Transvaginal Ultrasound Guidance Research Articles

A 20 year experience in the management of non-tubal ectopic pregnancies in a tertiary hospital – a retrospective review

BackgroundNon-tubal ectopic pregnancies account for < 10% of all ectopic pregnancies. Due to its rarity and wide variation in clinical practice, there is no guideline or consensus for its management. We reported our 20-year experience in the management of non-tubal ectopic pregnancies in a tertiary hospital.MethodsThis is a retrospective review of all women admitted for non-tubal ectopic pregnancies from January 2003 to December 2022 in a tertiary hospital. Women with non-tubal ectopic pregnancies diagnosed by ultrasound or operation were included for analysis.ResultsWithin the study period, 180 women were diagnosed to have non-tubal ectopic pregnancies at a mean gestation of 6.8 weeks. 16.7% (30/180) were conceived via assisted reproduction. Medical treatment was the first-line management option for 81 women, of which 75 (92.1%) women received intralesional methotrexate administered under transvaginal ultrasound guidance. The success rate of intralesional methotrexate ranges from 76.5% to 92.3%. Intralesional methotrexate was successful even in cases with a positive fetal pulsation or with high human chorionic gonadotrophin levels up to 252605U/L. Twenty seven women were managed expectantly and 40 underwent surgery. Nine (11.1%), two (6.1%), and one (2.3%) women required surgery due to massive or recurrent bleeding following medical, expectant, or surgical treatment. Hysterotomy and uterine artery embolization were necessary to control bleeding in one Caesarean scar and one cervical pregnancy.ConclusionsIntralesional methotrexate is more effective than systemic methotrexate and should be considered as first line medical treatment for non-tubal ectopic pregnancies. It has a high success rate in the management of unruptured non-tubal ectopic pregnancies even in the presence of fetal pulsations or high human chorionic gonadotrophin levels, but patients may require a prolonged period of monitoring. Close surveillance and readily available surgery were required due to the risk of heavy post-procedural intra-abdominal bleeding.

PD14-11 PERCUTANEOUS URETHRAL SPHINCTER STIMULATION: SWINE MODEL FOR FEASIBILITY OF USE IN STRESS URINARY INCONTINENCE

You have accessJournal of UrologyCME1 Apr 2023PD14-11 PERCUTANEOUS URETHRAL SPHINCTER STIMULATION: SWINE MODEL FOR FEASIBILITY OF USE IN STRESS URINARY INCONTINENCE Kyle Waisanen, Tyler Maiers, Peter Natalzia, and Teresa Danforth Kyle WaisanenKyle Waisanen More articles by this author , Tyler MaiersTyler Maiers More articles by this author , Peter NatalziaPeter Natalzia More articles by this author , and Teresa DanforthTeresa Danforth More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003261.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Current treatment modalities for stress urinary incontinence (SUI) include pelvic floor physical therapy, urethral bulking agents, and urethral sling support. We aim to assess direct electrical external urethral sphincter stimulation as a means for treating SUI patients with intrinsic sphincter deficiency. The objective of this study was to assess the feasibility of percutaneous external urethral sphincter access and urethral pressure profiles associated with direct electric sphincteric stimulation. METHODS: An IACUC-approved swine model study was performed under general anesthesia. The urinary bladder was accessed by open cystotomy for placement of antegrade 7F urethral pressure catheter. Stimulation leads were deployed into the external urethral sphincter under transvaginal ultrasound guidance and antegrade urethroscopy was performed to confirm urethral integrity. Leads were then stimulated with serial increases in amplitude from an external pulse generator from 0.1 mA to 3.6 mA with pressure monitoring of the external urethral sphincter. RESULTS: Three swine subjects were utilized in the study. All subjects underwent successful percutaneous insertion of stimulation leads into the EUS without urethral violation. External urethral sphincter pressures recorded with electric stimulation amplitudes of 0 mA, 1.8 mA, and 3.6 mA were found to exhibit increased urethral pressures of 6-10 cm H2O, 16-20 cm H2O, and 31-36 cm H2O, respectfully. EMG capture was achieved in each subject with a corresponding increase in EMG activity with pulse generator amplitude increase represented in the urodynamic strip from subject #2 (Figure 1). CONCLUSIONS: Direct external urethral sphincter stimulation with increased urethral closure pressures is achievable by an ultrasound-guided percutaneous approach. Further studies are required to assess long-term effects and success of the stimulation in SUI modeled subjects with promising results seen in this preliminary proof-of-concept study. Source of Funding: Lent Foundation, University at Buffalo © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e416 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kyle Waisanen More articles by this author Tyler Maiers More articles by this author Peter Natalzia More articles by this author Teresa Danforth More articles by this author Expand All Advertisement PDF downloadLoading ...

Contribution of Outpatient Ultrasound Transvaginal Biopsy and Puncture in the Diagnosis and Treatment of Pelvic Lesions: A Bicenter Study.

The use of transvaginal ultrasound guided biopsy and puncture of pelvic lesions is a minimally invasive technique that allows for accurate diagnosis. It has many advantages compared to other more invasive (lower complication rate) or non-invasive techniques (accurate diagnosis). Furthermore, it offers greater availability, it does not radiate, enables the study of pelvic masses accessible vaginally with ultrasound control in real time, and it is possible to use the colour Doppler avoiding puncturing large vessels among others. The main aim of the work is to describe a standardized ambulatory technique and to determine its usefulness. This is a retrospective study of ultrasound transvaginal punctures (core needle biopsies and cytologies) and drainages of pelvic lesions performed on an outpatient basis during the last two years. The punctures were made with local anesthesia, under transvaginal ultrasound guidance with an automatic or semi-automatic 18G biopsy needle with a length of 20-25 cm and a penetration depth of 12 or 22 mm. The material obtained was sent for anatomopathological, cytological and/or microbiological study if necessary. A total of 42 women were recruited in two centers. Fifty procedures (nine punctures, seven drains, and 34 biopsies) were performed. In five cases the punction and drain provided clinical relief in benign pelvic masses. Regarding material of the biopsies performed, 15 were vaginal in women previously histerectomized, finding 10 carcinomas, eight were ovarian tumours in advanced stages or peritoneal carcinomatosis obtaining the appropriate histology in each case, seven were suspicious cervical biopsies finding carcinomas in five of them, three were myometrial biopsies including one breast carcinoma metastasis in the miometrium and a benign placental nodule, and a periurethral biopsy was performed on a woman with a history of endometrial cancer confirming recurrence. The pathological diagnosis was satisfactory in all cases, confirming the nature of the lesion (25 malignant-ten vaginal recurrences of previous gynaecological cancers, eight cases of primary ovarian/peritoneal carcinoma, four new diagnosis of cervical malignant masses, one cervical metastasis of lymphoma, one periurethral recurrence of endometrial carcinoma and one recurrence of breast cancer in the myometrium-and 23 benign). The tolerance was excellent and no complications were detected. The ambulatory ultrasound transvaginal puncture and drainage technique is useful for obtaining a sample for pathological and microbiological diagnosis with excellent tolerance that can be used to rule out the recurrence of malignant lesions or progression of the disease, diagnose masses not accessible to gynecological exploration (vaginal vault, myometrium or cervix) and for early histologic diagnosis in cases of advanced peritoneal carcinomatosis or ovarian carcinoma as well as drainage and cytological study of cystic pelvic masses.

Effect of intra-ovarian platelet rich plasma in women with poor ovarian response.

Poor ovarian responder (POR) women, whose ovarian response to gonadotropin stimulation has decreased, are at higher risk of unsuccessful in-vitro fertilization (IVF). Therefore, this study designed to evaluate the effect of intra-ovarian platelet rich plasma (PRP) on POR women. This single-arm trial research was done on 20 POR women referred to the IVF Unit, university-based hospital, Tehran, Iran between October 2020 and September 2021. For all participants, autologous PRP was injected into each ovary by transvaginal ultrasound guidance under spinal anesthesia between days 12 and 14 of the menstrual cycle. After 12 weeks of PRP injection, embryo transfers were carried out following our routine IVF department protocol. The study outcomes were the number of mature oocytes, and pregnancy rates. The average age of the participants was 41.80±1.82 yr. The average infertility duration was 9.70±1.89 yrs., with 80% primary infertility type. After PRP injection, follicle-stimulating hormone levels dropped about 1% (P=0.499), anti-Mullerian hormone levels were on average 4.5% higher (P=0.356), and estradiol levels raised by 1.2% (P=0.681). The average number of oocytes and their quality increased after PRP injection, while these changes were not significant (p-value>0.05). Chemical pregnancy was detected in 3 (15%) women and clinical pregnancy was detected only in one person. This study revealed that PRP injection into ovaries of POR women is safe and had a tendency to improve ovarian reserve markers and serum levels of AMH, estradiol, number and quality of oocytes.

Combined transabdominal and transvaginal ultrasound-guided percutaneous microwave ablation of uterine myomas: an effective monitoring technique

Objective This study compared the feasibility and efficacy of transabdominal ultrasound (TAU) and combined transabdominal and transvaginal ultrasound (TA/TV US)-guided percutaneous microwave ablation (PMWA) for uterine myoma (UM). Method This study enrolled 73 patients with UM who underwent PMWA via the transabdominal ultrasound-guided (TA group) or the combined transabdominal and transvaginal ultrasound-guided (TA/TV group) approaches. The intraoperative supplementary ablation rates, postoperative immediate ablation rates, lesion reduction rates and other indicators three months postoperatively were compared between the groups. The display of the needle tip, endometrium, uterine serosa, rectum and myoma feeding vessels under the guidance of TAU, transvaginal ultrasound (TVU) and TA/TV US were evaluated in the TA/TV group. Results In the TA/TV group, the real-time position of the needle tip and the endometrium complete display rate of the same lesions with TVU guidance were significantly higher than those using TAU. TA/TV US guidance significantly improved the complete display rate of each indicator. The intraoperative supplementary ablation rate in the TA/TV group was lower than that in the TA group. Similarly, the postoperative immediate ablation and volume reduction rates of the lesions three months postoperatively were higher than those in the TA group, especially for lesions with a maximum diameter ≥6 cm. Conclusion TA/TV US is an effective monitoring method that can be used to improve imaging display. Its use is recommended in patients with obesity, poor transabdominal ultrasound image quality and large myoma volumes.

Follicular flushing during oocyte retrieval in assisted reproductive techniques.

Follicular aspiration under transvaginal ultrasound guidance is routinely performed as part of assisted reproductive technology (ART) to retrieve oocytes for in vitro fertilisation (IVF). The process involves aspiration of the follicular fluid followed by the introduction of flush, typically culture media, back into the follicle followed by re-aspiration. However, there is a degree of controversy as to whether this intervention yields a larger number of oocytes and is hence associated with greater potential for pregnancy than aspiration only. To assess the safety and efficacy of follicular flushing as compared with aspiration only performed in women undergoing ART. We searched the following electronic databases up to 13 July 2021: the Cochrane Gynaecology and Fertility Specialised Register of Controlled Trials, CENTRAL (containing output from two trial registries and CINAHL), MEDLINE, Embase, and PsycINFO. We also searched LILACS, Google Scholar, and Epistemonikos. We reviewed the reference lists of relevant papers and contacted experts in the field to identify further relevant studies. We included randomised controlled trials (RCTs) that compared follicular aspiration and flushing with aspiration alone in women undergoing ART using their own gametes. Primary outcomes were live birth rate and miscarriage rate per woman randomised. Two review authors independently assessed studies identified by search against the inclusion criteria, extracted data, and assessed risk of bias. A third review author was consulted if required. We contacted study authors as needed. We analysed dichotomous outcomes using Mantel-Haenszel odds ratios (ORs), 95% confidence intervals (CIs), and a fixed-effect model, and we analysed continuous outcomes using mean differences (MDs) between groups presented with 95% CIs. We examined the heterogeneity of studies via the I2 statistic. We assessed the certainty of evidence using the GRADE approach. We included 15 studies with a total of 1643 women. Fourteen studies reported outcomes per woman randomised, and one study reported outcomes per ovary. No studies were at low risk of bias across all domains; the main limitation was lack of blinding. The certainty of the evidence ranged from moderate to very low, and was downgraded for risk of bias, imprecision, and inconsistency. We are uncertain of the effect of follicular flushing on live birth rate compared to aspiration alone (OR 0.93, 95% CI 0.59 to 1.46; 4 RCTs; n = 467; I2 = 0%; moderate-certainty evidence). This suggests that with a live birth rate of approximately 30% with aspiration alone, the equivalent live birth rate with follicular flushing lies between 20% and 39%. We are uncertain of the effect of follicular flushing on miscarriage rate compared to aspiration alone (OR 1.98, 95% CI 0.18 to 22.22; 1 RCT; n = 164; low-certainty evidence). This suggests that with a miscarriage rate of approximately 1% with aspiration alone, the equivalent miscarriage rate with follicular flushing lies between 0% and 22%. We are uncertain of the effect of follicular flushing on oocyte yield (MD -0.47 oocytes, 95% CI -0.72 to -0.22; 9 RCTs; n = 1239; I2 = 61%; very low-certainty evidence); total number of embryos (MD -0.10 embryos, 95% CI -0.34 to 0.15; 2 RCTs; n = 160; I2 = 58%; low-certainty evidence); and clinical pregnancy rate (OR 1.12, 95% CI 0.85 to 1.51; 7 RCTs; n = 939; I2 = 46%; low-certainty evidence). The duration of the retrieval process may be longer with flushing (MD 175.44 seconds, 95% CI 152.57 to 198.30; 7 RCTs; n = 785; I2 = 87%; low-certainty evidence). It was not possible to perform a meta-analysis for adverse events, although individual studies reported on outcomes ranging from depression and anxiety to pain and pelvic organ injury. The effect of follicular flushing on both live birth and miscarriage rates compared with aspiration alone is uncertain. Although the evidence does not permit any firm conclusions on the impact of follicular flushing on oocyte yield, total number of embryos, number of cryopreserved embryos, or clinical pregnancy rate, it may be that the procedure itself takes longer than aspiration alone. The evidence was insufficient to permit any firm conclusions with respect to adverse events or safety.

Pre-Surgical Transcervical Tru Cut Biopsy of Myometrial Lesions with Abnormal Ultrasonographic Appearance

<h3>Study Objective</h3> Determining safety, feasibility, and validity of transcervical Tru-cut biopsy (TCB) as complementary method in the management of uterine mass with abnormal ultrasound (US) features. <h3>Design</h3> Prospective pilot study. <h3>Setting</h3> Out-patient procedure without the need for anesthesia performed in lithotomic position with 18-gauge disposable core tissue biopsy needle under transvaginal US guidance. <h3>Patients or Participants</h3> Ten premenopausal women with atypical myometrial mass on transvaginal US examination indicated for laparoscopic myomectomy (LM) were included. The myometrial lesion was described using MUSA (Morphological Uterus Sonographic Assessment) criteria. <h3>Interventions</h3> All patients underwent transcervical TCB. Transcervical approach without disruption of the perimetrium was chosen to ensure the oncological safety and exclude dissemination of potentially malignant cells. Three tissue samples of the tumor were collected for histopathological analysis from each patient 2 to 4 weeks prior to the surgery. In case of benign TCB histology result, LM with the use of enclosed morcellation was performed as planned. Acquired specimen was analyzed and both histological results were compared. <h3>Measurements and Main Results</h3> In all 10 cases TCB was feasible and without any peri- or post-procedural complications. The histology results from TCB and LM were identical and non-malignant in all cases. Following histological findings were recorded: conventional leiomyoma in 7 cases, cellular leiomyoma in 1 case, epithelioid leiomyoma in 1 case, leiomyoma with bizarre nuclei in 1 case. <h3>Conclusion</h3> Although small, our pilot data suggest that TCB using the transcervical approach is feasible and safe for patients with planned myomectomy and abnormal US appearance of the uterine mass. TCB can thus provide reliable and precise histopathological data and may allow the surgeon to set up an adequate, mini-invasive, and still maximally safe treatment plan.

Myoma with Hypermenorrhea Treated with Ultrasound-Guided Microwave Ablation of the Inflowing Blood Vessels to the Uterine Myoma: A Case

Microwave endometrial ablation (MEA) is a minimally invasive treatment for uterine myoma with hypermenorrhea, which can replace conventional hysterectomy. However, cases requiring additional treatment because of postoperative recurrence are often encountered. MEA cauterizes the endometrium and is not recommended for patients who wish to preserve fertility. We present the cases of a patient with myoma-related hypermenorrhea who underwent microwave ablation of the inflowing blood vessels to the uterine myoma under transvaginal ultrasound guidance. A 43-year-old woman was diagnosed with chronic myeloid leukemia and treated with dasatinib 2 years ago. Worsening hypermenorrhea was observed after treatment initiation. Ultrasound and pelvic magnetic resonance imaging revealed a uterine myoma. Therefore, she underwent MEA under transvaginal ultrasound guidance. Visual analog scale evaluation demonstrated considerable improvement in hypermenorrhea and dysmenorrhea; the myoma size showed reduction. The postoperative course was uneventful, and the patient was discharged on the day after surgery. No postoperative complications were observed. This patient is currently undergoing infertility treatment. The microwave ablation of myoma under transvaginal ultrasound guidance can effectively and safely reduce the myoma size. These findings suggest that this method is a novel treatment option for patients with myoma-related hypermenorrhea who wish to preserve their fertility and have children.

A new technique for performing interstitial implants for gynecologic malignancies using transvaginal ultrasound guidance

ObjectivesThis study concerns a new technique that aims to achieve precise interstitial brachytherapy of pelvic recurrent tumors under transvaginal ultrasound (US) guidance, enhance the conformity index of the brachytherapy (BT), and improve the curative effect of radiotherapy for gynecological oncology patients with pelvic relapse.MethodsA real-time transvaginal US-guided interstitial implant device was developed to assist in implant BT. Prior to implant brachytherapy, the size and location of the tumor in the pelvis and the interrelationship with adjacent organs were first assessed with intracavitary ultrasound. The transvaginal US-guided interstitial implant device was then placed on the endoluminal ultrasound probe, the probe was oriented intravaginally to determine a safe needle path, the implant needle was placed into the needle passage of the device, and the implant needle was inserted into the tumor tissue in the direction guided by the ultrasound puncture guide line. After the implant needle was placed in place, the cover of the transvaginal US-guided interstitial implant device was opened perpendicular to the ultrasound probe, and the needle was separated from the ultrasound probe smoothly, and then the cover was re-covered for subsequent implantation.ResultsIn this study, 56 patients who underwent real-time transvaginal ultrasound-guided implantation for gynecologic oncology were enrolled, and insertion of 736 implant needles was completed. Among them, 13 patients had recurrent pelvic tumors after cervical cancer surgery and 6 patients had recurrent pelvic tumors after endometrial cancer surgery. Thirty-two patients who underwent radical radiation therapy for cervical cancer did not have adequate regression of parametrial invaded tissue after completion of standard EBRT treatment; and 5 patients had recurrent tumors in the radiation field after previous standard course of pelvic radiotherapy. The accuracy of the implant therapy was improved. The radiotherapy dose for recurrent pelvic masses was successfully increased, and the cumulative dose of external irradiation combined with BT was augmented to 80–100 Gy. The use of a new device for transvaginal implant for recurrent masses located in the lateral wall of the pelvic cavity was successful.ConclusionThis intravascular US-guided interstitial implant device can realize interstitial implant with the shortest path under transvaginal US guidance. With convenient operation, high precision, and good security, the device not only improves the accuracy of implant therapy, but it also reduces the risks of anesthesia and organ injury, so it is suitable for widespread promotion and use.

Comparison of Follicular Fluid Paraoxonase 3 Level, Ovarian Hormones and Oocyte Quality between Fertile and Infertile Women.

The purpose of the current study was to evaluate the possible effect of follicular fluid paraoxonase 3 (PON 3) on oocyte quality and sex hormones. This descriptive-analytical study was performed on totally 90 enrolled women including fifty infertile women presenting with polycystic ovaries and uni-lateral tubal factor and forty fertile women with male factor infertility referring to Umm-al-Banin Infertility Clinic in Dezful, Iran for in vitro fertilization during October 2018 to November 2019. Oocyte removal was carried out under transvaginal ultrasound guidance, and follicular fluid (FF) was removed and preserved to detect PON3, estrogen, and progesterone levels. In addition, oocyte number and quality were assessed and its association with PON3 activity in the FF was evaluated. Oneway ANOVA and Fisher's least significant difference (LSD) were used for data analysis and p≤0.05 were considered statistically significant. A significant increase was observed in the total number of the oocytes and mature metaphase II oocytes with ≥20 pg/ml of PON3 concentration in the FF (p≤0.05). Moreover, a positive relationship was shown between the increased estradiol level in follicular fluid and PON3, so that the highest estradiol level was observed in the amount of 31-40 pg/ml of PON3 (p≤0.05). According to the results, as the number of the mature oocytes increased, the amount of PON3 as well as estradiol levels in the FF increased. This research displays an increase in the level of PON3 with mature oocytes, thus supporting the indirect evidence for the function of PON3 in follicle development.

Uterine dehiscence: a laparoscopic uterine repair in early pregnancy

To review the existing literature on uterine cesarean scar defect repair in pregnancy and describe an approach to minimally invasive surgical repair in early pregnancy to facilitate a term live birth. A case study and literature review, followed by a demonstration of the procedure with surgical video and concurrent ultrasound footage. Academic medical center. This video is a case presentation of a 35-year-old, gravida 2, para 1 woman with a previous cesarean section. She presented at 10 weeks and 3 days gestational age with complete uterine dehiscence at the site of her previous cesarean section scar, which was diagnosed by ultrasound. Surgical video and medical images have been extracted from this patient's chart after consent was obtained. Ultrasound-guided laparoscopic repair of cesarean scar defect at 11 weeks and 3 days of gestation. The video showed a large 2.6-cm uterine scar defect in early pregnancy confirmed using ultrasound and magnetic resonance imaging. This diagnosis was confirmed by direct visualization at the time of surgery. This video demonstrates our surgical approach as follows: careful uterine manipulation and identification of the defect with laparoscopy and concurrent transvaginal ultrasound; reflection of the bladder using an ultrasound-guided approach to confirm the borders of the defect; and repair with a running 2-layer closure under transvaginal ultrasound guidance. Through ultrasound-guided laparoscopic repair, we were able to demonstrate a restoration of approximately 8 mm of myometrial thickness across the cesarean scar defect on antenatal follow-up. The patient had a term live birth via cesarean section. With an increased number of cesarean sections and improved quality of ultrasound imaging, an increase in the incidental findings of cesarean scar defects has been observed. The risk of spontaneous prelabor uterine rupture remains unknown. There is a literature gap in this area regarding the appropriate standard of care. This video demonstrates that ultrasound-guided laparoscopic repair was possible, safe, and effective in our patient. However, further studies are required to establish the safety and efficacy of this approach.

A comparative study of transabdominal and transvaginal ultrasound guidance on consequences of embryo transfer at Mahdiyeh hospital of Tehran in 2020: An RCT.

Background Infertility is an important problem that affects many couples worldwide. Assisted reproductive technology (ART) helps infertile couples to have offspring. One of the critical parts of ART is embryo transfer (ET).ObjectiveTo compare the effect of transvaginal and transabdominal ultrasonography-guided ET on ART outcomes.Materials and MethodsIn this randomized clinical trial study, 90 women who were candidates for in vitro fertilization (IVF) referred to Mahdiyeh hospital of Tehran, Iran during the yr 2020 were randomly divided into two groups (n = 45/each) of transvaginal and transabdominal ultrasonography-guided ET. The embryos were transferred two-three days after oocyte retrieval. The patient pain, duration and difficulty of the procedure, three-dimensional vision quality and successful pregnancy rate were measured.ResultsIn this study, 63.2% of the 45 women who underwent IVF under the guidance of the transvaginal guidance and 36.8% of the 45 women who underwent IVF under the transabdominal guidance had a successful pregnancy, which was not significantly different (p = 0.19). Also, based on other results there was no difference between the two groups in terms of patient pain (p = 0.53), duration (p 0.50), difficulty of procedures (p 0.50) and ultrasonography vision; however, the three-dimensional vision quality in the transvaginal ultrasonography was better than that in the transabdominal ultrasonography (p 0.01).ConclusionOverall, the ART outcomes in the transvaginal and transabdominal ultrasonography-guided ET were similar, so we suggest that physicians evaluate the patient's situation, the hospital equipment, and their ability before selecting the type of ultrasonography.

Safety and Efficacy of a Single Local Methotrexate Injection for Cesarean Scar Pregnancy

To investigate the safety and efficacy of a single local methotrexate (MTX) injection for the treatment of cesarean scar pregnancy (CSP), assess reproductive outcomes after treatment, and confirm clinical outcomes after the treatment of CSP patients according to the presence of fetal cardiac activity or serum human chorionic gonadotropin (hCG) levels. A retrospective cohort study. A university hospital. Women with CSP. Single local MTX injection under transvaginal ultrasound guidance. A total of 45 CSP cases were identified; the mean (standard deviation, range) estimated gestational age was 7.7 (1.7, 5.4-12.5) weeks and the mean serum hCG level was 51 801 (40 761, 2307-187 898) mIU/mL. Three cases required additional treatment with MTX, and none of the cases needed uterine artery embolization or hysterectomy. The success rate for a single dose was 93.3%, and it was 100% if additional treatments with MTX were included. The mean time required for hCG normalization in those with fetal cardiac activity or with an initial level of hCG greater than 100 000 mIU/mL was not significantly longer than that in the controls (93.4 vs 77.1 days, p=.12; 113.7 days vs 83.6 days, p=.10). Of the 23 women who desired a subsequent pregnancy, 13 delivered 14 healthy newborns after treatment, 3 had an ongoing pregnancy, and 3 experienced recurrent CSP. A single local MTX injection is safe and effective for the treatment of CSP despite the presence of fetal cardiac activity or any initial level of hCG and may allow the possibility of a subsequent uneventful pregnancy.

Cesarean scar pregnancy treatment: a case series

BackgroundCesarean scar pregnancy is a complicated and potentially life-threatening type of ectopic pregnancy. This study reports two women with cesarean scar pregnancy who were successfully treated with systemic methotrexate administration, and two other women who needed local re-administration of methotrexate after systemic injection.Case presentationFour Iranian pregnant women aged 29–34 years who were between 5 to 7 gestational weeks with cesarean scar pregnancy diagnosis are described. After a single dose of systemic methotrexate injection, the level of serum beta-human chorionic gonadotropin decreased in two of the women, while fetal activity was observed in the other two women. In the latter patients, methotrexate was injected under transvaginal ultrasound guidance into the gestational sac. As a result, the serum beta-human chorionic gonadotropin level first increased and then decreased in these patients. During the follow-up period, all the patients were stable and no complications were observed. Serum beta-human chorionic gonadotropin levels reached the non-pregnancy range from 4 to 9 weeks after treatment.ConclusionWhen diagnosed at early gestation, cesarean scar pregnancy can be treated successfully with methotrexate administration alone. The clinicians should be aware that the beta-human chorionic gonadotropin level may initially increase after methotrexate injection in some patients. However, the final outcome will be promising if the patients remain stable.

Management of 14 patients with cornual heterotopic pregnancy following embryo transfer: experience from the past decade

ObjectiveThere are two major management approach for cornual heterotopic pregnancy, transvaginal cornual embryo reduction with ultrasound guidance, or laparoscopic cornual resection. This no consensus on the optimal management for cornual heterotopic pregnancy. Here, we are trying to determine the optimal management approach for patients with viable cornual heterotopic pregnancy following embryo transfer.MethodsThis is a retrospective cohort study conducted at the locally largest reproductive center of a tertiary hospital. A total of 14 women diagnosed as viable cornual heterotopic pregnancy following embryo transfer. Six patients were treated with cornual pregnancy reduction under transvaginal ultrasound guidance without the use of feticide drug (treatment 1), and eight patients were treated with laparoscopic cornual pregnancy resection (treatment 2).ResultsAll 14 patients of cornual heterotopic pregnancy following embryo transfer due to fallopian tubal factor, among which, 12 patients had cornual pregnancy occurred in the ipsilateral uterine horn of tubal pathological conditions. Nine (64.29%) showed a history of ectopic pregnancy. Thirteen (92.86%) patients were transferred with two embryos and only one patient had single embryo transferred. Six patients received treatment 1, and 2 (33.33%) had uterine horn rupture and massive bleeding which required emergency laparoscopic surgery for homostasis. No cornual rupture occurred among patients received treatment 2. Each treatment group had one case of spontaneous miscarriage. The remaining 5 cases in treatment 1 group and the remaining 7 cases in treatment 2 group delivered healthy live offspring.ConclusionPatients with tubal factors attempting for embryo transfer, especially those aiming for multiple embryos transfer, should be informed with risk of cornual heterotopic pregnancy and the subsequent cornual rupture. Compared with cornual pregnancy reduction under transvaginal ultrasound guidance, laparoscopic cornual resection might be a favorable approach for patients with viable cornual heterotopic pregnancy.

Successful conservative treatment of cesarean scar ectopic pregnancy with local injections of absolute ethanol

Cesarean scar ectopic pregnancy (CSEP) is becoming more common worldwide. Here, we report a case of cesarean scar pregnancy successfully treated using transvaginal ethanol injection. A 31-year-old female (gravida 3, para 2) with two prior cesarean sections presented at 9 weeks and 3 days of pregnancy. Her serum human chorionic gonadotropin level was 91,798 mIU/mL. CSEP was confirmed by transvaginal ultrasonography, pelvic magnetic resonance imaging, and color Doppler ultrasonography. Transvaginal absolute ethanol local injection under transvaginal ultrasound guidance was performed. She was discharged 7 days after treatment with no complications and resumed normal menses 1 month after treatment. We describe a safe and successful treatment option for CSEP.

Oocyte recovery rates in flushing versus nonflushing during oocyte retrieval in assisted reproductive techniques

Follicular aspiration under transvaginal ultrasound guidance is performed as part of assisted reproductive technology (ART) to retrieve oocytes for in vitro fertilization (IVF). However, controversy as to whether follicular flushing following aspiration yields a larger number of oocytes than aspiration only is ongoing. The aim of this study was to assess the safety and efficacy (oocyte recovery rates) of follicular flushing when compared with aspiration only performed in women undergoing ART. The study was conducted at Sir Gangaram Hospital, New Delhi. Retrospective data of 100 females undergoing ART was taken from September 2019 to September 2020. Patients were divided into two groups of 50 each. In first group, patients underwent oocyte retrieval using double lumen needle (flushing technique) and in the second group, single lumen needle (no flushing) were used. Females with age ≤37 years who were having ≤9 follicles, size ≥14 mm during oocyte retrieval when undergoing ARTs. Categorical variables were presented in number and percentage (%) and continuous variables, as mean ± standard deviation and median. Normality of data was tested by Kolmogorov–Smirnov test. If the normality was rejected, then nonparametric test was used. Quantitative variables were compared using Mann–Whitney test. Follicular flushing had significantly better oocyte recovery rates when compared with no flushing (P 0.05) in M2 rates in patients undergoing intracytoplasmic sperm injection (ICSI) when compared in both the groups. There was no significant difference (P > 0.05) in fertilization rates in patients undergoing IVF and ICSI, respectively, in both the groups. Double lumen needle with flushing technique gives better oocyte recovery rates in low responder women undergoing ARTs. Hence, follicular flushing may be considered in such patients for oocyte retrieval.

OVARIAN AUTOLOGOUS PLATELET-RICH PLASMA (PRP) TREATMENT IMPROVES OOCYTE AND EMBRYO QUALITY IN WOMEN WITH POOR OVARIAN RESPONSE

The application of platelet rich plasma (PRP) as a non-operative treatment is an innovative approach, introduced only recently in reproductive medicine. A few case studies have shown that intraovarian injection of PRP in women with poor ovarian reserve resulted in an increased number of MII oocytes and cleavage-stage embryos. However, little is known about the effect of autologous ovarian PRP treatment on oocyte and embryo quality. The objective of the present study was to evaluate the role of ovarian PRP treatment on the number and quality of oocytes and embryos in women with poor ovarian response undergoing IVF cycles. Prospective cohort study A total of 132 women with a history of poor ovarian response (according to the Bologna criteria) in the previous cycle(s) were included in this prospective study between June 2019 and February 2020. They were treated with ovarian autologous PRP injection in two subsequent menstrual cycles. Approximately 21 ml autologous blood obtained from peripheral vein was obtained and used to prepare PRP following standard protocols. PRP injection was performed using a 21Gx11.8 inch needle under transvaginal ultrasound guidance. Antral follicle counts (AFC) and FSH levels were determined at baseline. Biomarkers of ovarian reserve (AFC and FSH) and IVF outcome variables (fertilization rate, number and quality of MII oocytes, and the number and quality of blastocysts) were recorded and compared between the cycle before and after PRP treatment. All collected oocytes and obtained Day 5 embryos were graded morphologically (Grades 1–3; Grade 1 being highest relative quality and Grade 3 being the lowest quality of the three grades) based on the standard methods. The results were analysed using Student’s paired t-test. P<0.05 was considered statistically significant. Ovarian PRP treatment resulted in insignificantly lower FSH (12.6±1.46 vs. 13.8±1.55, P=0.37) and slightly higher number of mature follicles (3.4±1.8 vs. 2.8±1.5, P=0.56). There were also insignificant increases in the number of retrieved oocytes (4.71±2.6 vs. 4.63±2.8, P=0.34, respectively), fertilization rate (81 vs. 79, P = 0.81) and, consequently the total number of Day 5 embryos (3.93±0.43 vs. 3.29±0.39, P=0.23). However, the percentage of high-quality MII oocytes (67.2% vs. 40.7%, P=0.03) and the percentage of grade-I blastocysts (65.56% vs. 45.89%, P=0.05) were significantly higher after PRP treatment in comparison to the pretreatment period. In addition, the mean MII oocyte quality (1.76±0.61 vs. 2.03±0.73, P=0.05) and blastocyst quality (1.49±0.57 vs. 2.11±0.92, P=0.03) were significantly improved in the post-treatment period. The applied autologous ovarian PRP treatment is an effective approach in improving oocyte and embryo quality in poor responders. This approach may contribute to increased pregnancy rates.

IMAGE-Guided Brachytherapy for Primary Vaginal Cancers

To evaluate disease control and toxicities of primary vaginal cancer treated with image-guided brachytherapy. A retrospective study was performed on 26 consecutive patients treated for vaginal cancer with brachytherapy (BT) between 2010 and 2018, all treated after the introduction of ultrasound-based catheter guidance and modified dose optimization to reduce vaginal toxicities. External beam radiation therapy (EBRT) was used in 25/26 patients, with a median dose of 45 Gy in 25 fractions. 16/25 patients had concomitant chemotherapy with EBRT. Endocavitary BT alone was used in 3/26 patients. Interstitial BT was used in 23/26 patients. Standard procedure involved the use of a cylinder and interstitial catheters. They were usually inserted under Transrectal Ultrasound (TRUS) and/or TransVaginal Ultrasound (TVUS) guidance. Inverse Planning Simulated Annealing (IPSA) was used for dose optimization and a class solution was developed to reduce high-dose points in the vaginal mucosa by keeping most of the high dose inside the cylinder. Acute (<6 months) and late genitourinary (GU), gastrointestinal (GI), and vaginal toxicities were reported using the Common Terminology Criteria for Adverse Events version 5 (CTCAE v5). Local control (LC), metastatic disease-free survival (mDFS) and overall survival (OS) were evaluated using Kaplan-Meier survival curves. Mean age was 69,7 years old. Median follow-up was 35,5 months (range 0-85months). 18/26 patients had Squamous Cell Carcinoma (SCC), 5/26 Adenocarcinoma, 1/26 Clear Cell Carcinoma, 1/26 Melanoma and 1/26 Squamous Transitional Carcinoma. 13%, 71%, 8%, and 8% of patients had FIGO stages I, II, III, and IV respectively. LC of 83% and 83%, mDFS of 91 % and 91%, and OS of 80% and 66 %, were respectively achieved at 3 and 5 years. When limited to SCC only, LC of 88% and 88%, mDFS of 94 % and 94%, and OS of 87% and 70 %, were respectively achieved at 3 and 5 years. There were only 4 local relapses, which all occurred within 8 months after treatment. One was a stage IV SCC at diagnosis, one had a squamous transitional carcinoma, one was a clear cell carcinoma, and the last one had concomitant multiple distant metastasis at time of local relapse. There were no late G3-4 GU/GI toxicity. Acute and late G3 vaginal toxicity (stenosis) occurred in 19% and 42% of patients, respectively. 3 cases of vaginal necrosis and 1 suspicion of fistula were reported, all associated with a local progression of the disease except for one case where necrosis was limited and healed spontaneously. No patient needed Hyperbaric Oxygen Therapy (HBOT). Excellent local control can be achieved with the use of TRUS/TVUS-guided vaginal brachytherapy in primary vaginal cancer, especially for Squamous Cell Carcinoma, with a favorable toxicity profile. GU and GI toxicities are mild, but there is a significant number of G3 vaginal stenosis in this cohort of older patients. This might be reduced with the regular use of a vaginal dilator.

Transvaginal needle versus laparoscopic ovarian drilling in drug-resistant polycystic ovary syndrome: a randomized, controlled study

Objective The aim of this study was to evaluate the outcome of ovarian needle drilling using transvaginal ultrasound guidance as an alternative to the traditional laparoscopic electrosurgical drilling for patients with polycystic ovary syndrome (PCOS). Background Ovarian drilling has been established as a treatment for drug-resistant PCOS. Patients and methods The study comprised 84 patients with PCOS who are resistant to ovulation induction using clomiphene citrate. The patients were randomly divided into two groups; in the first group of 42 patients ovarian needle drilling was done using transvaginal ultrasound guidance, whereas in the other group of 42 patients laparoscopic electrosurgery ovarian drilling was done. Results No significant differences were found between the two groups with regard to age, parity, BMI, and ultrasound finding of PCOS. The duration of ultrasound-guided transvaginal ovarian drilling was 15.59 ± 2.83 min, whereas it was 38.45 ± 5.46 min for laparoscopic drilling, with a statistically significant difference between the two groups. There were significant improvements after intervention in both groups without differences regarding resumption of regular menstruation, improvement of hyperandrogenic symptoms such as acne and hirsutism, occurrence of ovulation, and pregnancy. As regards hormonal profiles; serum luteinizing hormone, and luteinizing hormone/follicle stimulating hormone levels, were found to be markedly decreased after intervention in both groups. Conclusion The results of this study have shown that the outcome of a simple rapid technique such as ultrasound-guided transvaginal ovarian drilling was comparable to the standard laparoscopic monopolar drilling in resumption of regular menstruation, improvement of hyperandrogenic symptoms, occurrence of ovulation and pregnancy in patients with PCOS resistant to ovulation induction using clomiphene citrate without all the risks expected from the later.