Dear Colleagues

Hello

First of all I wish you a very happy and prosperous 2009

In this news letter I am putting my own views regarding transvaginal sonography in infertile women . The views may not be acceptable to all our readers and I welcome their comments, regarding their experiences.

I found one topic very interesting which I got in journal that is regarding the comparison of LAVH and abdominal hysterectomy. It clearly shows that recovery wise both are same ,but in my view ,when we compare both of them in Cost of equipment , number of manpower required for a hysterectomy, total time of anesthesia, monitoring for raised intra abdominal pressure and  of hyper-carbia, it goes against LAVH. I feel by doing LAVH, are we helping patients or the instrument makers?. In Dr. Shirish Sheth’s words ( the legend in vaginal hysterectomy): LAVH seems to provide additional “assistance” in the form of increased profits to the instrument manufactures and surgeons who can charge separately for the individual components of the operation….Advances in Gynec surgery,page 60.

Next topic is that:There is a great role of vascular endothelial growth factor in hyperstimulation syndrome,and there are efforts to prevent it by inhibiting the vascular permeability aspect of VEGF without affecting angiogenesis.

With best wishes and regards

Dr.D’Pankar  Banerji

1.Transvaginal Sonography: What to be seen in Infertile women

Transvaginal Sonography (TVS) is one of  the most important investigation in dealing with infertile women. It has literally replaced the fingers of gynecologist who is practicing infertility or in other words it is a finger with an eye ,during per vaginum examination.

By doing TVS we can see uterus, ovaries and adnexa, their spatial relationship etc.

What to be seen and how to interpret the findings?

Uterus :

Whether it in midline or not ? A grossly deviated uterus creates a suspision of pelvic adhesions .

A anteverted or retroverted uterus does not make much difference, but its mobility maters. Whether the uterus moves with the probe or not. Immobile uterus , suspision of adhesions

Countour and size should be seen.

Myometrium : whether anterior and posterior walls are equal in width, whether the echogenicity is uniform. The intramural myomas are another  problem for pregnancy esp. if they are involving endometrium.

Abnormal echogenicity may indicate adenomyosis with overall enlarged uterus.

Endometrium : It is most important thing to see .

A thin endometrium in periovulatiory phase is bad , the implantation is poor in endometrium less than 7 mm at ovulation.

A irregular endometrium immediately after finishing the periods indicates endometrial polyp or tumor and requires a hysteropscopy before planning any treatment.

Sometimes the endometrial echo is deviated forwards or backwords by some intramural fibroid or adenomyosis , here too the implantation is poor and it is very difficult decision for fertility expert whether it is to be removed or not before any treatment( esp. if adenomysis like ).

The endometrium at pre-ovulatory phase should be three layered and should be more than 8 mm. An endometrium not three layered in follicular phase or dense in echolike that of secretory phase  indicates hormonal imbalance.

An endometrium with very less thickness and irregularity indicates endometrial adhesions and implantation is poor it requires hysteroscopy.

A clear three layered endometrium at preovulatory phase more than 8 mm thickness in unstimulated cycle gives a very good implantation and good endocrine millue.

The endometrium is best seen by sonography when patient is downregulated. A thin line ,which is in the center and unbreached is good indicator of downregulation and further implantation

Laparoscopic Hysterectomy : A requirement or a glamour

2. Recovery after hysterectomy

Source: European Journal of Obstetrics & Gynecology and Reproductive Biology 2008;140:108-13

Day-to-day recovery of general well-being occurs at the same rate after laparoscopic hysterectomy as after abdominal hysterectomy, according to new findings from a randomized multicenter trial.

Researchers from the University Hospitals in Linkoping and Uppsala, Sweden, studied a total of 117 women scheduled for hysterectomy for benign conditions. Of these women, 55 underwent abdominal hysterectomy and 62 underwent laparoscopic hysterectomy. In all cases at least one ovary was to be preserved.

The patients kept a diary logging their general well-being (by means of a visual analog scale) and analgesic consumption from 1 week before the operation, daily until day 35 after the operation, and 1 week before their 6-month postoperative visit. A psychometric assessment, including evaluation of ability to cope with stress, was also made preoperatively.

At discharge, all of the women were assigned a sick-leave (from work or normal daily activity) of 14 days. This was prolonged by 7 days at a time, if deemed necessary by the patient.

Reporting their findings in their paper in the European Journal of Obstetrics & Gynecology and Reproductive Biology, the researchers note that there was no significant difference between the two methods in the day-to-day recovery of general well-being, in any of the three time-periods studied. The level of well-being that the women self-reported at baseline, 7 days before the operation, was regained by day 17 postoperatively in the laparoscopic hysterectomy group, and by day 20 in the abdominal hysterectomy group.

There were no significant differences between the two groups in the use of analgesics after postoperative day 4. From the day of the operation to postoperative day 3 there was a significantly higher consumption of opioids in the abdominal hysterectomy group than in the laparoscopic hysterectomy group.

In both groups, the ability to cope with stress (as indicated by scores on the Stress Coping Inventory psychometric assessment) was significantly and positively associated with day-to-day recovery of general well-being.

The mean duration of sick-leave was significantly lower in the laparoscopic group than in the abdominal group (27.5 days versus 34.4 days). This duration was not influenced by stress-coping ability, nor by the occurrence of major complications (which were low in number and would largely occur and be managed in the immediate postoperative period anyway, the researchers point out), but was influenced by the occurrence of minor complications (which most often become a problem after the patient has left hospital).

The researchers conclude that the day-to-day recovery of general well-being “is not faster in laparoscopic hysterectomy than in abdominal hysterectomy” but that personality factors have an impact on recovery: “Women with high stress-coping abilities have a faster recovery in general well-being than women with low stress-coping abilities.”

They propose: “In order to speed up the postoperative recovery of general well-being, interventions to improve the stress-coping capability and efforts to prevent and detect complications should be encouraged.”

3. Vascular endothelial  growth factor ( VEGF ) and its role in hyper stimulation.

Vascular endothelial growth factor is the most important mediator of hCG-dependent ovarian angiogenesis. It is known that VEGF is expressed in human ovaries and that VEGF mRNA levels in granulosa cells increase after hCG administration . VEGF not only stimulates new blood vessels development but also induces vascular hyper-permeability by interacting with its VEGF receptor 2 ( VEGFR-2). The early stages of pregnancy are highly dependent on ovarian and uterine angiogenesis. It is well known that VEGF is a key factor in endometrial angiogenesis . The expression of VEGF and VEGFR-2 is up-regulated by ovarian steroids and hCG in different mammalian species . Similarly , the implanting embryo stimulates endometrial angiogenesis though VEGF – mediated . Thus it is assumed that VEGF-mediated angiogenesis is a fundamental step in mammalian embryo implantation. The vascular permeability is the main feature affected in hyper stimulation  syndrome .There are efforts to prevent the vascular permeability part without affecting angiogenesis . Dopmine agonist ,Cabergoline is one of leading drug which is shown to prevent vascular permeability without affecting the angiogenesis, but is still under trial.

VEGF may be responsible factor in stimulation of the Poly-cystic ovaries (PCOS). When polycystic ovaries are stimulated ,there is growth of multiple follicles . It is assumed that there is defect in the expression of VEGF gene in PCOS ovaries, and there is angiogenesis in all the follicles and gonadotropins are spread to all the follicles and each one grows. It might be the responsible factor for not having a single dominant follcile in un-stimulated state. as reduced FSH in late follicular phase ( because of negative feed back of Estradiol) is not sufficient for all follicles ( which is usually sufficient for one in normal cases). HCG stimulates VEGF expression and thus increases vascular permeability