Search

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 45 - N° 7 - p. 661-672

Resume Introduction Les myomes sont des tumeurs benignes frequentes qui peuvent avoir une influence negative sur la fertilite des patientes. Cinq a 10 % des infertilites sont associees a la presence de myomes et dans 1 a 3 % des cas, le myome est la seule cause d’infertilite retrouvee. Meme si l’impact general de la myomectomie chez les patientes infertiles avec uterus myomateux est source de controverses, la myomectomie par hysteroscopie pour les myomes de type 0, 1 et 2 a montre un benefice evident. L’objectif de cette etude est d’evaluer la fertilite de patientes infertiles âgees de moins de 46 ans avec desir de grossesse, apres resection hysteroscopique de myomes sous-muqueux. Patientes et methodes C’est une etude retrospective unicentrique realisee dans le service de gynecologie d’un centre hospitalo-universitaire. Toutes les patientes infertiles ayant beneficie d’une resection hysteroscopique de myomes sous-muqueux entre mars 2009 et mai 2013 ont ete incluses. Dans le but d’evaluer leur fertilite apres resection hysteroscopique de myomes sous-muqueux, un questionnaire telephonique et postal a ete realise afin d’evaluer le taux de grossesse et leurs issues, le mode d’obtention de la grossesse et le delai entre la conception et la resection des myomes. Resultats Soixante et onze patientes avec desir de grossesse de plus d’un an ont eu une resection hysteroscopique de myomes sous-muqueux. Apres un suivi moyen de 28,7 mois, le taux de grossesse est de 33,8 % compose de 50 % de naissances vivantes, 41,6 % de fausses couches spontanees et 8,4 % de fausses couches tardives. Le delai moyen entre la resection de myomes et la conception est de 9,9 mois. Les grossesses etaient obtenues apres une prise en charge en procreation medicalement assistee (PMA) chez 6 patientes (25 % des grossesses obtenues). Conclusion Cette etude rapporte une serie de resections hysteroscopiques de myomes sous-muqueux chez des patientes infertiles avec un taux de grossesse de 33,8 % apres traitement. more...

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 44 - N° 3 - p. 230-236

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 44 - N° 3 - p. 212-219

Study Objective To evaluate the rate of intrauterine adhesions (IUA) after dilatation and curettage (D&C) for miscarriage with and without hyaluronic acid gel. Design Multicentric prospective randomized controlled trial, with two years of follow up for each patient. Setting Eight hospitals, in France. Patients or Participants 343 patients who had a miscarriage were enrolled in the study. Interventions Women were randomly assigned to D&C alone, or D&C with intrauterine instillation of hyaluronic acid gel. An office hysteroscopy was planned six to eight weeks after D&C. Measurements and Main Results Primary endpoint was the rate of IUA during the office control hysteroscopy. 169 patients had D&C alone and 174 had D&C with hyaluronic acid gel. 278 patients finally had an office hysteroscopy. Global rate of intrauterine adhesions was 13.3% (37/278). In women with D&C alone, rate of IUA was 17.9% (24/134), whereas in women with D&C and hyaluronic acid gel, this rate was 9.0% (13/144), and significantly lower (p=0.0294). Only 77 patients answered the fertility survey one year after D&C. The pregnancy rate twelve months after D&C was 68.8% (53/77), and was significantly higher in D&C + gel group than in D&C alone group (77.6% and 53.6%, p=0.0289). Conclusion Intrauterine instillation of hyaluronic acid gel reduces the rate of intrauterine adhesions in women with D&C for miscarriage. more...

Resume But Faire le point sur l’interet de l’utilisation hors AMM du misoprostol en gynecologie et en particulier pour faciliter la dilatation cervicale. Methode Revue de la litterature via PubMed en anglais et en francais sur l’utilisation du misoprostol en gynecologie. Resultats Les resultats de 3 meta-analyses, d’etudes randomisees ou de revues de la litterature ont ete colliges. Ces resultats montrent que le misoprostol n’a pas d’interet scientifiquement prouve en termes de dilatation cervicale avant un geste par hysteroscopie ou avant la pose d’un dispositif intra-uterin (DIU). Ces resultats sont retrouves dans le sous-groupe des patientes menopausees et des patientes nullipares. Il ne permet pas non plus une diminution du taux de complications mais augmente les effets indesirables. Conclusion Il ne semble pas indique d’utiliser le misoprostol avant un geste gynecologique. more...

Resume Objectif Evaluer l’effet lymphostatique du combipatch TachoSil® dans la prevention des lymphoceles apres curage axillaire dans le cancer du sein localise. Patientes et methodes Etude retrospective, cas–temoin, realisee entre janvier 2007 et decembre 2009, dans deux services de gynecologie-obstetrique de l’AP–HP. Soixante-six patientes (45 dans le groupe temoin et 22 dans le groupe TachoSil®) ayant subi un curage axillaire seul, avec mise en place d’un redon ou associe a une tumorectomie, ont ete incluses. La quantite totale de lymphe drainee durant le sejour, le nombre de jours de drainage, la duree d’hospitalisation, le nombre de lymphoceles et le nombre de ponctions realisees au decours de l’hospitalisation ont ete recueillis. Resultats La population etait similaire concernant l’âge, l’indice de masse corporelle (IMC), les donnees cliniques et anatomopathologiques. Il n’existait pas de difference significative en termes de volume total de lymphe draine (268,2 ± 220,7 mL sans TachoSil® et 228,6 ± 128,8 mL avec TachoSil®, p = 0,89) et le nombre de jours de drainage (3,9 ± 1,6 j sans TachoSil® et 3,1 ± 0,9 j avec TachoSil®, p = 0,10). Par contre, la duree d’hospitalisation etait significativement plus elevee dans le groupe TachoSil® (5 ± 1,6 j avec TachoSil® et 3,8 ± 1,1 j sans TachoSil®, p = 0,006). Conclusion Cette etude ne demontre pas de benefice du combipatch (TachoSil®) dans la prevention des lymphoceles apres curage axillaire. Une etude randomisee avec de grands effectifs est desormais necessaire. more...

International audience; Our objective is to describe off-label use of methotrexate in ectopic ă pregnancy treatment using evidence based medicine. The patient group ă includes all women with a pregnancy outside the usual endometrium, or of ă unknown location. ă Method used was a Medline search on ectopic pregnancy managed using ă methotrexate treatment; evidence synthesis was done based on this ă current literature analysis. ă Level of evidence (LE) were given according to the centre for evidence ă base medicine rules. Grade was proposed for guidelines but no ă recommendation was possible as misoprostol is off label use for all the ă indications studied. ă In the absence of any contraindication, the protocol recommended for ă medical treatment of ectopic pregnancy is a single intramuscular ă injection of methotrexate (MTX) at a dosage of 1 mg/kg or 50 mg/m(2) ă (Grade A). It can be repeated once at the same dose should the hCG ă concentration not fall sufficiently. Pretreatment laboratory results ă must include a complete blood count and kidney and liver function tests ă (in accordance with its marketing authorization). ă MTX is an alternative to conservative treatment such as laparoscopic ă salpingotomy for uncomplicated tubal pregnancy (Grade A) with ă pretreatment hCG levels 20001U/1, routine MTX treatment is an option. ă MTX is not indicated for combination with treatments such as ă mifepristone or potassium. (C) 2016 Published by Elsevier Ireland Ltd. more...

Resume But L’objectif de cette synthese des connaissances etait d’examiner la relation entre la menopause et l’incontinence urinaire (IU). Patientes Notre travail s’est appuye sur une revue de la litterature portant sur l’epidemiologie de l’IU de la femme et les effets du traitement hormonal sur les symptomes de fuites urinaires. Une recherche dans la base de donnees Medline entre janvier 2000 et avril 2012 a ete effectuee en croisant les mots cles urinary incontinence, stress urinary incontinence, urge incontinence, over active bladder, menopause, estrogen therapy . Resultats Vingt-neuf articles sur 482 articles ont ete initialement selectionnes. L’IU etait un symptome frequent lors de la menopause avec une prevalence comprise entre 15 et 30 % et une incidence annuelle comprise entre 5 et 10 %. L’association entre IU et menopause etait controversee. En effet, bien que sous-tendue par des mecanismes physiopathologiques comme la sensibilite des tissus originaires du sinus urogenital aux estrogenes, les donnees epidemiologiques disponibles restaient contradictoires et devaient etre interpretees, si possible, en fonction du type d’IU. Ainsi, il restait difficile de distinguer l’effet de la menopause de celui du vieillissement. Les effets des estrogenes medicamenteux sur l’IU differaient selon le mode d’administration et le type d’IU. Les etudes randomisees montraient que l’administration orale d’estrogenes apres la menopause favorisait la survenue d’une IU ou d’une IU a l’effort(IUE). En revanche, les estrogenes administres par voie vaginale amelioraient IU par urgenturie (IUU) et l’hyperactivite vesicale. Conclusion Les donnees de notre revue etaient en accord avec les dernieres recommandations francaises et europeennes. more...

The main aim of this study is to present the impact on the sexuality of patients after prolapse repair by a vaginal approach using the Elevate™ kit. Secondary objectives include the evaluation of the quality of life and presentation of anatomical results and complications.This is a retrospective unicentric study of 177 patients with symptomatic urogenital prolapse, repair from 2009 to 2013, using anterior and/or posterior Elevate™ kit. Assessment sexuality was performed using a validated questionnaire, the PISQ-12. Anatomical outcomes and quality of life were assessed using the classification POP-Q and questionnaires PFDI20 and PFIQ-7 respectively.Response to the questionnaire was 53.1 % with a mean follow-up of 29 months (8-60). Forty-six patients were sexually (49 %) active after the procedure. The average score of postoperative questionnaire PISQ-12 was 34.5/48. De novo dyspareunia rate is 10.8 %. The anatomic success rate was 90 %, the exposure rate was 2.8 % and the retraction rate was 2.2 %. No patient with de novo dyspareunia had postoperative complication.The Elevate™ kit is associated with satisfactory functional and anatomical results. De novo dyspareunia rate is "acceptable" compared to the literature data. more...

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 42 - N° 5 - p. 499-501

To make a literature analyse about methotrexate as a treatment of tubal ectopic pregnancy.We made a PubMed research and found articles, randomized control studies, systematic revues and meta-analyses of the Cochrane Database about ectopic pregnancies treated by methotrexate. We made a summary of these articles.Methotrexate can be used as a treatment of tubal ectopic pregnancy with hCG5000 UI/L and expectative is an option if hCG level is lower than 1500 UI/L. Medical treatment by methotrexate seems to be less effective than surgical salpingotomy but the rate of recurrence and the rate of intra-uterine pregnancy are similar regardless of the treatment chosen. Fertility seems to be the same after treatment by methotrexate. Economically, methotrexate is less expensive than the surgical management (laparoscopy).Methotrexate can be used as a treatment of tubal ectopic pregnancies if every criterions of safety are gathered. more...

Myoma is the most frequent benign uterine tumor and might have a negative impact on fertility. In 5 to 10% of cases, infertility is associated with myoma and in 1 to 3% myoma is the only infertility factor. Even if effect of myomectomy on fertility is controversial, benefit of hysteroscopic myomectomy for submucosal myoma on fertility has already been shown. The aim of this study is to evaluate fertility of infertile women less than 46years old after hysteroscopic resection of submucosal myoma.This retrospective unicentric study took place in the gynecologic unit of a teaching hospital. All infertile women with a hysteroscopic myomectomy for submucosal myoma between March 2009 and May 2013 were included. A phone questionnaire was conducted to evaluate pregnancy rate, eventual medical assistance, time between submucisal resection and pregnancy and issue of pregnancies.Seventy-one infertile women with a hysteroscopic resection of submucosal myoma were included. Pregnancy rate was 33.8% with 50% of live births, 41.6% of miscarriages and 8.4% of late fetal losses with a mean follow-up of 28.7months. Mean time between hysteroscopic resection and pregnancy was 9.9months. A medical assistance was necessary for 6 women (25% of pregnancy).This study reports hysteroscopic resection of submucosal myoma for infertile women. The rate of pregnancy after treatment is 33.8%. more...

Management of intrauterine synechiae in a context of infertility remains a challenge, in spite of hysteroscopic microsurgery progress. There is no published prospective study to be used as a guideline. Anatomic, but most of all functional prognosis are directly correlated to the severity of adhesions and the number of surgical procedures required to complete treatment. Complications during surgery are not infrequent, but are well known and often benign. Obstetrical complications are much less frequent but often severe (abnormal placentation, uterine rupture). Recurrences are common enough to impose a systematic second-look diagnostic hysteroscopy. However, the benefit gained by the recovery of fertility (either spontaneous or not) remains superior, in my opinion, to the risks of the surgical management. more...

To assess the interest of misoprostol in gynaecology and particularly for cervical priming.Research in PubMed in English and French about misoprostol and its use in gynaecology.We summarized the results of 3 meta-analyses, randomized controlled trials and literature review. Results show that misoprostol did not scientifically prove a benefit for cervical priming before hysteroscopy or before intra-uterine device (IUD). Results are the same with post-menopausal or nulliparous women. It did not lead either to lower the complications but increase adverse effects.It is not indicated to use misoprostol for cervical priming in gynaecology. more...

Resume Contexte La cystocele constitue la forme clinique la plus frequente du prolapsus genital de la femme. Il s’agit d’une pathologie frequente et invalidante. Le traitement chirurgical de reference en est la promontofixation indirecte par prothese synthetique sous-vesicale par laparotomie. L’abord cœlioscopique tend a supplanter la laparotomie. L’utilisation de la voie d’abord vaginale pour la mise en place d’une prothese sous-vesicale pourrait presenter de nombreux interets : simplicite de realisation, duree operatoire moindre, convalescence plus courte, mais pourrait exposer a une morbidite accrue en ce qui concerne les complications liees aux protheses. La promontofixation indirecte cœlioscopique et la mise en place de protheses par voie vaginale sont couramment pratiquees en France bien que la HAS ait souligne l’absence d’evaluation suffisante de la securite et de la tolerance de la mise en place des protheses synthetiques par voie vaginale. Methode L’objectif principal de l’etude est de comparer la morbidite de la promontofixation cœlioscopique a la chirurgie par voie vaginale pour le traitement des cystoceles par prothese synthetique sous-vesicale. Le critere principal d’evaluation sera le taux de complications chirurgicales superieur ou egal au grade II de la classification de Clavien-Dindo survenant dans l’annee de suivi. Les objectifs secondaires sont de comparer les resultats fonctionnels a moyen terme (sexualite, signes fonctionnels urinaires et digestifs, douleurs), le retentissement sur la qualite de vie, ainsi que les resultats anatomiques. PROSPERE est une etude prospective randomisee multicentrique qui sera menee dans 12 centres hospitaliers francais. Deux cent soixante-deux patientes ayant une cystocele superieure ou egale au stade 2 POP-Q isolee ou non, âgees de 45 a 75 ans, seront inclues. Les patientes ne doivent pas avoir d’antecedent de chirurgie du prolapsus ou de conditions defavorables ou contre-indiquant l’une ou l’autre des voies d’abord. La realisation de cette etude devrait permettre de repondre a la problematique non resolue actuellement du choix de la voie d’abord pour la pose des renforts prothetiques sous-vesicaux. Cet essai permettrait de mieux determiner les indications respectives de l’une ou l’autre de ces voies d’abord, qui reposent actuellement sur des attitudes d’ecoles et des choix subjectifs. more...

Cystocele is a frequent and invalidating type of genital prolapse in woman. Sacropexy using synthetic mesh is considered the surgical gold standard, and the laparoscopic approach has supplanted the open abdominal route because it offers the same anatomical results with a lower morbidity. The use of mesh through the vaginal route may have many advantages: easiness to perform, shorter operative time and recovery, but may increase morbidity. In France, both laparoscopic sacropexy and vaginal mesh are commonly used to treat cystoceles. The French Haute Autorité de santé (HAS) has highlighted the lack of evaluation of safety assessment for vaginal meshes.The main objective of the study is to compare the morbidity of laparoscopic sacropexy with vaginal mesh for cystocele repair. The primary endpoint will be the rate of surgical complications greater or equal to grade 2 of the Clavien-Dindo classification at 1-year follow-up. The secondary aims are to compare the functional results in the medium term (sexuality, urinary and bowel symptoms, pain), the impact on quality of life as well as anatomical results. PROSPERE is a randomized controlled trial conducted in 12 participating French hospitals. 262 patients, aged 45 to 75years old, with cystocele greater or equal to stage 2 of the POP-Q classification (isolated or not) will be included. Exclusion criterias are a previous surgical POP repair, and inability or contra-indication to one or the other technique. We have designed this study to answer the question of the choice between laparoscopic sacropexy and vaginal mesh for the treatment of cystocele. The PROSPERE trial aims to help better determine the indications for one or the other of these techniques, which are currently based on subjective choices or school attitudes. This is the reason why competent authorities have asked for such studies. more...

The aim of this review was to examine the relationship between menopause and urinary incontinence (UI).Our work is based on a review of the literature on the epidemiology of UI in women and the effects of hormone therapy on symptoms of urinary leakage. A search of the Medline database between January 2000 and April 2012 was performed by crossing the keywords "urinary incontinence, stress urinary incontinence (SUI), urge incontinence, over active bladder, menopause, estrogen therapy".Twenty-nine articles over the 482 articles were initialy selected. The UI was a common symptom during menopause, with a prevalence of 15 to 30% and an annual incidence of 5 to 10%. The association between UI and menopause was controversial. Indeed, although underpinned by pathophysiological mechanisms such as the sensitivity of tissues of the urogenital sinus to estrogen, the epidemiological data available were contradictory and should be interpreted, if possible, depending on the type of UI. Thus, it remained difficult to distinguish the effect of menopause of the aging. The effects of estrogen on IU differed depending on the route of administration and of the type of UI. Randomized trials showed that oral administration of estrogen after menopause increased the occurrence of UI or SUI. However a vaginal administration of estrogen improved urge urinary incontinence (UUI) and overactive bladder.The data of this review were consistent with the French and European guidelines. more...

Management of intrauterine synechiae in a context of infertility remains a challenge, in spite of hysteroscopic microsurgery progress. There is no published prospective study to be used as a guideline. Anatomic, but most of all functional prognosis are directly correlated to the severity of adhesions and the number of surgical procedures required to complete treatment. Complications during surgery are not infrequent, but are well known and often benign. Obstetrical complications are much less frequent but often severe (abnormal placentation, uterine rupture). Recurrences are common enough to impose a systematic second-look diagnostic hysteroscopy. However, the benefit gained by the recovery of fertility (either spontaneous or not) remains superior, in my opinion, to the risks of the surgical management. more...