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INTRODUCTION: Periadnexal adhesions are known to contribute to subfertility. The restoration of the tubo-ovarian anatomy is one the key principles in reproductive surgery, and this involves adhesiolysis. However, adhesion formation/reformation is very common after periovarian adhesiolysis. It is not known if the application of Hyalobarrier®, an anti-adhesion gel, around the adnexal region postsurgery influences ovulatory status. The study is a pilot randomized controlled trial (RCT) randomizing women into the application of Hyalobarrier® versus no Hyalobarrier® at the time of laparoscopy, where postsurgical ovulatory status and pregnancy rates were evaluated. METHODS: This was a pilot RCT where women were recruited from the gynecological and subfertility clinic who were deemed to require an operative laparoscopy. If intraoperatively they were found to have periovarian adhesions, they were randomized into having adhesiolysis with and without usage of Hyalobarrier®. Demographic details and intraoperative details including the severity, extent, and the ease of use of Hyalobarrier® were recorded. Prior to the surgery and postoperatively, the participants had their serum hormonal status (day 2 FSH, LH and day 21 progesterone) evaluated. Postoperatively, they underwent a follicular tracking cycle at 3 months. RESULTS: Fifteen women were randomized into use of Hyalobarrier® (study group) and 15 into the no Hyalobarrier® group (control group) between December 2011 and January 2014. There was no difference in the patient characteristics in terms of age, BMI, the number of previous pregnancies, or the extent, site, and severity of adhesions between the two groups. There was no significant difference between the study versus control groups in terms of the hormonal profile (day 2 FSH and day 21 progesterone) before or after surgery. The 3-month postoperative day 10-12 follicular tracking findings and endometrial thickness were similar between the study and control groups. Four women were pregnant in the study group (24%) and one in the control group (7%) cumulatively over 2 years. CONCLUSION: The use of Hyalobarrier® post salpingo-ovariolysis did not influence follicular development as inferred from the results of the day 21 progesterone and folliculogram on day 10-12 3-month postsurgery. TRIAL REGISTRATION: ISRCTN number, ISRCTN1833588. FUNDING: Nordic Pharma.

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STUDY OBJECTIVE: To quantify our experience and that of the literature with diagnosis and management of the auto-amputated adnexa in a pediatric population. DESIGN: Case series and literature review. SETTING: Tertiary care medical center. PARTICIPANTS: Case series of pediatric patients (<18 years of age) with surgically documented adnexal auto-amputation collected from our medical center and the literature. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Auto-amputated adnexa. RESULTS: In addition to the 3 cases discussed from our institution, 91 cases of auto-amputated adnexa were identified in the literature dating back to 1943, for a total of 94 cases. Forty-nine percent (46/94) of the cases involved girls in a pediatric population (<18 years of age). Of these, the majority (n = 26) were identified in a subgroup of girls who were diagnosed with an adnexal cyst by antenatal ultrasound. Most of these neonates were asymptomatic at birth or had a palpable abdominal mass (n = 6) and at the time of surgical exploration were found to have an auto-amputated adnexa. 34 out of 46 cases were analyzed in detail. The right adnexa were involved in 56% of the cases. The most common presenting complaint verbalized by the older girls was pain; however, 8 cases were identified in asymptomatic girls undergoing unrelated diagnostic testing. CONCLUSION: The auto-amputated adnexa is a rare finding in the pediatric population, but it must be considered as a possible explanation for the incidental finding of absence of the fallopian tube or ovary in the subgroup of patients who undergo surgery for any reason. Patients with an antecedent history of pelvic pain either chronic or intermittent in nature may be diagnosed with torsion or less frequently auto-amputation of the adnexa. A fetal "pelvic mass" or "ovarian cyst" may predispose the adnexa to torsion and subsequent auto-amputation either in-utero or post-delivery. Many of these antenatally diagnosed cysts and even subsequent auto-amputations are completely asymptomatic, however, and do not compromise fertility assuming the contralateral adnexa are normal. Thus expectant management is appropriate for small (less than 4 cm), asymptomatic simple cysts and even suspected auto-amputated adnexa in an asymptomatic patient.

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OBJECTIVE: To evaluate complications of transient ovariopexy performed to reduce adhesions in patients with severe endometriosis. METHODS: A bicentric retrospective study involved 193 consecutive patients who underwent laparoscopic surgery for severe endometriosis at 2 French university hospitals from 1997 to 2009. At the end of surgery, unilateral or bilateral transient ovariopexy was performed on 297 ovaries. Immediate (e.g. reproducibility, tolerance, and hospital stay) and long-term (evaluated via vaginal access to the ovaries, ovarian function, and ovarian vascularization) complications were assessed. RESULTS: The technique, which was easy and reproducible, did not increase hospital stay and was well tolerated. There were 2 (0.7%) immediate complications. There was no difference in ovarian accessibility before and after surgery (177/183 [96.7%] vs 176/183 [96.1%]). Potential vaginal oocyte retrieval for in vitro fertilization was possible for all patients. The antral follicle count and the pulsatility index of suspended ovaries were not different from those of contralateral unsuspended ovaries. Endometrioma excision did not modify these results. CONCLUSION: The short- and long-term safety results of transient ovariopexy for adnexal adhesions in patients with severe endometriosis were encouraging.

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OBJECTIVE: To assess adhesion formation and fertility outcome after transient abdominal ovariopexy performed in patients with severe endometriosis. STUDY DESIGN: Retrospective study including 218 patients who underwent surgery for severe endometriosis from 1997 to 2009. One hundred and thirty-nine (64%) patients were infertile. The initial ASRM stage was IV in 139 cases, III in 43 cases and II in 36 cases. Adnexal adhesions were scored by using the Operative Laparoscopy Study Group (OLSG) and modified AFS scoring systems. Unilateral or bilateral transient abdominal ovariopexy of 336 ovaries was performed to prevent adhesion formation or reformation for extensive surgery. In patients who underwent a second operation, adnexal adhesion scores were reported. Fertility outcome was evaluated by a questionnaire. RESULTS: Second-look surgery was performed after 11.7 ± 2.4 months in 24 patients (11%) who had undergone 38 ovariopexies. Transient abdominal ovariopexy significantly decreased adnexal adhesion scores (p<0.05). Regarding fertility outcome, the median follow up was 19.6 ± 1.5 months. Fifty-eight patients, out of 105 infertile women who actively tried to conceive after surgery, conceived, 21 (36%) spontaneously and 37 (64%) after ART. The median time interval for conception was 8.6 ± 1 months. CONCLUSION: In patients with severe endometriosis, transient abdominal ovariopexy is an effective technique in preventing postoperative adhesion formation and in improving fertility outcome. CONDENSATION: In 218 patients with severe endometriosis, transient abdominal ovariopexy was an effective technique in preventing adhesion formation and improving fertility outcome.

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STUDY OBJECTIVE: To assess the efficacy of oophoropexy in obviating recurrent torsion and its possible long-term effects. DESIGN: Case series and review of the literature (Canadian Task Force classification III). SETTING: University hospital. PATIENTS: Women who underwent oophoropexy for recurrent torsion of normal adnexa between 2003 and 2008. MEASUREMENTS AND MAIN RESULTS: Retrieved information included the indication for oophoropexy, surgical methods, recurrence, and follow-up. Seven women underwent oophoropexy during the study period because of recurrent torsion of normal adnexa. One additional patient had experienced 3 torsion events of cystic adnexa. Surgical methods included suturing of the ovary to the pelvic sidewall or to the round ligament and plication of the utero-ovarian ligaments. Recurrence occurred in 1 of 6 patients for whom follow-up was available. All 6 patients reported spontaneous menstruation, and 2 conceived spontaneously and gave birth. Ultrasound at long-term follow-up (9-58 months) demonstrated normal ovaries. CONCLUSION: Oophoropexy seems to be efficacious in preventing recurrent torsion. It is our impression that plication of the utero-ovarian ligaments has advantages over other approaches insofar as surgical feasibility and anatomical conservation.

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OBJECTIVE: To report a case of adnexal torsion after in vitro fertilization (IVF) with two subsequent episodes of contralateral adnexal torsion and a novel approach for reducing the risk of recurrence. DESIGN: Case report. SETTING: University-based IVF program. PATIENT(S): A 32-year-old woman who conceived with IVF and experienced sequential bilateral adnexal torsion. Left adnexal torsion was diagnosed with laparoscopic detorsion performed 2 days after embryo transfer. At 7 weeks' gestation, right adnexal torsion occurred and was managed with laparoscopic detorsion. Subsequently, right adnexal torsion recurred at 10 weeks' gestation, and laparoscopic detorsion with shortening of the uteroovarian ligament was performed. INTERVENTION(S): Gonadotropin ovulation induction, IVF, and laparoscopic detorsion of both right and left adnexa with shortening of the right uteroovarian ligament. MAIN OUTCOME MEASURE(S): Preservation of adnexa after torsion and successful pregnancy. RESULT(S): Successful pregnancy and birth; resolution of torsion, prevention of recurrence with viable bilateral adnexa after detorsion and shortening of the utero-ovarian ligament with novel use of laparoscopic Endoloop. CONCLUSION(S): This is a unique case of multiple episodes of adnexal torsion following IVF with a new form of treatment using the laparoscopic Endoloop. Management of the infertility patient should be conservative and warrants ovarian preservation whenever possible. Multiple sequential episodes of adnexal torsion during a single pregnancy are a rare complication of IVF. Shortening of the utero-ovarian ligament is an alternative to oophoropexy to prevent recurrence.

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OBJECTIVE: To describe a novel technique for application of a Seprafilm (modified hyaluronate-carboxymethylcellulose) barrier laparoscopically, and to assess the adequacy of coverage of desired sites. DESIGN: Retrospective cohort study. SETTING: University tertiary hospital. PATIENT(S): One hundred twenty-seven patients who underwent fertility-sparing laparoscopic surgery. INTERVENTION(S): The Seprafilm was rolled up in a plastic package, then delivered through the main trocar. It was unrolled and positioned to cover the traumatized surface of the uterus, ovaries, and tubes. During application, the pelvis was photographed, videotaped, and the pictures were reviewed by two surgeons. MAIN OUTCOME MEASURE(S): The adequacy of the application was divided into three levels as to whether the Seprafilm could cover all the traumatized surfaces. RESULTS: Of the first 15 patients, 4 of 15 (26%) had successful coverage of the traumatized surface with the first sheet of Seprafilm. Of the following 112 patients, 97 of 112 (86.5%) had successful coverage with the first sheet. The success rate climbed to 96% after the second or third sheet. The average time for the application of six pieces (one sheet cut into six pieces) was 21 +/- 4 minutes. The posterior cul-de-sac is difficult to apply well. CONCLUSION(S): It is feasible to apply the antiadhesion barrier Seprafilm laparoscopically. Further studies will be needed to assess the efficacy of reducing adhesion following such use.

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OBJECTIVE: The purpose of this study is to investigate the effects of diphenhydramine-HCl and Na-hyaluronate derivatives on the development of postoperative peritoneal adhesion and tubal obstruction. STUDY DESIGN: Forty female rats of Sprague-Dawley type were used in the study. The rats were divided into four groups, each comprising 10 subjects. After all the rats were anaesthetized with 50mg/kg ketamine HCl, their abdomens were opened with a lower midline incision. Injury was induced on the right pelvic peritoneum and on the peritoneal surface of left uterine tube. No additional procedure was applied to the first group. 10 mg/kg diphenhydramine-HCl was given to the second group intravenously. In the third group, 0.25 mg/kg Orthovisc, a Na-hyaluronate derivative was diluted with 2 ml physiological saline and poured into the abdomen. For the fourth group, Seprafilm, a Na-hyaluronate derivative was covered in a layer of 0.7 cm x 3 cm over the left uterine tube. After 14 days, the rats were anaesthetized with ketamine HCl again, and 5 cm(3) blood sample was taken with cardiac puncture. The abdomen was opened with an incision transverse to the upper end of the midline incision, and the presence of adhesions was investigated. Detected adhesions were staged according to the Mazuji classification. Tubal patencies were inspected by injecting methylene blue from the uterine corpus into the lumen using an injector. A piece of abdominal wall of 4 cm x 4 cm was removed by extending the incision in the reverse U shape. The tensile strength and bursting pressure of the suture line were determined using the Peacock method. One gram of tissue was taken from the incision line, and hydroxyproline levels were determined by the Bergman-Loxley method. Aspartate aminotransferase (AST) levels were measured. RESULTS: All of the rats completed the study. AST levels, tissue hydroxyproline levels and tensile strength and bursting pressure test results were found to be similar in all groups. While adhesion rates in the groups were 100, 40, 40 and 30%, respectively, adhesion stages were found to be, respectively as 2.1+/-1.7, 0.6+/-0.67, 0.6+/-0.67 and 0.5+/-0.85. Adhesion stages in the study groups were significantly lower (P<0.05). Tubal obstruction rates were found to be 70, 30, 30 and 20%, respectively. CONCLUSION: Diphenhydramine, Orthovisc and Seprafilm significantly reduce postoperative peritoneal adhesion development, and they allow the uterine tubes to remain open.

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OBJECTIVE: To evaluate adhesion formation after classic abdominal myomectomy and the role of early, second-look laparoscopic adhesiolysis in the management of post-myomectomic pelvic adhesions in a prospective study. METHOD: Forty-eight patients with infertility, recurrent abortion or symptomatic myoma underwent second-look laparoscopy (SLL) 8 days after abdominal myomectomy. The degree of adnexal adhesions were scored according to the American Fertility Society Classification and were lyzed laparoscopically. The success of the SLL was evaluated in 18 patients who underwent a third-look procedure (cesarean section or laparoscopy) RESULTS: Myomectomy incisions on the posterior uterine wall were associated with more adhesions than that on the fundus or anterior wall (P < 0.01). Myomectomies performed on uteri larger than 13 weeks gestation resulted in significantly higher adhesion scores than smaller ones (P < 0.001) and mainly intra-mural myomas than only sub-serous ones (P < 0.01). More than one uterine incision was found to result in more adhesions (P < 0.05), while the number of myomas removed were not found to affect adhesion formation (P > 0.05). In the patients who underwent a third-look procedure, adhesion scores were found to be significantly lower than the SLL (6.2 +/- 6.4 vs. 3.1 +/- 3.4) (P < 0.01). CONCLUSION: Myomectomy operations frequently result in pelvic adhesions, which may impair fertility. Early laparoscopy and adhesiolysis after myomectomy is useful for assessing the degree of adhesions, technical ease in performing adhesiolysis and resulting in lower adhesion scores as shown by third-look procedures.

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A randomized controlled trial was performed in 30 Sprague-Dawley white rats to compare the efficacy of the synthetic adhesion-barrier Interceed (Johnson & Johnson Medical Inc.) when fixed in place using 6/0 vicryl sutures or lying freely on damaged tissues. The rats were randomly assigned to 3 groups; control, Interceed (fixed) and Interceed (free). Adhesion formation was measured 2 weeks later, using a scoring system related to extent and density. There was no significant difference whether the adhesion-barrier was fixed in place with sutures or not, so that the fixation of Interceed to cover traumatized tissues does not appear to provide any benefits against adhesion formation in rats.

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This study investigated the effects of vitamin E on adhesion formation and fibrosis. Forty-eight adult, virgin, female Sprague-Dawley rats were divided equally into two groups, one of which received 300 mIU/kg vitamin E orally in their daily diet in comparison with the control group, which received the vehicle only. Laparotomy was performed and the uterine horns identified. Denuding of the serosa was performed over a segment of the right horn; bipolar coagulation over a similar area on the left horn was performed. Following the procedure the animals continued on the same diet for three weeks. They were then killed, the adhesions were graded, and microscopic evaluation for fibrosis was accomplished. Although there was a trend of less fibrosis with vitamin E, there was no statistically significant difference, nor was there a difference with respect to a reduction in adhesion formation.

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Eighteen patients with extensive adhesions and 10 undergoing myomectomy had GORE-TEX Surgical Membranes placed in order to prevent adhesion formation/reformation. At the time of second-look laparoscopy the membranes were removed easily and the extent of adhesion was minimal. Preliminary data from 10 additional patients undergoing adhesiolysis demonstrated that the GSM resulted in significantly fewer adhesions than did oxidized regenerated cellulose. The number of patients in this group will be expanded to insure that this difference is maintained.

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Prevention of postoperative adhesion formation is a subject of concern to the reproductive surgeon. We developed a model to test the efficacy of calcium channel blockade-mediated adhesion prophylaxis after lysis of established pelvic adhesive disease. New Zealand White rabbits received a standardized primary adhesiogenic traumatic lesion to the left uterine horn. One week later, a laparotomy was performed for evaluation (prescore scale: 0 = no adhesions to 4+ = severe) and subsequent lysis of adhesions. Before operative closure, animals were allocated randomly to intraperitoneal treatment with either verapamil 2.5 micrograms/kg/hour or vehicle, delivered by mini-osmotic infusion pumps over the course of 200 hours. Seven days later, the animals were sacrificed and evaluated blindly for extent of adhesion reformation (postscore). Prescores for verapamil and control rabbits were not significantly different (3.3 versus 2.9). Verapamil-treated animals formed considerably fewer adhesions than did controls after adhesiolysis (postscore 0.5 versus 3.5; P less than .001). These data demonstrate a marked inhibition of adhesion reformation after lysis of pelvic adhesions under the influence of verapamil.

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The uterine horns of 35 female rabbits were subjected to injury by cautery. Ten days later the adhesions were scored and lysed, and in 30 animals the lesion on one side was covered with a segment of silicone. The contralateral uterine horn served as an internal control. After 5, 10, or 15 days, the silicone was removed (groups A, B, and C, respectively). Five animals (group D) in which no silicone barrier was introduced served as an external control. The rabbits were killed ten days later, and the pelvic adhesions were scored again. A significant reduction in adhesion formation following lysis was found in groups A, B, and C. The largest difference between the treated and the untreated side was obtained in group A. In each of these groups, the mean adhesions score on the treated side was significantly lower following lysis than in group D.

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33 patients with tubal pregnancies, who had been treated by pelviscopy with organ preservation between 1978 until the beginning of 1988 have had follow-up examinations from within 4 months to 2 years after their first operation. In 15 (45%) of these 33 patients we found adhesions in the true pelvis on initial pelviscopy; these adhesions were lysed in all cases. During a second inspection of the abdominal cavity-either by laparotomy (Cesarean section; 4 patients) or by repelviscopy (29 patients)-mainly avascular, filmy adhesions on one or both adnexae were found in 17 cases (52%). The pelviscopic treatment of ectopic pregnancy does not completely prevent the development of postoperative adhesions. The concomitant pelviscopic adhesiolysis during the treatment of ectopic pregnancy reduces the degree of severity of the recurring adhesions.

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This prospective study was designed to investigate the effect of glucocorticoids, promethazine (Phenergan), hyskon, heparin, and Ringer's lactated solution in the prevention of pelvic adhesion formation after pelvic surgery. The patients were divided into two groups: The first consisted of 396 patients who had laparotomy for different types of pelvic surgery, and the second group consisted of 546 patients who had operative laparoscopy for different types of pelvic disease. Patients in these two major groups were divided prospectively into different subgroups with different modalities of adjuvant therapy to prevent postoperative pelvic adhesions. A second-look laparoscopy was performed for some of the patients who failed to conceive in each of these subgroups. Pregnancy rate and adhesion formation were compared between these subgroups with no statistical difference noted. It is concluded that glucocorticoids, promethazine, heparin, and hyskon have no therapeutic advantage over Ringer's lactated solution in the prevention of postoperative pelvic adhesion formation.

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Oxidized cellulose gauze (Surgicel) was evaluated for its ability to prevent postsurgical pelvic adhesions. Ten New Zealand white female rabbits were subjected to laparotomy and standardized bilateral trauma to the fimbria and ovaries. On one side in each rabbit the ovary and uterine tube were wrapped in Surgicel. The untreated side in each rabbit served as the control. Four weeks later the rabbits' pelvises were reexplored, and the adhesions on both sides were scored. The overall adhesion scores on the treated sides (mean +/- SD = 4.24 +/- 1.28) were significantly higher than those on the control sides (mean +/- SD = 1.5 +/- 1.06, P less than .001). Surgicel appeared to enhance, rather than prevent, adhesion formation in the rabbits.

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Infertile women of reproductive age requiring an operation for distal tubal disease, endometriosis, or pelvic adhesions were recruited from nine study centers. Prior to closing the peritoneal cavity, 250 ml of 32% dextran 70 (n = 55) or saline (n = 47) was instilled into the dependent portion of the pelvis; 8 to 12 weeks later, laparoscopy was performed on those patients not pregnant. Patients with severe adnexal adhesions at the initial laparotomy had a greater reduction in adhesions if they received 32% dextran 70. Further, patients with a marked reduction in adhesion formation following the initial laparotomy were found to occur more frequently in the 32% dextran 70-treated group (26 of 51 for 32% dextran 70 versus 12 of 40 for saline; P less than 0.05). During second-look laparoscopy, adhesions were found to occur more frequently in control patients than in 32% dextran 70-treated patients at the following anatomic sites: ovary (P less than 0.05); cul-de-sac (P = 0.017); pelvic side wall (P less than 0.001). Thus, in a prospective, randomized, blinded clinical trial, the intraperitoneal high-molecular-weight dextran was found to reduce postoperative adhesion formation effectively.

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