Endometrial Ablation With the Nd-yag Laser in Dysfunctional Bleeding

Endometrial laser ablation (ELA) was evaluated in two consecutive series of 50 and 100 patients with dysfunctional bleeding without intrauterine lesions. ELA of the entire cavity was carried out in the first series with an amenorrhoea rate of 34% and a hypomenorrhoea rate of 60%. In the second series, 'partial' endometrial laser ablation (PELA) was carried out in order to provoke not a complete amenorrhoea but a reduction of heavy menstrual flow. Amenorrhoea and hypomenorrhoea rates were 1% and 93% respectively. In conclusion, endometrial laser ablation could be proposed as an alternative to hormonal therapy or hysterectomy in dysfunctional bleeding without intrauterine lesions

Neodymium: YAG laser hysteroscopy in large submucous fibroids.

The preoperative use of a potent, subcutaneously injected gonadotropin-releasing hormone agonist (GnRH-a) was evaluated in a series of 60 women with large submucosal fibroids. Myomectomy by hysteroscopy and Nd:YAG laser was easily performed. In 12 cases, the largest portion of the myoma was not inside the uterine cavity and myomectomy was carried by a two-step hysteroscopy. In women who wished to become pregnant, a pregnancy rate of 66% was achieved. Advantages of preoperative use of a GnRH-a are (1) the significant decrease of the fibroid size, (2) a lower fluid absorption, and (3) the restoration of a normal hemoglobin concentration

Treatment of uterine fibroids with implants of gonadotropin-releasing hormone agonist: assessment by hysterography.

The effect of a potent, subcutaneously injected gonadotropin-releasing hormone (GnRH analog) (Buserelin, Hoechst, Frankfurt/Main West Germany) on the size of uterine leiomyomas and the uterine cavity area was studied in a group of 20 women. In all patients except 1, the uterine cavity area calculated by hysterosalpingography was decreased, with an average decrease of 35% (from 12.0 +/- 5.4 cm2 to 7.8 +/- 3.3 cm2) by 8 weeks of therapy. Significant decrease was observed in the group of women with initial uterine cavity area greater than 10 cm2. In patients with very large submucous fibroids, myomectomy by hysteroscopy and neodymium:YAG laser was easily performed. Rapid relief of symptoms such as menometrorrhagia permits the restoration of a normal hemoglobin concentration. In conclusion, use of GnRH analog represents an adjunct for preoperative reduction of tumor size and may permit surgical treatment by hysteroscopy

In vitro fertilization outcome according to age and follicle-stimulating hormone levels on cycle day 3.

PURPOSE: In a retrospective study, the prognostic factors of in vitro fertilization outcome were studied in women of 39 years of age or older, with an elevated cycle day 3 follicle-stimulating hormone (FSH) level. METHODS: Ovarian stimulation was achieved with a combination of gonadotropin-releasing hormone agonist/human menopausal gonadotropin in a short protocol. All patients underwent FSH dosage on cycle day 3 prior to stimulation. The pregnancy rate was studied according to age, FSH levels, and stimulation parameters. RESULTS: There was a negative correlation between day 3 FSH levels and the number of ovocytes retrieved. Cycles canceled because of the absence of ovarian response had a significantly higher mean FSH value (18.2 mlU/ml) than cycles ending in ovocyte retrieval (14.6 mlU/ml). Patients with three or more growing follicles during stimulation achieved a significantly higher pregnancy rate per egg retrieval (16%) compared to patients with fewer than three growing follicles (6%). Eighty percent of those pregnancies were obtained during the first two IVF cycles. Even with an elevated FSH level, some patients developed three or more follicles after stimulation. In such cases, the number of embryos available for transfer was the only significant limiting factor to achieving pregnancy. CONCLUSIONS: As our results suggest, there is a discrepancy between biological and chronological ovarian age. In patients with an elevated cycle day 3 FSH level and over 40 years of age, alternatives to fertility treatments (ovum donation, adoption, or no treatment) should not be considered as first choices. Indeed, even with elevated FSH levels, a 16% pregnancy rate per egg retrieval may be obtained if three or more growing follicles can be seen during ovarian stimulation. However, in the presence of fewer than three growing follicles during ovarian stimulation, the patient should be informed about the discouraging prognosis of the running cycle

La place des agonistes de la GnRH dans le traitement par voies endoscopiques de l'endométriose et des fibromyomes.

Uterine myomas and endometriosis are benign pathologies frequently encountered in women. Myomas are often associated with infertility and/or menorrhagia particularly if they are sub-mucosal. Endometriosis is diagnosed in more than 35% of infertile patients. These two common pathologies are oestrogen-dependent and the administration of a GnRH agonist has been proposed as a non-surgical approach to the treatment of myomas and endometriosis. GnRH agonists cannot, however, be considered as definitive medical therapy because most myomas and endometriotic cysts return to their initial size within 4 months following the cessation of treatment. Moreover, because of the menopausal-like state that they induce, GnRH agonists provoke bone demineralization and for this reason, their long-term use is not recommended. These agents should, therefore, be considered as an adjuvant preoperative therapy. The aim is, above all, to achieve a preoperative reduction of tumour size, thus facilitating the endoscopic surgery: either hysteroscopic resection in the case of sub-mucosal myomas, or vaporization of ovarian cysts in the case of cystic endometriotic lesions

[Endometrial evaluation prior to tamoxifen: preliminary results of a prospective study]

The objective of this study was to try to identify by pretreatment screening, a group of patients at higher risk of developing endometrial carcinoma on tamoxifen. Between January 1993 and January 1997, 360 postmenopausal patients with breast cancer were enrolled in this prospective study. Basal screening included gynaecologic examination with a Papanicolaou smear and endovaginal sonography. In the case of an abnormal ultrasound (endometrial thickness greater than 4 mm), an outpatient hysteroscopy with an endometrial biopsy was carried out. There examinations were repeated annually. By means oft his preliminary evaluation, two groups of patients were identified: patients without initial lesions (group I) and patients with initial endometrial lesions (group II). These two groups of patients were followed up separately exactly in the same way. Endometrial lesions taken into account were: adenocarcinomas (in situ and invasive), polyps with or without atypia, myomas and adenomyotic lesions with irregular mucosa. After 3 years and after 4 years of follow-up, the percentage of atypical lesions was significantly higher in the group with initial lesions than in the group without initial lesions. This study suggests that a group of high risk patients more sensitive to the carcinogenic effect of tamoxifen can be identified by pretreatment evaluation