of PCOS. FSH and E-selectin, as determined at the initial PCOS diagnosis, had an impact on the disappearance of the syndrome years after.

General population screening for ovarian cancer

Ovarian cancer is the most lethal gynaecological malignancy, in large part because it presents with non-specific symptoms and is often diagnosed at a late stage. 58% of ovarian cancers are metastatic at diagnosis, with a 5-year relative survival of only 30%.1 However, the 5-year relative survival for localised ovarian cancer is 93%.1 This factor has spurred great efforts to develop a screening tool that could allow for earlier detection of ovarian cancer in women who are asymptomatic. The CA125 blood test and transvaginal ultrasound scan (TVS) have been the most promising screening tools to date.