Abstract: This report describes a case of a 55-year old woman presenting with evisceration of small bowel through the vagina, five years after a Total abdominal hysterectomy and bilateral salpingoopherectomy for irregular bleeding and a benign ovarian cyst. Examination under anesthesia revealed a 70 cm loop of bowel prolapsing through a 5 cm defect in the vaginal vault. She underwent an exploratory laparotomy and repair of vaginal vault defect. Small bowel prolapse through vaginal vault defect is a rare complication after abdominal hysterectomy. Appropriate management includes prompt recognition, thorough assessment of the herniated viscus and surgical repair of the vaginal defect. Combining abdominal and vaginal approaches as in our case may facilitate repair and avoid further morbidity.

Abstract: In this paper, we aim to describe the clinical features and treatment outcome following the laparoscopic treatment of endometriosis in teenagers and adolescents. This is a retrospective review of girls aged 21 and below who underwent operative laparoscopy for endometriosis. We identified two groups: (1) the EMAT group, being those who underwent their primary laparoscopic surgery under the Endometriosis and Minimal Access Therapy team (EMAT), and (2) the non-EMAT group, consisting of those referred to the EMAT team with recurrent symptoms following primary operative laparoscopy by other gynaecologists. Symptom recurrence and the need for re-operation was compared between the two groups. Twenty-eight girls, age range 15–21 years, were identified. All had pelvic pain unresponsive to the pill and non-steroidal anti-inflammatory drugs (NSAIDs). Most disease was atypical, with the uterosacral ligaments and ovarian fossae being the most common sites. The re-operation rate per surgical team at 24 months was 14.2% for the EMAT group vs. 42.8% for the non-EMAT group. All recurrences in the non-EMAT group coincided with the location of primary disease. Disease recurrence occurred most commonly in the uterosacral ligaments. Endometriosis in teenagers is mainly atypical and, in our series, commonly affects the uterosacral ligaments. Disease in this location is deeply infiltrating and is usually not amenable to electrocoagulation. We advocate disease resection to minimise recurrence. --------------------------------------------------------------------------------

Abstract: Hirsutism is the presence in women of terminal hair in patterns and sequence similar to those that develop in the normal post-pubertal male. It is a distressing endocrine and cosmetic condition associated with significant psychological morbidity. Hyperandrogenism is the underlying disease in most cases and polycystic ovarian syndrome is the commonest cause. There is a strong familial component and a high degree of hereditability. Thorough history-taking and physical examination are pivotal to establishing cause. Initial assessment should exclude underlying serious disease, establish change in sexuality, and assess impact on fertility. Physical examination should include assessment of the severity of hirsutism using the modified Ferriman–Gallway score. A sympathetic approach is vital for successful management. Treatment includes lifestyle modification, mechanical/cosmetic measures, and pharmacological treatment, including androgen suppressors, peripheral androgen blockers, and biological modifiers of hair follicular growth. In general, treatment is combination therapy, and pre-treatment psychological preparation is essential to establish realistic treatment goals. Therapy should be long-term and continuous because hirsutism tends to recur if treatment is withdrawn.

Abstract: PROBLEM: To investigate changes in the ratio of T-cell subpopulations expressing intracellular T helper1 (Th1) and T helper 2 (Th2) cytokines in women with a history of recurrent failed implantation under going in-vitro fertilization (IVF)-embryo transfer. METHOD OF STUDY: Twenty-eight peripheral blood samples were obtained at two time points, from 14 women undergoing IVF treatment; eight women with a history of recurrent failed implantation, who did not get pregnant in the index IVF cycle and six who had one or more previous successful IVF pregnancy and who became pregnant in the index IVF cycle. The proportion of lymphocytes expressing interferon-gamma (IFN-gamma), tumour necrosis factor-alpha (TNF-alpha), and interleukin 4 (IL-4) and the Th1:Th2 ratios of IFN-gamma:IL-4, and TNF-alpha:IL-4 in T helper cells was measured by flow cytometry, in samples obtained before commencing IVF treatment and in samples obtained after ovarian stimulation (on the day of oocyte retrieval). RESULTS: In samples collected during oocyte retrieval, women with a history of recurrent failed implantation had a higher IFN-gamma:IL-4 and TNF-alpha:IL-4 ratio than the control group, (18.6+/-9.3 versus 6.47+/-1.68, P=0.009) and (39.1+/-15.7 versus 11.53+/-3.76, P=0.001) respectively. In women with a history of recurrent failed implantation the ratio of IFN-gamma:IL-4 and TNF-alpha:IL-4 at oocyte retrieval was higher than pre-treatment ratios (18.6+/-9.3 versus 12.01+/-9.8, P=0.018) and 39.10+/-15.7 versus 18.66+/-11.42, P=0.010) respectively, showing a Th1 bias. In women with a successful IVF the converse was true; the ratio at oocyte retrieval was significantly lower than pre-treatment ratios (6.47+/-1.68 versus 9.37+/-6.8, P=0.035) and 11.53+/-3.76 versus 18.60+/-12.9, P=0.027) respectively, representing a Th2 bias. CONCLUSION: Women with a history of unexplained recurrent failed IVF treatment have a Th1 bias and this polarization is more enhanced following hormonal manipulations during IVF treatment. Comparing pre-treatment ratios of IFN-gamma:IL-4 and TNF-alpha:IL-4 to ratios obtained at oocyte retrieval may be clinically useful. Women with recurrent failed IVF have increasing ratios.

Abstract: Intrauterine retention of foetal bones is an uncommon but recognised complication of late termination of pregnancy. Secondary subfertility, abnormal uterine bleeding and vaginal discharge are the usual presenting complaints. We report a case of prolonged retention of foetal bones for 14 years in a woman who presented with chronic pelvic pain. Hysteroscopic examination was diagnostic and therapeutic. Retained foetal bones are an uncommon intrauterine cause of chronic pelvic pain that should be considered particularly when a woman with a history of late termination presents with pelvic pain. Hysteroscopic evacuation is curative.

Abstract: Premature ovarian failure (POF) generally describes a syndrome consisting of amenorrhea, sex steroid deficiency, and elevated/menopausal levels of ganadotropins in a woman aged more than two standard deviations below the mean age at menopause estimated for the reference population. Numerous questions relating to this condition remain unanswered, and several important management issues are yet to be addressed. The challenges posed by this important condition range from difficulties with nomenclature to the absence of standardized diagnostic criteria and management guidelines. In the present paper we discuss the management of spontaneous premature ovarian failure, highlight the challenging issues, review the current literature and propose a practical management outline based on our local practice. Women with POF have unique needs that require special attention. There is an urgent need for a more suitable terminology and evidence-based guidelines on which to establish the diagnosis and manage this difficult condition.

Abstract: OBJECTIVES: To investigate the effects of single blastocyst transfer (SBT) on live birth and multiple pregnancy in women undergoing in vitro fertilisation (IVF). DESIGN: Descriptive cohort study. SETTING: A London private IVF/postgraduate training unit. SAMPLE: A total of 700 fresh and 102 frozen blastocyst cycles performed between January 2005 and December 2006. METHODS: Young women aged 25-37 years and those aged 38-43 years were further divided into those who had SBT and those who received two blastocysts (double blastocyst transfer [DBT]). Live birth and multiple pregnancy rates were compared between groups. Cumulative live birth was compared between women who had DBT and those who received a SBT followed by a frozen blastocyst if the fresh cycle was unsuccessful. MAIN OUTCOME MEASURES: Live birth rate, cumulative live birth rate, multiple pregnancy rate, uptake of SBT. RESULTS: Among women aged 25-37 years, live birth rate following SBT was 59.0 versus 60.7% following DBT. The twin pregnancy rate in this group was 2.3 and 47.6% respectively. For women aged 38-43 years, live birth following SBT was 29.4% and multiple pregnancy rate was 33.3%. DBT in older women gave a higher live birth rate (44.3%) and a multiple pregnancy rate of 36.4%. Cumulative live birth following SBT in women aged 25-37 years was 72.8% versus 60.5% following DBT. Among the women aged 38-43 years, cumulative live birth was higher (63.3%) following DBT versus 28.6% following SBT. CONCLUSION: Single blastocyst transfer followed by transfer of a frozen blastocyst if the preceding fresh cycle was unsuccessful resulted in a better cumulative live birth and lower twin pregnancy in young women. In older women, two fresh blastocysts gave better results than one fresh followed by a frozen cycle. Older women should have the option of replacing two fresh blastocysts as this optimises their chances of taking home a baby.

Abstract: OBJECTIVE: To evaluate the effectiveness of pre-clinic request of investigations to facilitate diagnosis in couples referred to the infertility clinic and to assess patient satisfaction of the concept. STUDY DESIGN: Prospective cohort study with analysis of patient satisfaction questionnaire. Investigation packs were sent to patients in advance of their clinic appointment. These contained written explanation about various fertility tests to enable patients to have investigations before their first clinic appointment. The results should then be available at the time of consultation enabling a diagnosis to be made at their first clinic visit. RESULTS: Eighty percent (43/54) of couples had completed all the investigations requested by the time of their clinic appointment. The full investigation results of 41 couples were available at the time of consultation. From the available results, a diagnosis could be reached in 76% of couples at the first clinic visit. Twenty-three percent of couples were not happy with the concept of pre-clinic investigation and would prefer to come to clinic first to discuss these tests, even if that meant a delay in diagnosis. There appears to be a trend in age, with those who were satisfied with the concept of pre-clinic investigation being older. Older women seem to have an increasing sense of urgency with advancing age. CONCLUSION: While the concept of pre-clinic request of investigations may not be suitable for every couple it does allow for early initiation of treatment in selected patients.

Abstract: BACKGROUND: Controlled ovarian hyper-stimulation (COH) in combination with intrauterine insemination (IUI) has been shown to result in significantly higher pregnancy rates compared to un-stimulated (natural cycle) IUI. This may however not be true in all ages. METHODS: We performed a retrospective cohort study and analysed data collected prospectively on 1759 IUI cycles in couples with unexplained infertility. The results were analysed to show the outcome of IUI with COH, and IUI in natural cycle (unstimulated), in younger women compared to their older counterparts. RESULTS: In women age 37 and younger, COH resulted in a significantly higher pregnancy rate (13.0% vs 6.5%) and live-birth rate (10.7% vs 5.2%) compared to natural cycle IUI (p = 0.025, p = 0.045 respectively). However for older women age >37 years, natural cycle (unstimulated) IUI, resulted in a significantly higher pregnancy rate (12.0% vs 8.5%) live-birth rate (7.5%vs 3.5%) than IUI with COH ((p = 0.0037). This difference is even more significant when COH was performed with clomiphene citrate (7.5% vs 2.1%) (p = 0.0017). CONCLUSION: COH was associated with a lower live birth rate in older women, irrespective of the agent used, and it seems to be worse when the anti-oestrogenic drug clomiphene citrate was used for COH. Older women may benefit more from natural cycle (unstimulated) IUI. A randomised controlled trial is required to confirm this observation.

Abstract: OBJECTIVE: To study the serum and peritoneal fluid cytokine profiles in infertile women with minimal/mild active endometriosis. METHODS: Fifty-seven consecutive infertile women undergoing laparoscopy for unexplained infertility had peritoneal fluid and serum samples obtained at the time of laparoscopy. The levels of interleukin-6 (IL-6), interleukin-8 (IL-8), interleukin-1 beta (IL-1 beta), vascular endothelial growth factor (VEGF), tumor necrosis factor-alpha (TNF-alpha), monocyte chemotatic protein-1 (MCP-1), RANTES, platelet derived growth factor (PDGF), soluble Fas (sFas), and soluble Fas Ligand (sFasL) in peritoneal fluid and serum were measured to compare the concentration in both biological fluids, in women who have minimal/mild red endometriosis using women with no endometriosis as controls. RESULTS: Peritoneal fluid levels of MCP-1, IL-8 and IL-6 were significantly higher in the endometriosis group (P < 0.012, P = 0.003, and P = 0.015, respectively). There was no significant difference in the peritoneal fluid levels of IL-1 beta, TNF-alpha, RANTES, VEGF, PDGF, sFas and sFasL in the two groups. Although serum levels of IL-8 were higher in women with endometriosis, the difference was not significant (P = 0.07). Serum levels of PDGF, IL-6, RANTES, IL-1 beta, TNF-alpha, and sFas, were not significantly different in the two groups. CONCLUSION: The elevated levels of MCP-1, IL-6, and IL-8 in peritoneal fluid but not serum may indicate the importance of local macrophage activating factors in the pathogenesis of endometriosis.

Abstract: A 34-years-old primigravida conceived following a fourth attempt at in vitro fertilization and embryo transfer for severe bilateral tubal disease and grade IV endometriosis. Pregnancy progressed well until 17 weeks gestation when she spontaneously ruptured her membranes. She elected to continue with the pregnancy despite the significant risks associated with prolonged rupture of membranes (PROM) and anhydramnion at extremes of viability. Pregnancy was carried to 28 weeks gestation, when delivery was necessitated by a major antepartum haemorrhage following abruption placentae. A male infant weighing 1,100 g was delivered by emergency caesarean section in good condition, and with no features oligohydramnion tetrad (Potter's features, skeletal deformities, intrauterine growth restriction, and pulmonary hypoplasia). This case adds to the small number of cases in the literature of successful outcome following prolonged pre-viability PROM. Counselling and psychological support to the parents in this situation is extremely important since the anxiety and uncertainty associated with expectant management of PROM does not end with the "successful" delivery of the baby but persists all through the neonatal period and for several years later.

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Abstract: Intestinal obstruction in pregnancy is rare and difficult to diagnose. Common causes of gestational intestinal obstruction include adhesions, volvulus, intussuscetion, carcinoma, hernia and appendicitis [3]. Abdominal pain is a common feature, but the displacement of abdominal organs as pregnancy progresses results in atypical location of the pain and hence delay in diagnosis. We report a case of intestinal obstruction at 33 weeks gestation in a woman with previous appendicectomy. Clinical suspicion of the presence of obstruction is required for prompt diagnosis and aggressive intervention, to minimise the morbidity and mortality of this rare complication of pregnancy.

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Abstract: A 29 year old woman with difficult to control acromegaly and a pituitary macroadenoma responded to pegvisomant therapy and subsequently conceived with her first cycle of in-vitro fertilization and intra-cytoplasmic sperm injection. Pregnancy was complicated by gestational diabetes, pituitary gland enlargement and deteriorating visual fields. Conservative management with elective cesarean section was performed at 32 weeks gestation. A healthy boy was delivered who remains developmentally normal at 1 year. This complex case required intricate care by a multi-disciplinary team and is likely to represent the first in many cases of assisted conception on pegvisomant therapy for active acromegaly.

Abstract: This fourth best practice review examines four series of common primary care questions in laboratory medicine are examined in this review: (1) safety monitoring for three common drugs; (2) use of prostate-specific antigen; (3) investigation of vaginal discharge; and (4) investigation of subfertility. The review is presented in question-answer format, referenced for each question series. The recommendations represent a precis of the guidance found using a standardised literature search of national and international guidance notes, consensus statements, health policy documents and evidence-based medicine reviews, supplemented by Medline Embase searches to identify relevant primary research documents. They are not standards but form a guide to be set in the clinical context. Most of them are consensus based rather than evidence based. They will be updated periodically to take account of new information.

Abstract: CASE REPORT: We present the case of a 42-year-old woman with an incidental finding of a large right adnexal mass during pelvic ultrasound scan for a spontaneous miscarriage. Ultrasound suggested the mass was ovarian in origin and serum Ca125 was normal. Laparotomy, however, revealed normal ovaries with no ovarian pathology. The right adnexal mass was appendiceal in origin and was delivered intact with no spillage. Histology confirmed a diagnosis of mucinous cystoadenoma of the appendix. DISCUSSION: Pre-operative diagnosis of this condition is difficult. Various radiological tools including CT scans, MRI, and ultrasound scans have been used with poor results. Pre-operative diagnosis would be useful, as extra measures could be taken to avoid intra-peritoneal rupture during surgery with the consequent development of pseudomyxoma peritonei. For a similar reason, needle aspiration should be avoided. In malignant cases co-existing ovarian neoplasm must be excluded as this will be present in 2-24% of cases. Simple appendicectomy is curative in uncomplicated, unruptured cases. CONCLUSION: Although relatively rare, appendiceal tumours should be considered in women who present to gynaecologists with a right adnexal mass.

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Abstract: INTRODUCTION: Acute pancreatitis in pregnancy is often associated with severe morbidity. It is usually an antepartum problem occurring in late pregnancy. It rarely occurs in the postpartum period and when it does diagnosis can be difficult. CASE REPORT: We report a case of 'unexplained' ascites following ventouse delivery, diagnosed 6 weeks later as acute pancreatitis. CONCLUSION: Although it is rare, acute pancreatitis must be considered when evaluating patients presenting with abdominal pain and/or ascites in the postpartum period. Serum amylase may not always be elevated and early recourse to CT scan will facilitate diagnosis and allow for appropriate management.

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Abstract: In a survey in 1989 Spector observed that 70% of women who had had bilateral oophorectomy had never received hormone replacement therapy. Ten years after his survey we decided to audit not only the number of women who started hormone replacement therapy following bilateral oophorectomy, but also to determine long-term compliance, as this is vital if the full benefits of oestrogen replacement are to be obtained. We carried out a survey of 91 women age 45 years and below who had bilateral oophorectomy in a teaching hospital and who were under the care of GPs in 53 general practices in the north-east of England. Of these women, 72.4% were prescribed oestrogen replacement therapy in hospital before discharge. However, within 2 months following bilateral oophorectomy, 97.4% of these women had commenced hormone replacement; 88.4% have maintained hormone replacement for 5 years or more, 11.8% who had started hormone replacement had discontinued within 5 years and 2.6% have never been on hormone replacement therapy, despite the lack of any medical contraindication. This survey shows a marked improvement in the long-term compliance of women on hormone replacement following bilateral oophorectomy. Continuous education of medical staff and patients on the benefits of hormone replacement therapy, preoperative counseling of patients with the opportunity for them to choose the route of administration that best suits them, and regular review of patients on hormone replacement therapy may further enhance long-term compliance.