No abstract

A 35-year-old patient attended the clinic after 1 year of primary infertility and 9 years secondary amenorrhoea. Her BMI was 21.9 kg/m². Transvaginal scan examination showed a small uterus with 1.7 mm thick endometrium. The left ovary was quiescent and measured 2.9 cm x 61.2 cm x 62.1 cm. 3D images manipulation showed a large (96.9 cm³) solid mass attached to the right ovary. Follicle stimulating hormone (FSH) level was 3.8 IU/l, oestradiol was 57 pmol/l and testosterone was 0.9 nmol/l. She had normal thyroid indices, serum prolactin, 17-hydroxyprogesterone and cortisol levels. Inhibin B and luteinising hormone (LH) blood levels were high at 408 pg/ml and 19.5 IU/l, respectively. The mass was shelled laparoscopically off the right ovary, and proved histologically to be a parasitic leiomyoma. She resumed regular menstruation 1 month after surgery and conceived in her fourth cycle. To the best of our knowledge, this is the first case to be reported relating high inhibin B and luteinising hormone blood levels to an ovarian leiomyoma.

A 38-year-old woman presented for early pregnancy ultrasound scanning 6 weeks and 4 days following an assisted reproduction treatment cycle. She had ß human chorionic gonadotrophin (ßhCG) blood level of 10,853 IU/L 2 weeks before presentation. She gave previous history of termination of pregnancy, myomectomy and bilateral salpingectomy. The uterus was retroverted with multiple fibroids and non-homogenous myometrium in many areas. The endometrium was 21.1 mm thick with no intrauterine pregnancy. An initial diagnosis of cornual/interstitial ectopic pregnancy was made. However, 3D images rendering and the multiplanar technique showed a 27.5-mm gestation sac, medial and above the interstitial part of the right tube, with 7.6-mm-long foetal pole. ßhCG and progesterone blood levels on the same day were 19,551 IU/L and 43.2 nmol/l, respectively. The patient opted against methotrexate treatment. An ectopic pregnancy bulging out of the fundal area was excised laparoscopically. Histopathological assessment showed chorionic villi surrounded by myometrium, as well as foci of adenomyosis, reaching the outer serosa. To our knowledge, this is the second case of subserosal intramural ectopic pregnancy to be reported and the first in a subserosal area of adenomyosis.

The purpose behind this observational study was to find whether age, parity, ethnicity, uterine position or the mode of presentation (infertility or gynaecological) could be used to predict acute cervicouterine angulation (ACUA) before intrauterine office surgical procedures. Uterine version, flexion and ACUA were recorded after transvaginal scanning in 914 patients and during subsequent examinations in a subgroup of 422 patients. ACUA was tested against presentation, age, parity, ethnicity and uterine position using chi-square and logistic regression. A two-tailed p value <0.05 was considered significant. One hundred and forty-two of 667 nulliparous (21.30%) and 23 of 247 (9.3%) parous women showed ACUA (p< 0.001), which persisted during repeated examinations. More patients with anteflexed (153/767, 19.9%) than retroflexed uteri (12/147, 8.2%) had ACUA p<0.001. It was more common in Afro-Caribbean (39/179, 21.8%) and Middle East women (37/129, 28.7%) than Caucasians (89/606, 14.7%; p=0.001). Age and presentation were not significant. Accordingly, ACUA should be considered before office intrauterine surgical procedures in nulliparous patients, especially those with anteflexed uteri. We debate the clinical implications of ethnicity.

The objective of this preliminary observational study was to monitor changes in focal cystic and non-cystic subendometrial lesions reminiscent of adenomyosis seen during the luteal phase of the cycle by repeating transvaginal ultrasound scan examinations during the follicular phase. Five patients who presented with abnormal uterine bleeding with or without dysmenorrhoea showed such lesions, following luteal phase transvaginal scanning. All lesions became smaller and less conspicuous, or an indiscriminate endometrial/myometrial interface was seen in the suspected areas during the follicular phase. Midcycle scanning of one patient showed enhancement of the irregular subendometrial area, but still without reaching the same size, or attaining an echogenic pattern as seen during the initial luteal phase examination. We hypothesise that luteal phase transvaginal scan examinations of the uterus may have better potential for diagnosing focal subendometrial adenomyosis than follicular phase scanning. This is because of the echogenic characteristics of a secretory endometrium relative to the neighbouring inner myometrium. More work is needed to verify these findings and to test our hypothesis.