Splenic artery aneurysm rupture is a rare complication of pregnancy with very high maternal and fetal mortality rate. In this paper, a case of splenic artery aneurysm rupture at 34 weeks of gestation with both maternal and fetal survival is presented.

Background: This retrospective study compares the safety and efficacy of temporary ovarian suspension (TOS) to the anterior abdominal wall using absorbable versus non-absorbable suture after operative laparoscopy to elevate the ovaries away from the ovarian fossa to reduce postoperative adhesion development. Methods: Patients (n=152) underwent TOS to the anterior abdominal wall at the conclusion of surgery between 1998 and 2017. One hundred forty-two patients underwent operative laparoscopy for advanced stages of endometriosis (93.4%) and 10 patients for other indications (6.6%). In 78 patients the ovaries were suspended to the fascia using absorbable 3-0 plain catgut sutures (Group 1). In 74 earlier patients non-absorbable 3-0 mono-filamentous nylon was used to suspend the ovaries to the anterior abdominal (Group 2). Results: In both groups there was no reported incidence of any major intra-operative complications such as bleeding, or late complications such as infection, hematoma or bowel herniation through the suture loop and its sequalae (bowel obstruction or strangulation). In all patients in both groups the ovaries were present in its anatomical location on transvaginal ultrasound scan, one week after surgery following absorption or removal of the TOS suture. There was no significant difference in clinical pregnancy (34.3% vs 44.2%) and delivery (31.3% vs 36.5%) rates in patients who conceived with non-IVF methods between Group 1 and Group 2 respectively. Conclusions: TOS to the anterior abdominal wall, using absorbable or non-absorbable sutures, in an attempt to reduce postoperative adhesion development between the ovary and ovarian fossa, is simple, safe, easy to learn, and has potential effectiveness.

STUDY OBJECTIVE:To demonstrate a modified technique of temporary suspension of the ovary to the fascia of the anterior abdominal wall after operative laparoscopy for advanced stage-endometriosis to reduce postoperative adhesion formation.DESIGN:Video illustrating this modified technique of ovarian suspension (Canadian Task Force classification III).SETTING:A previous study described a technique of temporary suspension of the ovary to the abdominal wall using nylon suture [1]. Here we demonstrate a modification of this technique involving underwent temporary suspension of the right ovary, using dissolvable 3-0 plain catgut suture, after operative laparoscopy for advanced-stage endometriosis (American Society for Reproductive Medicine stage III classification).INTERVENTIONS:This patient underwent right ovariolysis for stage III endometriosis. A CO2 laser was used to evaporate spots of endometriosis on the surface of the ovary, ovarian fossa, and the wall of a small endometrioma. A 3-0 plain catgut suture was placed in the right ovarian ligament, and the needle was cut and removed from the peritoneal cavity. The ends of the sutures were brought out of the peritoneal cavity through a 3-mm skin incision using an Endo Close device (Medtronic, Minneapolis, Minnesota). The suture was tied over the fascia while allowing CO2 gas out of the peritoneal cavity, to ensure that the suture remained under tension and the ovary was well suspended without touching the abdominal wall. The suture was used to elevate the ovary away from the ovarian fossa, to avoid recurrence of adhesions between it and the ovary. Postoperatively the patient did well and was discharged home on oral pain medication on the same day of surgery. No postoperative complications related to the suspension procedure were reported. The patient had an uneventful recovery.CONCLUSION:This modified approach of temporary ovarian suspension to the fascia of the anterior abdominal wall appears to be simple, safe, and easy to learn.

Study ObjectiveTo determine the incidence of postoperative ascending infection without antibiotics with the use of a pediatric Foley catheter (PFC) after operative hysteroscopy for intrauterine pathology.DesignRetrospective case series (Canadian Task Force classification III).SettingUniversity-affiliated outpatient medical center.PatientsPatients who underwent operative hysteroscopy for uterine septum, arcuate uterine anomaly, or multiple submucosal myomas between 1992 and 2015.InterventionsIn all patients, a PFC was placed in the endometrial cavity at the conclusion of operative hysteroscopy and left in place for 7 days to reduce intrauterine adhesion formation.Measurements and Main ResultsA total of 1010 patients who underwent operative hysteroscopy for uterine septum (n = 479), arcuate uterine anomaly (n = 483), or multiple submucosal myomas (n = 48) were studied. All patients presented with infertility, recurrent pregnancy loss, or excessive uterine bleeding (in patients with submucous myomas). In all patients, a PFC was placed at the conclusion of the procedure and left in place for 7 days. An 8Fr PFC was used after hysteroscopic division of uterine septum or arcuate uterine anomaly, and a 10Fr PFC was used after hysteroscopic myomectomy. Patients with a history of pelvic inflammatory disease were excluded. Following PFC placement, patients were prescribed estrogen for 6 weeks and progestogen for the last 10 days of the estrogen course. No prophylactic antibiotic therapy was provided. All patients were discharged to home on the same day. Postoperative pain was well controlled with oral pain medication in 98.5% of the patients. There were no reported postoperative infections, and all patients had an uneventful recovery.ConclusionIn 1010 consecutive operative hysteroscopies followed by temporary (7-day) PFC placement, no clinically significant uterine infection was observed.

cant. RESULTS: In the implanted group, 21(51.2%) embryos were observed withmononucleationat2-cellstage,while15(36.6%)presented1-cellmultinucleation (C1), 5 (12.2%) presented both cells multinucleation(C2), and 5 (12.2%) presented RC. In the non-implanted group, 25(50%) embryos were observed with mononucleation at 2-cell stage, while 14 (28%) presented C1, 11 (22%) presented C2, and 6 (12%) presented RC. Comparisons of 2-cell stage mononucleation and multinucleation rates between implanted and non-implanted were not significant. The implantation rates of mononucleation, C1, and C2 were 45.7%, 51.7%, and 31.3% respectively. The implantation rates of RC and non-RC groups were 45.5 % and 45%. The differences between these implantation rates were not significant, either. CONCLUSION: Blastocysts from mono and multinucleated 2-cell embryos have equal chances of implantation success. Reverse cleavage is not a significant factor in unsuccessful implantation.

Introduction: Interstitial pregnancy is a rare and life-threatening condition. Diagnosis and appropriate management are critical in preventing morbidity and death. Case Description: Four cases of interstitial pregnancy are presented. Diagnostic laparoscopy followed by laparotomy and cornuostomy with removal of products of conception was performed in 1 case. Laparoscopic cornuostomy and removal of products of conception were performed in the subsequent 3 cases with some modifications of the technique. Subsequent successful reproductive outcomes are also presented. Discussion: Progressively conservative surgical measures are being used to treat interstitial pregnancy successfully, with no negative impact on subsequent pregnancies.

To help determine the relationship between assisted reproductive technology (ART) and risk for preterm birth (PTB) by comparing the incidence of PTB in women with primary infertility, normal uterine cavity, and subsequent singleton gestation conceived spontaneously (SC), via intrauterine insemination (IUI), or in vitro fertilization (IVF). A retrospective cohort study was conducted on data collected from 1992 to 2011. The study included women with a diagnosis of primary infertility and normal uterine cavity by hysteroscopic evaluation who subsequently achieved a singleton gestation by SC ± Clomid, IUI, or IVF. IUI and IVF groups underwent similar ovarian stimulation protocols. The primary outcome was PTB defined as < 37 completed weeks of gestation. Secondary outcomes were gestational age (GA) at delivery and birth weight (BW). Statistical analysis was performed using ANOVA and Chi-square test. 166 women were included in the study. 56 conceived spontaneously, 41 with IUI, and 69 with IVF. No significant difference was noted between the three groups with regards to maternal characteristics including age, BMI, duration of infertility, baseline FSH values, or etiology of infertility. There was no significant difference in the incidence of PTB, mean GA at birth, or mean BW between the SC, IUI, and IVF groups. 21% of the SC group, 34% of the IUI group, and 21% of the IVF group resulted in PTB. Mean GA at delivery was 38.2 ± 2.8 for the SC group, 37.6 ± 2.8 for IUI, and 38.2 ± 2.6 for IVF. Mean BW (kg) was 3.35 ± 0.7 for the SC group, 3.15 ± 0.6 for IUI, and 3.18 ± 0.7 for IVF. In women with primary infertility and normal uterine cavity, we found no significant difference in PTB, mean GA at delivery, or mean BW between the SC, IUI, and IVF groups. The relationship between ART and risk of PTB and low BW may be a result of undiagnosed uterine cavity abnormality rather than ART itself.

Background: We describe a patient with a single large type II submucous fibroid distorting and occupying the entire endometrial cavity, which was managed successfully with an approach less invasive than laparotomy. Case: The patient was a 36-year-old woman who presented with primary infertility of 2 years duration. Her associated complaints were menorrhagia and known uterine fibroids. She had undergone hysteroscopic myomectomy in the past without any improvement. An hysterosalpingogram revealed that the uterine cavity was occupied by a single large submucosal fibroid. Transvaginal ultrasound and saline infusion hysterosonogram showed a large anterior type II submucous, intramural, subserous fibroid. Diagnostic hysteroscopy and laparoscopy revealed a type II submucous fibroid occupying the entire anterior wall of the uterus. Laparoscopic myomectomy was performed and a fibroid measuring 8 cm was dissected. During the process, the endometrial cavity was entered and a minilaparotomy via a 5-cm transverse skin incision was performed to repair the endometrial cavity and overlying myometrium adequately and to remove the myoma. Results: Her postoperative course was uneventful. Six weeks later, saline infusion hysterosonogram revealed a uniform endometrial cavity with no filling defects or synechiae. Conclusions: Laparoscopic myomectomy with minilaparotomy is a safe, cost effective, and less invasive approach for the treatment of patients with large type II submucous fibroids who want to preserve their reproductive potential.

Background: This case report describes an infertile patient with a rare endometrial cavity pathology diagnosed on hysteroscopy. Case: The patient was a 39-year-old female with primary infertility of 9 years' duration. A diagnosis of a possible T-shaped uterus on a previous hysterosalpingogram was not confirmed on diagnostic hysteroscopy 5 years earlier at a different infertility center, where she had undergone a cycle of in-vitro fertilization with embryo transfer (IVF-ET) but was unable to conceive. At the time of diagnostic hysteroscopy at the current, unit the patient was found to have a T-shaped cavity and a trans-fundal uterine membrane obscuring an arcuate fundus. Hysteroscopic division of this thin membrane was performed successfully, followed by hysteroscopic division of the uterine septum and hysteroscopic metroplasty of her T-shaped uterus. Results: Subsequently, the patient conceived with IVF-ET but had an early miscarriage. A second IVF-ET cycle resulted in resulted in delivery of a healthy male infant at term. Conclusions: This report described a case of an infertile patient with a trans-fundal membrane in association with a uterine anomaly. The discovery of such a membrane and the uterine anomaly described above, and their hysteroscopic surgical correction, may have contributed to the successful reproductive outcome for this patient.

Background: We describe a patient presenting with recurrent pregnancy loss secondary to concurrent uterine factors. Case: The patient was a 31-year-old white female who presented with recurrent pregnancy loss on two occasions. The couple had a normal work-up for recurrent miscarriages except for a fundal type II submucosal fibroid on transvaginal 3D ultrasound (US) with saline infusion hysterosonogram (SIH). Laparoscopic myomectomy and repair of the myometrial defect was performed. At the conclusion of the procedure, a diagnostic hysteroscopy suggested a possible concurrent incomplete short uterine septum, which could not be corrected for fear of cutting the myomectomy sutures. The patient did not appear for follow up, which led her to have three more miscarriages and one chemical pregnancy. The presence of a short uterine septum was confirmed on SIH with 3D US. The patient underwent hysteroscopic division of the short uterine septum. Results: Postoperative SIH showed a normal uterine cavity, and currently the patient is trying to conceive. Conclusion: Coexistence of a type II submucous fibroid in the fundal region of the uterus and an incomplete uterine septum presents both a diagnostic and management challenge. Surgical management of such coexisting uterine pathology cannot be performed in a single session.

To compare the implantation rates in two groups of women with Polycystic Ovary Syndrome (PCOS) after embryo transfer based on the initiation time of GnRH antagonist. Secondary outcome measures included clinical pregnancy, delivery and miscarriage rates. This is a prospective, randomized trial in which 140 PCOS patients underwent ICSI, with 122 having ET performed. GnRH-antagonist was started on day 1 of stimulation in 69 patients (Group 1) or day 5 in 71 patients (Group 2). The overall implantation rate in Group 1 (46.2 %) was clinically higher than Group 2 (35.5 %), although not statistically significant (p = 0.075). For blastocysts transfer, the implantation rate in Group 1 was 55.1 %, compared to 40.4 % in Group 2 (p = 0.051). There was a clinically, but not statistically, higher clinical pregnancy rate (68.3 % vs. 56.5 %) and delivery rate (60.0 % vs. 53.2 %) per transfer in Group 1 compared to Group 2, respectively. There was a statistically significant lower biochemical pregnancy rate in Group 1 (2.4 %) compared to Group 2 (18.6 %) [p = 0.015]. There was no difference in miscarriage rates between the two groups. Our data suggest that early initiation of GnRH antagonist on day 1 of ovarian stimulation in PCOS patients undergoing ICSI-ET may improve implantation rates, especially after blastocyst transfer.

following a second trimester loss, required a transvaginal cerclage.Her next transvaginal cerclage failed, resulting in a twenty-two week loss.Given this history, she required an abdominal cerclage.Another laparotomy might have increased the morbidity of her desired third cesarean delivery.Extensive laparoscopic adhesiolysis utilizing intermittent backfilling of the bladder skeletonized the anatomy without injuring the uterus or its support structures.The port strategy included use of a suprapubic port to facilitate intracorporeal ties of the mersilene tape.This video, geared towards obstetric providers as well as gynecologic surgeons, demonstrates that prior cesarean deliveries and/or uterine surgeries should not preclude safe placement of a laparoscopic abdominal cerclage.

The objective of this study is to compare the effectiveness of two surgical techniques (suturing versus flowering of Bruhat) after fimbrioplasty for treatment of distal tubal pathology in infertile women with endometriosis. This is a historical cohort study with 12 months of follow-up comparing pregnancy rates achieved spontaneously or after controlled ovarian hyperstimulation (COS) with intrauterine insemination (IUI) in infertile women with endometriosis who underwent laparoscopic fimbrioplasty. A total of 154 patients with endometriosis-related infertility (pelvic inflammatory disease was excluded by absent history and negative Chlamydia trachomatis serology) had fimbrioplasty using salpingostomy procedure for treatment of distal tubal pathology. The edges of the fimbrial ostium were everted using either the flowering technique of Bruhat or 6-0 Vicryl sutures (intracorporeal knot) using microsurgical techniques. Forty-six patients had flowering (group 1) and 108 had suturing (group 2) technique, followed by timed intercourse and/or ovarian hyperstimulation with insemination (COSIUI) with follow-up until pregnancy or at least 12 months. There was no significant difference in patients' characteristics (age, infertility duration, and endometriosis stage) between the two groups. The pregnancy rate per cycle or per patient and cumulative pregnancy rates were not significantly different between the two groups. There appears to be no advantage of the suturing technique over flowering after salpingostomy for fimbrioplasty. The latter method is easier to learn and requires less operative time to perform.

STUDY OBJECTIVE:The presence of fimbrial pathology in advanced endometriosis is clearly understood. However, little is known about the prevalence of fimbrial pathology in early stages of endometriosis. The purpose of this study is to determine the prevalence of fimbrial pathology in patients with infertility with early stages of endometriosis.DESIGN:Historical cohort study (Canadian Task Force classification II/III).SETTING:Tertiary referral center.PATIENTS:The study group (Group 1) consisted of 315 infertile women who were found to have stage I or stage II endometriosis, and the control group (Group 2) consisted of 152 infertile women without endometriosis (Group 2).INTERVENTION:Laparoscopic evaluation for the presence and type of fimbrial pathology.MEASUREMENTS AND MAIN RESULTS:The prevalence of fimbrial pathology was significantly higher in infertile patients with early stages of endometriosis (50.2%) compared with infertile patients with no endometriosis (17.8%, p <.0001).CONCLUSION:These preliminary data suggest the presence of fimbrial pathology in many patients with early stages of endometriosis. Such pathology may act as a mechanical factor interfering with the ovum pick-up mechanism.