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ImportanceVacuum aspiration is commonly used to remove retained products of conception in patients with incomplete spontaneous abortion. Scarring of the uterine cavity may occur, potentially impairing future fertility. A procedural alternative, operative hysteroscopy, has gained popularity with a presumption of better future fertility.ObjectiveTo assess the superiority of hysteroscopy to vacuum aspiration for subsequent pregnancy in patients with incomplete spontaneous abortion who intend to have future pregnancy.Design, Setting, and ParticipantsThe HY-PER randomized, controlled, single-blind trial included 574 patients between November 6, 2014, and May 3, 2017, with a 2-year duration of follow-up. This multicenter trial recruited patients in 15 French hospitals. Individuals aged 18 to 44 years and planned for surgery for an incomplete spontaneous abortion with plans to subsequently conceive were randomized in a 1:1 ratio.InterventionsSurgical treatment by hysteroscopy (n = 288) or vacuum aspiration (n = 286).Main Outcomes and MeasuresThe primary outcome was a pregnancy of at least 22 weeks’ duration during 2-year follow-up.ResultsThe intention-to-treat analyses included 563 women (mean [SD] age, 32.6 [5.4] years). All aspiration procedures were completed. The hysteroscopic procedure could not be completed for 19 patients (7%), 18 of which were converted to vacuum aspiration (8 with inability to completely resect, 7 with insufficient visualization, 2 with anesthetic complications that required a shortened procedure, 1 with equipment failure). One hysteroscopy failed due to a false passage during cervical dilatation. During the 2-year follow-up, 177 patients (62.8%) in the hysteroscopy group and 190 (67.6%) in the vacuum aspiration (control) group achieved the primary outcome (difference, −4.8% [95% CI, −13% to 3.0%]; P = .23). The time-to-event analyses showed no statistically significant difference between groups for the primary outcome (hazard ratio, 0.87 [95% CI, 0.71 to 1.07]). Duration of surgery and hospitalization were significantly longer for hysteroscopy. Rates of new miscarriages, ectopic pregnancies, Clavien-Dindo surgical complications of grade 3 or above (requiring surgical, endoscopic, or radiological intervention or life-threatening event or death), and reinterventions to remove remaining products of conception did not differ between groups.Conclusions and RelevanceSurgical management by hysteroscopy of incomplete spontaneous abortions in patients intending to conceive again was not associated with more subsequent births or a better safety profile than vacuum aspiration. Moreover, operative hysteroscopy was not feasible in all cases.Trial RegistrationClinicalTrials.gov Identifier: NCT02201732

Objective To highlight the possible correlation between Deep Infiltrating Endometriosis (DIE) resection and subsequent uterine rupture. Design Case series and Review of the literature. We report seven cases of uterine rupture in pregnancy, in patients who received a resection of deep infiltrating endometriosis. As of 2019, no publications in the literature considering uterine rupture amongst the obstetrical complications of endometriosis. Therefore, we present 7 cases of uterine rupture in pregnancy following surgical resection of DIE.The reporting of such findings is crucial considering the increase in surgical management of endometriosis. Setting Three Endometriosis Referral Hospitals. Patients Seven young women who underwent laparoscopic resection of deep infiltrating endometriosis (DIE). Six of them had Uterine rupture before or during labor. The seventh patient had posterior wall defect putting her at increased risk of future uterine rupture. Interventions Diagnosis of uterine rupture before or during labor in patientswith a history of prior resection of deep infiltrated endometriosis, leading to delivery by emergency caesarean section or emergency laparotomy for exploration and repair. Main outcome measure Immediate neonate and maternal salvaging caesarean section or laparotomy, followed bya surgical correction of the rupture. Results In six patients,surgeons found uterine rupture at the level of the previous resected endometriosis and diagnosed a posterior wall defect at the same level in one patient. Conclusion Our case series sheds light on the potential increased risk of uterine rupture in pregnancy among women who have had a prior resection of DIE, and raises the question of whether those patients should be considered high risk pregnancy cases, and should be classified as high risk pregnancies and their care rendered by a high risk obstetric specialist.

To develop a nomogram for predicting the type of ureteral procedure in pelvic deep endometriosis (DE) surgery (1) and to describe the factors and complications associated with the ureteral procedure (2).Retrospective monocentric study of 920 patients who underwent surgery for pelvic DE between June 2009 and March 2020 in the gynecologic surgery department of the Versailles Hospital Center. The main criterion was evaluation of the ureteral procedure, classified as simple (isolation of the ureter) or complex (dissection of the ureter, segmental ureteral resection, or nephroureterectomy). Postoperative complications, including ureteral stenosis and fistula formation, were tabulated.Tertiary referral hospital and expert center in endometriosis.A total of 920 patients with DE.Ureteral procedure during surgery for DE.In total, 724 patients (79%) underwent a ureteral procedure, of which 307 (33%) were complex, including 17 (1.8%) segmental ureteral resections. In multivariate analysis, the predictive variables for a complex ureteral procedure were age (p = .036), a previous surgery for endometriosis (p.01), and ureteral dilatation on magnetic resonance imaging (p.001). The area under the curve for the model predicting a complex ureteral procedure was 0.68 (95% confidence interval, 0.60-0.71). A complex ureteral procedure was associated with a 3.5% rate of ureteral fistula (n = 15).Age, a previous surgery for endometriosis, a rectovaginal nodule size ≥30 mm, endometriotic involvement of the rectum or sigmoid, and ureteral dilatation are significantly associated with a complex ureteral procedure. Our results allowed us to build a nomogram that can be used to better inform patients, anticipate the therapeutic strategy, and optimize the modalities of postoperative surveillance.

International audience; Objectives: To study the measurement properties, the responsiveness and the minimal clinically important difference of the ENDOPAIN-4D: a new questionnaire for assessing pain in endometriosis. Methods: A prospective, observational, multicentre study was conducted including all women ≥18 years consulting for symptomatic proven endometriosis between 1 January 2017 and 30 June 2018 and volunteering to participate. Each patient had to answer a new self-administered patient-reported outcome (PRO) questionnaires (the ENDOPAIN-4D) at inclusion (T0) and 12 months after medical or surgical treatment (T1). Criteria defined by COSMIN were used to validate the questionnaire's measurement properties. The minimal clinically important difference was esti-mated by the anchor-based method. Results: The study included 199 women. The ENDOPAIN-4D score had a four dimensional structure with good internal consistency (measured by Cronbach α): I) pain-related disability (α = 0.79), II) painful bowel symptoms (α = 0.80), III) dyspareunia (α = 0.83), and IV) painful urinary tract symptoms (α = 0.77). They produced four subscores that can be summed to obtain a single score (α = 0.61). The ENDOPAIN-4D total score ranged from 0 to 94.00 (mean ± SD: 46.7 ± 22). The total score was significantly correlated with the PROs used in endome-triosis. Sensitivity to change was good with large effect sizes (ES) (mean of the differences: 36.3 p = 1.8 10−7, ES 0.76). The minimal clinically important difference of the global score was determined to be 10.9. Conclusions: The ENDOPAIN-4D questionnaire is easy to use, valid, and effective in assessing patient reported pain symptoms in women treated for endometriosis. This new instrument can be used as the primary outcome for future clinical trials and as a tool for routine patient follow-up.

Resume Nous decrivons dans cette video une myomectomie d’un volumineux fibrome interstitiel de 10x8x9 cm apres occlusion selective et transitoire des arteres uterines afin de diminuer les pertes sanguines peroperatoire et ainsi limiter les risques de laparoconversion et d’anemie en postoperatoire [1, 2]. Les specificites d’installation comprennent un manipulateur uterin, deux trocarts de 5 mm (en fosse iliaque droite et gauche), un trocart de 12 mm en transombilical (pour la suture et le morcellement des myomes) et un trocart en hypocondre gauche pour l’optique. Nous avons egalement utilise une pince d’ultracision-HARMONIC et des clips chirurgicaux de 5 mm a usage unique en titane. Nous avons incise le peritoine de la paroi posterieure du ligament large en regard de l’uretere apres reperage de ce dernier. A noter que l’abord du peritoine posterieur du ligament large etait fait en interne du cote droit et en externe du cote gauche par rapport a l’uretere. Ensuite, nous avons disseque l’espace retro peritoneal pour reperer l’uretere, l’artere uterine et l’artere ombilicale. La traction au niveau de l’artere ombilicale nous a permis de reperer l’origine de l’artere uterine et de poser par la suite des clips metalliques retires a la fin de l’intervention en utilisant une pince a prehension plate (atraumatique). Le temps operatoire pour realiser la ligature transitoire des arteres uterines etait de dix-huit minutes. Les saignements etaient mesures a 70 cc a la fin de l’intervention. Parmi d’autres methodes chirurgicales decrites dans la litterature on peut citer : l’occlusion transitoire des arteres uterines en utilisant le clan de Bulldog, l’enucleation intracapsulaire du fibrome, la ligature de la pseudocapsule a l’aide d’une Endoloop et la pose d’un tourniquet pericervical surtout pour les myomectomies par laparotomie [3-5]. Cependant l’occlusion transitoire des arteres uterines en utilisant des clips metalliques est facile a apprendre, ne diminue pas la fertilite ulterieure et permet de reduire la morbidite operatoire en diminuant les pertes sanguines et le taux de laparoconversion [6, 7]. Pour completer la presentation voir les figures 1 a 14

STUDY QUESTION Is the Sexual Activity Questionnaire (SAQ) a valid tool for patients treated for symptomatic endometriosis? SUMMARY ANSWER For women having surgical treatment for endometriosis, we determined that the SAQ is a valid and responsive tool. WHAT IS KNOWN ALREADY Endometriosis adversely affects sexual quality of life. Suitable validated sexual quality of life instruments for endometriosis are lacking both in clinical practice and for research. STUDY, DESIGN, SIZE, DURATION A total of 367 women with proven endometriosis undergoing medical or surgical treatment were included in an observational study conducted between 1 January 2012 and 31 December 2014 in two French tertiary care centers. Both hospitals are reference centers for endometriosis treatment. Of these 367 women, 267 were sexually active and constituted the baseline population. PARTICPANTS/MATERIALS, SETTINGS, METHODS Women >18 years old with histological or radiological proven endometriosis, consulting for painful symptoms of at least 3 months duration, infertility, or other symptoms (bleeding, cysts) were invited to complete self-administered questionnaires before (T0) and 12 months after treatment (T1). Tests of data quality included descriptive statistics of the data, missing data levels, floor and ceiling effects, structural validity and internal consistency.The construct validity was obtained by testing presupposed relationships between previously established SAQ scores and prespecified characteristics of the patients by comparing different subgroups of patients at T0. Sensitivity to change was subsequently calculated by comparing the SAQ score between T1 and T0 overall and for different subgroups of treatment. Effect sizes (to T1) were calculated according to Cohen's method. The minimally important difference was estimated by a step-wise triangulation approach (including anchor-based method). MAIN RESULTS AND THE ROLE OF CHANCE In total, 267 sexually active patients (204 surgical and 63 medical treatment) completed the SAQ at T0 and 136 (50.9%) at T1. The SAQ score ranged from 2.0 to 28.0 (mean ± SD: 16.8 ± 5.7).The SAQ score was one-dimensional according to the scree plot with good internal consistency (Cronbach alpha = 0.78, 95% CI 0.74-0.81) and had good discriminative ability according to pain descriptors and quality of life in endometriosis. The SAQ was responsive in patients treated by surgery but the effect size was low (0.3, 95% CI (0.0-0.6), P = 0.01). The minimally important difference was determined at 2.2. LIMITATIONS, REASONS FOR CAUTION The effect size for medical treatment was non-significant. Other effect sizes were low but statistically significant. This could be explained by lower libido due to progestin intake, which was used for both surgically and medically treated patients. WIDER IMPLICATIONS OF THE FINDINGS The SAQ is easy to use, valid and effective in assessing sexual quality of life in patients with endometriosis. This patient-reported score could be used as a primary outcome for future clinical studies. The minimally important difference estimation will be useful for future research. We recommend using 2.2 for the minimally important difference of the SAQ. STUDY FUNDING/COMPETING INTEREST(S) This work was funded by the 'Direction a la Recherche Clinique et a l'Innovation' of Versailles, France and the 'Institut de Recherche en Sante de la Femme' (IRSF). The authors have no conflicts of interest to declare.

In this review, images during surgical excision of Deep Infiltrating Endometriosis (DIE) were correlated to preoperative Magnetic Resonance Imaging (MRI) findings. MRI is known to be the best tool for mapping DIE, it displays a high accuracy in the diagnosis and the characterization of endometriosis lesions. Recent studies showed also that MRI findings can be correlated to the length of operating time, to the duration of hospital stay, and to the risk of voiding problems. In this article we emphasize on the importance of having an experienced radiologist that has the ability of detecting adhesions and superficial peritoneal lesions, a value that was underestimated in previous studies. DIE presents on MRI as an intermediate signal intensity on T1-weighted images, hypointense signal on T2-weighted images, and homo- or heterogeneous enhancement after intravenous gadolinium injection. Preoperative MRI findings help doctors to elaborate a tailored therapeutic plan for each patient depending on the clinical context (Fertility preservation, IVF, complete surgical excisions). Most importantly correct investigation and accurate description of small lesions enhance surgical planification and adequate information of the patients.

International audience; Introduction: High-dose progestins are used as an effective therapy for painful symptoms of endometriosis but their impact on sexual function has been poorly studied. The study aims to assess the impact of high-dose progestin on sexual function among women treated for endometriosis. Material and methods: In this bicenter prospective observational study, women with endometriosis who received medical or surgical treatment for endometriosis and who were sexually active were included. They completed the Sexual Activity Questionnaire (SAQ, a validated tool) before (T0) and 12 months after (T1) endometriosis treatment. We classified patients into two groups according to whether they were using high-dose progestins at T1: a high-dose progestin group and a control group. The main outcome was sexual function measured by the SAQ score (from 0 to 30) at T1. The secondary outcomes were each individual SAQ item, the dyspareunia 100-mm visual analog scale (VAS) and the quality of life assessed with EuroQoL Group 5D Index (EQ-5D) at T1. We also assessed the change in dyspareunia VAS and quality of life between T0 and T1. The Ethics Committee of Ile-de-France (Act 2004-806, 9 August 2004) approved the study. Results: Among 214 women included, 25 (12%) were exposed to high-dose progestins at T1. The SAQ score of women exposed to high-dose progestins was significantly lower compared with the control group, with or without adjustment for covariates (15.5 ± 6.3 vs 18.3 ± 6.2, P =.03, adjusted effect size −0.44 [95% CI −0.86 to −0.02], P =.04). High-dose progestin intake at T1 was associated with a lower subscore on two SAQ items: pleasure (1.8 ± 0.8 vs 2.2 ± 0.9, P =.02), and satisfaction with frequency of intercourse (1.2 ± 1.2 vs 1.8 ± 1.1, P =.02). In the overall population, dyspareunia VAS and quality of life assessed by EQ-5D improved between T0 and T1 (45 ± 29 at T0 vs 28 ± 29 at T1, P

First-line diagnostic investigations for endometriosis are physical examination and pelvic ultrasound. The second-line investigations are: targeted pelvic examination performed by an expert clinician, transvaginal ultrasound performed by an expert physician sonographer (radiologist or gynaecologist), and pelvic MRI. Management of endometriosis is recommended when the disease has a functional impact. Recommended first-line hormonal therapies for the management of endometriosis-related pain are combined hormonal contraceptives (CHCs) or the 52mg levonorgestrel-releasing intrauterine system (IUS). There is no evidence base on which to recommend systematic preoperative hormonal therapy solely to prevent surgical complications or facilitate surgery. After surgery for endometriosis, a CHC or 52mg levonorgestrel-releasing IUS is recommended as first-line treatment when pregnancy is not desired. In the event of failure of the initial treatment, recurrence, or multiorgan involvement, a multidisciplinary team meeting is recommended, involving physicians, surgeons and other professionals. A laparoscopic approach is recommended for surgical treatment of endometriosis. HRT can be offered to postmenopausal women who have undergone surgical treatment for endometriosis. Antigonadotrophic hormonal therapy is not recommended for patients with endometriosis and infertility to increase the chances of spontaneous pregnancy, including postoperatively. Fertility preservation options must be discussed with patients undergoing surgery for ovarian endometriomas.

The objective was to compare results of two groups of population (novices and experts) on a virtual reality simulator of hysteroscopy resection for different metrics and for a multimetric score to assess its construct validity.Nineteen gynecologist who had at least 5 years of experience with hysteroscopy and self-evaluated their expertise at 4/5 or 5/5 were included as expert population. Twenty first-year gynecology residents in Paris were included as novice population. A standardized set of 4 hysteroscopy resection cases (polypectomy, myomectomy, roller ball endometrial ablation and septum resection) was performed on a virtual reality simulator (HystSim™) by the group of novices and experts. Results obtained on the simulator for overall score and for the parameters were compared by applying the Mann-Whitney test.Overall score of novices and experts were significantly different for three resection cases (polypectomy P0.001, myomectomy P0.001, roller ball endometrial ablation0.001). The overall score was not different in the septum resection (P=0.456). For the four cases, the economy score (included cumulative path length, procedure time and camera alignment) were statistically different between novices and experts (polypectomy P0.001, myomectomy P=0.001, roller ball endometrial ablation P0.001, septum resection P0.001).The overall score on HystSim™ was able to discriminate novices between experts on polypectomy, myomectomy and roller ball endometrial ablation cases but not on septum resection. The economy score was the more reliable to reflect the surgeon experience. It could be used to evaluate and to train students on hysteroscopic resection on a virtual reality simulator.

Resume Objectif Le College national des gynecologues obstetriciens francais (CNGOF), en accord avec la Societe de chirurgie gynecologique et pelvienne (SCGP), a constitue en 2017 une commission chargee de definir les centres experts en endometriose, afin d’optimiser la prise en charge des patientes atteintes en France. Methode La commission endometriose comportait des membres issus d’hopitaux universitaires, d’hopitaux generaux et de structures privees, representant a la fois les aspects medicaux, chirurgicaux et radiologiques de l’endometriose. L’avis d’associations des patientes a ete sollicite en prealable a la redaction de ce travail. Le texte final a ete presente et valide a l’unanimite des membres du conseil d’administration du CNGOF dans sa seance du 13 octobre 2017. Resultats A partir de l’etat des lieux de la prise en charge de l’endometriose en France et des opportunites des dix dernieres annees, la commission a pu definir les contours des centres experts en endometriose. Les objectifs, le cahier des charges, le mode de fonctionnement, les missions et les sources de financement de ces centres ont ete decrit. Les missions d’organisation territoriale, de soin global et de recours, de communication et d’enseignement, ainsi que de recherche et d’evaluation ont ete definies. Conclusion Du fait de son impact quotidien et des couts de sante qu’elle induit en France, l’endometriose justifie la creation des centres experts que la labellisation par les autorites de sante permettra d’officialiser, idealement dans le cadre du plan de sante national.

Gestational trophoblastic disease (GTD) is rare and encompasses several clinicopathologic forms from pre-malignant to malignant disorders. Clinical presentation is most of the time dominated by vaginal bleeding. Only few cases of uterine rupture during GTD have been reported in literature. We present the case of a female patient admitted to the hospital for hemorrhagic shock secondary to a uterine rupture due to an undiagnosed GTD. After an emergency laparoscopy, the patient underwent total hysterectomy with bilateral salpingectomy and bilateral ovarian cystectomy. Pulmonary metastasis were discovered on imaging after stagnation of the beta-hCG level. The surgical treatment was completed by 6 cycles of Methotrexate followed by 7 cycles of Actinomycine D with a good response.

Background The question of assessing surgical competence is the focus of mainly Anglo-Saxon studies. The GOALS questionnaire (Global Operative Assessment of Laparoscopic Skills) specific to laparoscopic surgery assessment has been developed since 2005. The aim of the study was to assess the metrological qualities of the GOALS questionnaire after ratification in French language. Methods To produce a French version of the GOALS surgical competence assessing tool according to an established method (translation – backward translation – retranslation) and to check the metrological qualities (user satisfaction, acceptability, reliability and validity) of this questionnaire through observing residents while in training program on 22 residents in Gynaecology Obstetrics during the laparoscopy training, with the performance of a nephrectomy on a porcine model. Results The discrepancies in the initial translations were mainly due literal translations. Only synonymous differences were observed in the two backward translations. Comparison with original version led to 8 minor changes. No changes occurred between the 2 French versions. Satisfaction surveys when using the GOALS questionnaire by both examiners and students are similar. Face and content validity seemed good and there is no significant discrepancy between the examiners and the students (11.5 [9–15]; 12.4 [9–15]; P = 0.40). Assessment by examiners showed an median value of 17.8 [9–26] with good correlation (α = 0.80). By contrast, self-assessment, although there is no significant discrepancy, showed heterogeneity. GOALS French version was able to prove a significant progression both in self-assessment and external evaluation between the act performed on the first nephrectomy on the first day of the first session of the training and the fourth nephrectomy performed on the first day of the second session of the training. Conclusion Our work allowed obtaining a GOALS French version with acceptable validity, good consistency between the assessments and ability to measure progress.

Hysteroscopy is performed often and in many indications but is challenging to learn. Hands-on training in live patients faces ethical, legal, and economic obstacles. Virtual reality simulation may hold promise as a hysteroscopy training tool. No validated curriculum specific in hysteroscopy exists. The aim of this study was to develop a hysteroscopy curriculum, using the Delphi method to identify skill requirements. Based on a literature review using the key words “curriculum,” “simulation,” and “hysteroscopy,” we identified five technical and non-technical areas in which skills were required. Twenty hysteroscopy experts from different French hospital departments participated in Delphi rounds to select items in these five areas. The rounds were to be continued until 80–100% agreement was obtained for at least 60% of items. A curriculum was built based on the selected items and was evaluated in residents. From November 2014 to April 2015, 18 of 20 invited experts participated in three Delphi rounds. Of the 51 items selected during the first round, only 25 (49%) had 80–100% agreement during the second round, and a third round was therefore conducted. During this last round, 80–100% agreement was achieved for 31 (61%) items, which were used to create the curriculum. All 14 residents tested felt that a simulator training session was acceptable and helped them to improve their skills. We describe a simulation-based hysteroscopy curriculum focusing on skill requirements identified by a Delphi procedure. Its development allows standardization of training programs offered to residents.

Introduction The Endometriosis Fertility Index (EFI) is a validated score for predicting the postoperative spontaneous pregnancy rate in patients undergoing endometriosis surgery. However, the practical use of the EFI to advise patients about postoperative fertility management is unclear. Materials and methods All patients participating in the ENDOQUAL study–a prospective observational bi-center cohort study conducted between 01/2012 and 06/2018–who underwent surgery for infertility were asked to complete a questionnaire collecting time and mode of conception. Statistical analysis was performed with the Fine and Gray model of competing risks and analysis of fertility according to the EFI. Results Of the 234 patients analyzed, 104 (44.4%) conceived postoperatively including 58 (55.8%) spontaneous pregnancies. An EFI of 0–4 for spontaneous pregnancies was associated with a lower cumulative pregnancy incidence compared to an EFI of 5–10 (52 versus 34 pregnancies respectively, Subdistribution Hazard Ratio (SHR) = 0.47; 95% CI [0.2; 1.1]; p = 0.08). An EFI of 0–4 was associated with a higher cumulative pregnancy rate for pregnancies obtained by artificial reproduction technology (ART), compared to an EFI of 5–10 (12 versus 6 pregnancies respectively, SHR = 1.9; CI95% [0.96; 3.8]; p = 0.06). Fecundability decreased from 12 months for EFI 0–4 and from 24 months for EFI 5–10. Conclusion Our analysis suggests that patients with an unfavorable EFI (≤4) have more ART pregnancies than patients with a favorable EFI (≥5) and should be referred for ART shortly after surgery. Patients with a favorable EFI may attempt spontaneous pregnancy for 24 months before referral.

International audience; Purpose: The Endometriosis Health Profile 5 (EHP-5) is a short version of an endometriosis-specific quality of life questionnaire. The objective of the study was to assess the psychometric validity of its French version. Methods: A total of 125 patients with histologically proven endometriosis who underwent surgery for painful symptoms and 80 asymptomatic controls completed the EHP-5. Principal components analysis was performed to determine the dimensions of the instrument. Internal consistency was assessed using Cronbach’s alpha. Construct validity was assessed by testing the relationship between the EHP-5 and the characteristics of endometriosis. Results: For each item of EHP-5, endometriosis patients scored significantly higher than control women (p > 0.0001). Eleven items of the EHP-5 were unidimensional with excellent internal consistency (Cronbach’s alpha = 0.92), and a summary aggregated index was then constructed. The EHP-5 index was sensitive to the presence of endometriosis, the type, location, severity of the disease, and pain or infertility as the main complaint with effect sizes ranging from 0.48 (95 % CI 0.11–0.85) for superficial endometriosis to 2.56 (95 % CI 2.18–2.93) for deeply infiltrating endometriosis. Conclusion: The French version of EHP-5 is valid and can be used for reporting patient-orientated outcome in future studies of French-speaking patients with endometriosis.

Objective Three-dimensional sonography is a good alternative method to assess the position of microinserts. Adequate position after three months allows for the interruption of other contraception. Objective is to evaluate inter-observer reproducibility of the interpretation of coronal transvaginal 3D ultrasound view of the uterus to evaluate the position of Essure ® . Study design Inter-observer reproducibility study. Fifty women underwent successful bilateral placement of microinserts (Essure ® ) by hysteroscopy in the Department of Gynaecology of a teaching hospital and were included in the study. At three month, 3D ultrasound coronal views of the fifty uterus (accounting for one hundred microinserts) were assessed by five different observers and microinsert position was classified according to the classification described by Legendre et al. Inter-observer reproducibility in reading the 3D coronal view of the uterus was evaluated. Results The k -value was disparate, from 0.26 to 0.82. Inter-observer reproducibility then ranged from fair to almost perfect, depending on a prior knowledge of the position classification. Conclusions Transvaginal 3D coronal view of the uterus is sufficient to assess the positioning of the microinserts when the practionner or the surgeon is familiar with the classification method.

First-line investigations to diagnose endometriosis are clinical examination and pelvic ultrasound. Second-line investigations include pelvic examination performed by a referent clinician, transvaginal ultrasound performed by a referent echographist, and pelvic MRI. It is recommended to treat endometriosis when it is symptomatic. First-line hormonal treatments recommended for the management of painful endometriosis are combined with hormonal contraceptives or levonorgestrel 52mg IUD. There is no evidence to recommend systematic preoperative hormonal therapy for the unique purpose of preventing the risk of surgical complications or facilitating surgery. After endometriosis surgery, combined hormonal contraceptives or levonorgestrel SIU 52mg are recommended as first-line therapy in the absence of desire of pregnancy. In case of initial treatment failure, recurrence, or multiple organ involvement by endometriosis, medico-surgical and multidisciplinary discussion is recommended. The laparoscopic approach is recommended for the surgical treatment of endometriosis. HRT may be offered in postmenopausal women operated for endometriosis. In case of infertility related to endometriosis, it is not recommended to prescribe anti-gonadotropic hormone therapy to increase the rate of spontaneous pregnancy, including postoperatively. The possibilities of fertility preservation should be discussed with the patient in case of surgery for ovarian endometrioma.

Endometriosis is a common condition that causes pain and infertility. It can lead to absenteeism and also to multiple surgeries with a consequent risk of impaired fertility, and constitutes a major public health cost. Despite the existence of numerous national and international guidelines, the management of endometriosis remains suboptimal. To address this issue, the French College of Gynaecologists and Obstetricians (CNGOF) and the Society of Gynaecological and Pelvic Surgery (SCGP) convened a committee of experts tasked with defining the criteria for establishing a system of care networks, headed by Expert Centres, covering all of mainland France and its overseas territories. This document sets out the criteria for the designation of Expert Centres. It will serve as a guide for the authorities concerned, to ensure that the means are provided to adequately manage patients with endometriosis.

Purpose To develop a questionnaire based on patients’ verbal descriptors, to measure the painful symptoms of endometriosis. Methods We performed a two-round modified DELPHI procedure mixing endometriosis patients and physicians to select a set of statements to describe the painful symptoms of endometriosis. Each panelist rated each statement based on diagnosis validity and clarity. The clinicians were experts in endometriosis management selected from various geographic regions in France. Patients were women with surgically confirmed endometriosis who volunteered from a patient association and from the recruitment of the participating physicians. The first round questions were derived from words and phrases in narratives of pain by endometriosis patients. Results Overall, 76 experts were invited, and of these 56 (74%), comprising 33 patients and 23 gynecologists, responded to the first round questionnaire, and 40 (71.4%) to the second round. Among the 48 statements assessed in the first-round questionnaire, 11 were selected after completion of the two round DELPHI procedure. After discussion and rewording of some items, a total of 21 questions were selected during a final face-to-face meeting. The content of the final questionnaire is organized according to four dimensions: (i) spontaneous pelvic pain and dysmenorrhea, (ii) dyspareunia, (iii) painful bowel symptoms, (iv) and other symptoms. We also provide an English (UK) version produced using several steps of translation and back-translation. Conclusions The questionnaire has content validity to measure the subjective experiences of patients with painful endometriosis and can provide a solid basis on which to develop an efficient patient-centered outcome to measure the painful symptoms in therapeutic or in diagnostic studies of endometriosis.

Outpatient hysteroscopic sterilisation without anaesthetic, using the Essure® system, is quick, successful, safe, and associated with a high rate of patient satisfaction. The technique provides a convenient, cost-effective, and welcome alternative to couples regarding their choice of permanent fertility control. However, that permanent birth control presents adverse effects of the procedure: pain, discomfort, vasovagal syncope, nausea, fainting; benign adverse effects: pain, contractions, vaginal bleeding, discharge, pelvic inflammatory disease, menstrual period turned irregular, allergic reactions; and serious side effects: expulsion, perforation, failure, risk of regret. Erin Brockovich warned about new adverse events. According to her they could be caused by the Essure device: skin rash, chronic infections (vaginal, respiratory), fatigue, chronic sleeping, shakiness, memory loss, autoimmune disease, loss of voice, dysesthesia, blood pressure drop, weight changes, hair loss, mood changes such as depression, and various kinds of pain including headache, muscle pain, pain in legs, and so on.

Although exceptional, endometriotic lesions of the troncular nerves of the lower limb may occur and are often diagnosed with delay. We report, hereby, the first case of femoral nerve endometriosis the treatment of which consisted of radical resection with femoral nerve transplant. We completed a review of the literature on sciatic nerve endometriotic lesions and discussed the physiopathology and surgical treatment.

To compare the rates of pregnancy among women who underwent Essure hysteroscopic sterilization versus tubal ligation in France between 2006 and 2010.Retrospective cohort study.Hospital care in France (nationwide). Anonymised database of all hospital discharge summaries in France.Recruitment was based on procedure codes in the national database of hospital discharge summaries. The study included all women who underwent tubal sterilization by Essure microinserts or by tubal ligation and subsequently were hospitalised either for all unexpected pregnancies related diagnosis (e.g., miscarriage, legal abortion, or delivery) or for pregnancies following reversal microsurgery or invitro fertilization (IVF) treatment.During the study period, French hospitals performed 109,277 tubal sterilization procedures: 39,169 Essure sterilizations and 70,108 laparoscopic tubal ligations. The respective indication of both techniques depended on the surgeons' skill. The median age of the two populations was similar, 41 years (range 28-52) for Essure patients and 40 years (range 27-54) for those undergoing tubal ligation (p=0.42). A Cox model has been performed. Following sterilization, after adjustment on age Essure patients became pregnant at a significantly lower rate than laparoscopic ligation patients 0.36% versus 0.46%, respectively (HR=0.62 (040-096)), and their pregnancy rate of post-sterilization procedure was significantly lower (reversal microsurgeries: 0.02% versus 0.19% (p0.001), IVF treatment: 0.08% versus 0.27%) (p0.001). The pregnancy rates after IVF were 12.5% and 5.35%, respectively, and 0% and 11.36% after tubal repair.This nationwide study of tubal sterilization demonstrates that Essure was associated with lower rates of pregnancy versus tubal ligation.

Objective The objective of this multicenter, randomized study was to investigate the efficacy of the hydrophilic resorbable film PREVADH™ in preventing postoperative adhesions following myomectomy. Study design Women scheduled for laparotomic myomectomy with intramural and/or subserous myomas of >60 mm in diameter, and who wished to preserve fertility, were eligible. Patients were randomized immediately prior to abdominal wall closure to receive either hydrophilic resorbable film applied directly to the incisions (P-Group, n = 33) or 500 mL Ringer's lactate solution instilled into the pelvic cavity (R-Group, n = 28). Incidence, severity, and extent of postoperative adhesions to the uterine incisions and adnexal and abdominopelvic adhesions were assessed during second-look laparoscopy 10–20 weeks after the initial surgery. Unedited videotapes of this second-look procedure were reviewed by two blinded independent surgeons. Results Fifty-four patients (P-Group, n = 28; R-Group, n = 26) underwent second-look laparoscopy. Significantly fewer P-Group patients developed adhesions to uterine incisions than R-Group patients (43% vs. 92%, P = 0.001). Adhesions, which were confirmed by independent reviewers, were found in significantly fewer P-Group sites than R-Group sites (29% vs. 76%, P = 0.001). No serious adverse events related to the barriers used or adhesion-related complications were reported in either group. Conclusion The hydrophilic resorbable anti-adhesion film PREVADH™ significantly reduced adhesion incidence and severity after laparotomic myomectomy. Clinical trial registration NCT01388907 ( www.clinicaltrials.gov ).

Key points Hysterectomy is the most effective treatment for symptomatic myoma with no possible recurrence. Hysterectomy for myoma is associated with a high rate of patient satisfaction (95%). Quality of life is globally improved by hysterectomy, as is sexuality with less pelvic pain, asthenia, urinary symptoms and impaired mental health. Vaginal and laparoscopic routes should be preferred to diminish blood loss, hospital stay and postoperative pain. Patients with hysterectomy are at twice as much risk of requiring surgical treatment for incontinence later on. Stress urinary incontinence must be looked for during the preoperative history-taking.

Essure appears to be a safe reliable contraception. The aim of this study is to report French pregnancies after Essure hysteroscopic sterilization. This study is a retrospective national survey between January 2003 and September 2010. Data were collected in two ways: – a mail-in questionnaire addressed to all surgeons performing Essure procedures in France – pregnancies reported directly to the manufacturer. The surgeons contacted in our study were responsible for 63.4% of all Essure procedures in France. Fifty-eight cases of unintended pregnancies after Essure sterilization in France were reported during the study period. Factors associated to unintended pregnancies were patient’ non compliance with follow-up (22 pregnancies, 38% of cases) and misinterpretation at the 3rd-month confirmation test (19 cases, 33%). Other causes were physician's deviation from protocol (10 cases) and undetected pre-procedure pregnancy (3 cases). Three pregnancies happened before the 3-months confirmation test. Based on the number of kits sold during the period, the estimated pregnancy rate was between 1.07 and 1.09/1000 procedure. The pregnancy risk after hysteroscopic sterilization may be reduced by improving patient education and physician knowledge concerning the 3rd month confirmation test.

Does treatment for the resolution of ectopic pregnancy (EP) affect subsequent spontaneous fertility [occurrence of an intrauterine pregnancy (IUP)]?There is no significant difference in 2 years subsequent fertility neither between methotrexate and conservative surgery for less active EP nor between conservative and radical surgery for the most active EP.No randomized trial has compared radical and conservative surgery treatments. A recent review of the Cochrane database did not conclude about fertility due to insufficient data. Prospective studies from EP registries in two regions of France (Auvergne and Greater Lille) have suggested that fertility is similar after medical treatment and conservative surgery and lower after radical surgery.This randomized controlled trial included all women with an ultrasound-confirmed EP. Women were divided into two arms according to the activity of the EP (defined by Fernandez's score). In arm 1 (less active ectopic pregnancies, i.e. Fernandez's score13 and no haemodynamic failure), medical treatment was considered practicable, and women were randomly allocated to conservative surgery with a systematic post-operative i.m. methotrexate injection within 24 h or to an i.m. methotrexate injection alone. In arm 2 (active ectopic pregnancies), medical treatment was considered impracticable, and, thus, all women had to undergo surgery; they were randomly allocated to either a radical or conservative procedure, the latter including a post-operative methotrexate injection. Sample sizes (n = 210 in arm 1 and n = 230 in arm 2) were computed to provide a statistical power of 80% to detect a 20% difference in subsequent cumulative fertility rates between treatments in each arm. The total duration of the trial was 5 years.The trial took place in 17 centres in France from 2005 to 2009. Two hundred and seven women were included in arm 1 and 199 in arm 2. Cumulative fertility curves were drawn with the Kaplan-Meier method and compared with the log-rank test. Hazard ratios (HRs) were computed with the Cox model. Analysis was performed according to the intention-to-treat principle.Arm 1: cumulative fertility curves were not significantly different between medical treatment and conservative surgery. HR was 0.85 (0.59-1.22) P = 0.37. The 2-year rates of IUP were 67% after medical treatment and 71% after conservative surgery. Arm 2: cumulative fertility curves were not significantly different between conservative and radical surgery. HR was 1.06 (0.69-1.63) P = 0.78. The 2-year rates of IUP were 70% after conservative surgery and 64% after radical surgery.Inclusion in this trial was more difficult than expected, especially in arm 2 in which women were reluctant to radical surgery. In consequence, the sample size was slightly lower than planned. However, due to a lower proportion of lost to follow-up than expected (10% instead of 15%), the statistical power remained very close to 80%.As it is a multicentre randomized trial, the results may be generalized with satisfactory confidence. The results of this trial invite gynaecologists to reconsider the management of EP and to modify balance between considerations of initial recovery and preservation of fertility.NCT00137982 on the WHO International Clinical Trials Registry Platform.

International audience; Objectives Potentially life-threatening gynecological emergencies (G-PLEs) are acute pelvic conditions that may spontaneously evolve into a life-threatening situation, or those for which there is a risk of sequelae or death in the absence of prompt diagnosis and treatment. The objective of this study was to identify the best combination of non-invasive diagnostic tools to ensure an accurate diagnosis and timely response when faced with G-PLEs for patients arriving with acute pelvic pain at the Gynecological Emergency Department (ED). Methods The data on non-invasive diagnostic tools were sourced from the records of patients presenting at the ED of two hospitals in the Parisian suburbs (France) with acute pelvic pain between September 2006 and April 2008. The medical history of the patients was obtained through a standardized questionnaire completed for a prospective observational study, and missing information was completed with data sourced from the medical forms. Diagnostic tool categories were predefined as a collection of signs or symptoms. We analyzed the association of each sign/symptom with G-PLEs using Pearson's Chi-Square or Fischer's exact tests. Symptoms and signs associated with G-PLEs (p-value < 0.20) were subjected to logistic regression to evaluate the diagnostic value of each of the predefined diagnostic tools and in various combinations. Results The data of 365 patients with acute pelvic pain were analyzed, of whom 103 were confirmed to have a PLE. We analyzed five diagnostic tools by logistic regression: Triage Process, History-Taking, Physical Examination, Ultrasonography, and Biological Exams. The combination of History-Taking and Ultrasonography had a C-index of 0.83, the highest for a model combining two tools. Conclusions The use of a standardized self-assessment questionnaire for history-taking and focal ultrasound examination were found to be the most successful tool combination for the diagnosis of gynecological emergencies in a Gynecological ED. Additional tools, such as physical examination, do not add substantial diagnostic value.

International audience; Introduction and hypothesis: Patients with deep infiltrating pelvic endometriosis (DIE) often describe having lower urinary tract symptoms (LUTS). Bladder pain syndrome in women is also often associated with endometriosis. In this study, we aimed to describe the characteristics of LUTS and urodynamic observations in patients with posterior endometriosis versus those with posterior and anterior endometriosis. Methods: This was a prospective observational study of 30 patients from two gynecologic surgical settings with experience in DIE surgery. All patients underwent preoperative standardized investigation including detailed evaluation of LUTS and urodynamic studies. During surgery, endometriosis locations were recorded and correlated to symptoms and urodynamic observations. Results: Twenty-three patients (76.7 %) had one or more LUTS symptoms and 29 (96.7 %) had one or more abnormalities at urodynamic examination. At surgery, all patients had posterior endometriosis and ten of them also had anterior endometriosis. Patients with anterior endometriosis had increased bladder sensation (90.0 % versus 45.0 %, p = 0.024) and painful bladder filling (70.0 % versus 30.0, p = 0.04) compared with patients with posterior endometriosis only. Voiding symptoms (60.0 %), impairment of flowmetry (30.0 %), and increased maximum urethral closure pressure (90.0 %) were frequent and not correlated with any specific location. Conclusions: Endometriosis infiltrating the bladder wall is associated with painful bladder symptoms. Dysfunctional voiding suggests an impairment of the inferior hypogastric plexus by posterior DIE. Clinical preoperative evaluation of bladder function should be systematic; urodynamic tests could be of interest in selected patients with DIE. Endometriosis may be a major cause of bladder pain syndrome.

Objective To assess the effectiveness and complication rate with Essure microinsert placements for tubal sterilization and the concomitant bipolar intrauterine surgical procedure. Design Case control study. Setting Department of gynecology and obstetrics of a general hospital in France. Patient(s) 382 women, including 41 undergoing one or several concomitant uterine procedures with Essure placement, and 341 undergoing Essure placement only (controls). Intervention(s) Essure placement with or without bipolar hysteroscopic procedure for polyp, myoma, or endometrial ablation. Main Outcome Measure(s) Success rate for microinsert placement and complications at 3 months. Result(s) Forty-one patients had Essure microinserts placed in combination with a bipolar hysteroscopic procedure: endometrial resection (n = 32), fibroma resection (n = 4), or polyp ablation (n = 5). They were compared with 341 patients who underwent Essure placement only. The success rate for Essure placement was 97.6% in the combination group versus 97.6% in the control group. The complication rate was 4.9% (n = 2) in the combination group versus 2.6% (n = 9) in the control group. The difference in the success and complication rates was not statistically significant. Conclusion(s) Performing intrauterine bipolar resection during hysteroscopy for sterilization is possible without reducing the Essure placement success rate and without increasing morbidity.

Hysteroscopic sterilization through the Essure® method is preferably performed in the outpatient department without any form of anesthesia. This approach requires the hysteroscopic skills of the gynecologist to use the vaginoscopic route. Initially, the manufacturer advised to remove any type of intrauterine device (IUD), 1 month before the procedure, to prevent difficult procedures and also to increase the success rate of placement. This observational prospective study analyzed the outcome in women in where the IUD was left in the uterus during the sterilization. During a period of 2 years, all women have been included consecutively in seven public hospitals located in France and the Netherlands. During this procedure, 32 out of 239 IUDs had to be removed to finish the sterilization successfully. The placement success rate was 97%. Placement failures were not related to the IUD being present at the time of the procedure. At confirmation tests 3 months after insertion of the Essure®, only five tubes were still patent. No complications were registered. Pain was recorded, and women responded well on oral nonsteroidal anti-inflammatory drug medication. The IUD did not need to be removed before the start of the hysteroscopic sterilization; only in case the procedure could not be completed, the IUD had to be removed during the sterilization itself. Placement rate was 97.1%.

Introduction Malgre l’existence de multiples dispositifs de declaration des evenements indesirables, il existe toujours une sous-declaration importante des complications operatoires, en particulier concernant le prolapsus genital.

Resume Objectifs La loi du 4 juillet 2001 a liberalise la pratique de la sterilisation tubaire en France. Dans le meme temps est apparue une nouvelle methode de sterilisation feminine par voie hysteroscopique. Cette methode se developpe d’autant plus qu’elle ne necessite pas toujours d’anesthesie, ne laisse pas de cicatrice, reduit la duree d’hospitalisation et diminue les couts totaux de sterilisation. Le but de l’etude est d’analyser les modalites et le succes de pose des implants en France. Patientes et methodes Cette etude a ete realisee dans sept centres francais de janvier 2004 a juin 2006. Elle concerne l’analyse de 1061 tentatives de pose (495 prospectives et 566 retrospectives) d’implants Essure® commercialises par le laboratoire Conceptus™ SAS (France). Cette etude a ete realisee dans sept centres francais de janvier 2004 a juin 2006. Resultats Le taux de succes de pose est de 94,4 % lors d’une premiere tentative (n = 992). Trente-neuf patientes ont eu une deuxieme tentative. Le succes de pose en deuxieme intention etait de 59 % (n = 23). La douleur ressentie par la patiente etait en moyenne de 3,23 ± 0,19 a L’EVA. Quatre-vingt-treize pour cent des patientes etaient satisfaites ou tres satisfaites. Discussion et conclusion La sterilisation tubaire par les implants Essure® est une methode fiable, reproductible qui necessite une courte periode d’apprentissage. La voie hysteroscopique pourrait, a l’avenir, devenir la technique de reference.

Resume La chirurgie coelioscopique de l’endometriose profonde atteignant les ligaments uterosacres et le rectum induit classiquement des troubles mictionnels postoperatoires imputables aux lesions nerveuses du plexus presacre dont les terminaisons nerveuses peuvent etre lesees en per-operatoire. Cependant, les patientes consultant pour ce type de pathologie decrivent frequemment des signes fonctionnels urinaires avant toute intervention chirurgicale.

Resume Objectif La chirurgie cœlioscopique de l’endometriose profonde atteignant les ligaments uterosacres et le rectum induit classiquement des troubles mictionnels postoperatoires imputables aux lesions nerveuses du plexus presacre dont les terminaisons nerveuses peuvent etre lesees en peroperatoire. Cependant, les patientes consultant pour ce type de pathologie decrivent frequemment des signes fonctionnels urinaires avant toute intervention chirurgicale. Cette etude a pour but d’evaluer l’existence de troubles mictionnels preexistants par un bilan urodynamique preoperatoire. Patientes et methodes Il s’agit d’une etude prospective, descriptive, non comparative, chez 12 patientes consecutives venues consulter pour prise en charge chirurgicale d’une endometriose profonde, atteignant cliniquement et radiologiquement les ligaments uterosacres, le torus uterin et/ou le rectum. Resultats L’âge moyen de ces patientes est de 34,6 ± 5,3 ans (24–42) au moment de la prise en charge. La parite moyenne est de 0,5 ± 0,8 enfants (0–2). Ces patientes sont atteintes d’une endometriose profonde evaluee par un examen clinique soigneux et par une imagerie de type echographie abdominopelvienne suspubienne et endovaginale associee a une imagerie par resonance magnetique (IRM). A l’interrogatoire, quatre patientes ne presentent aucun signe fonctionnel urinaire (33 %). Les huit autres ont au moins un signe parmi les suivants : pollakiurie diurne, incontinence urinaire, miction par poussee, pollakiurie nocturne, urgenturie, brulures mictionnelles, crampes vesicales, diminution de la sensibilite vesicale (une infection urinaire a systematiquement ete eliminee). Le bilan d’imagerie retrouve une atteinte annexielle dans trois cas (25 % cas), de l’adenomyose dans trois cas (25 %), de l’endometriose au niveau rectal dans huit cas (66,7 %), au niveau du torus uterin dans neuf cas (75 %), au niveau des ligaments uterosacres dans dix cas (83,3 %). Aucune atteinte vesicale n’a ete mise en evidence. Le bilan urodynamique realise en preoperatoire est strictement normal pour deux patientes seulement (16,7 %). Trois patientes presentent un residu postmictionnel notable (25 %), pathologique dans un cas (superieur a 100 mL). La pression moyenne de cloture uretrale est de 87,8 ± 33,5 cm H20 (38–150). Quatre patientes presentent une hypertonie uretrale (30 %), trois patientes une instabilite uretrale (25 %), trois patientes une dysurie (25 %), deux patientes une vessie hypersensible (16,7 %), deux patientes une insuffisance sphincterienne (16,7 %), une patiente une grande vessie hypoesthesique avec pression de cloture limite (8,3 %) et enfin, une patiente une petite capacite vesicale. Discussion et conclusion Les patientes atteintes d’endometriose profonde dont la localisation touche les ligaments uterosacres et/ou la face anterieure du rectum presentent tres frequemment une symptomatologie fonctionnelle urinaire preoperatoire. L’interrogatoire est fondamental dans l’evaluation de celle-ci mais seul le bilan urodynamique permet de preciser l’atteinte reelle et de la quantifier. L’atteinte mise en evidence est une atteinte de type neurologique et vraisemblablement, une atteinte du plexus hypogastrique inferieur, il ne s’agit pas d’une atteinte vesicale. Dans cette etude, il n’existe pas de correlation entre les troubles preoperatoires et la localisation peroperatoire de la maladie. Une etude sur un plus grand nombre de patientes pourrait preciser les ameliorations et complications eventuelles imputables a la chirurgie.

Background Incomplete spontaneous abortions are defined by the intrauterine retention of the products of conception after their incomplete or partial expulsion. This condition may be managed by expectant care, medical treatment or surgery. Vacuum aspiration is currently the standard surgical treatment in most centers. However, operative hysteroscopy has the advantage over vacuum aspiration of allowing the direct visualization of the retained conception product, facilitating its elective removal while limiting surgical complications. Inadequately powered retrospective studies reported subsequent fertility to be higher in patients treated by operative hysteroscopy than in those treated by vacuum aspiration. These data require confirmation in a randomized controlled trial comparing fertility rates between women undergoing hysteroscopy and those undergoing vacuum aspiration for incomplete spontaneous abortion. Methods After providing written informed consent, 572 women with incomplete spontaneous abortion recruited from 15 centers across France will undergo randomization by a centralized computer system for treatment by either vacuum aspiration or operative hysteroscopy. Patients will not be informed of the type of treatment that they receive and will be cared for during their hospital stay in accordance with standard practices at each center. The patients will be monitored for pregnancy or adverse effects by a telephone conversation or questionnaire sent by e-mail or post over a period of two years. In cases of complications, failure of the intervention or diagnosis of uterine cavity disease, patient care will be left to the discretion of the medical center team. Discussion If our hypothesis is confirmed, this study will provide evidence that the use of operative hysteroscopy can increase the number of pregnancies continuing beyond 22 weeks of gestation in the two-year period following incomplete spontaneous abortion without increasing the incidence of morbidity and peri- and postoperative complications. The standard surgical treatment of this condition would thus be modified. This study would therefore have a large effect on the surgical management of incomplete spontaneous abortion. Trial registration ClinicalTrials.gov Identifier: NCT02201732; registered on 17 July 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-0900-1) contains supplementary material, which is available to authorized users.

Resume Objectif. – Evaluer la morbidite postoperatoire d'une technique de cesarienne sans fermeture du peritoine visceral et parietal. Patientes et methodes. – Nous avons realise une etude prospective de cohorte randomisee sur 170 patientes et etudie la duree d'intervention, la douleur postoperatoire, les complications (infections, hematomes de paroi, abces de paroi, desunions de cicatrice) et la duree d'hospitalisation. Resultats. – La duree d'intervention est reduite de maniere statistiquement significative en l'absence de peritonisation (38,89 au lieu de 42,00 minutes ; p Discussion et conclusion. – Il s'agit de la premiere etude francaise sur le sujet. Dans cette etude, l'absence de peritonisation viscerale et parietale raccourcit le temps operatoire et semble diminuer les complications a court terme. Une evaluation a long terme notamment des sequelles adherentielles reste necessaire.

Early-onset group B streptococcal (GBS) infections remain a leading cause of morbidity and mortality in infants. To prevent the vertical transmission of GBS and neonatal GBS infection, guidelines recommend intrapartum penicillin or amoxicillin prophylaxis. This intrapartum antibiotic prophylaxis (IAP) is suspected to favor colonization by antibiotic-resistant bacteria. However, the effects of this prophylaxis on the patterns of acquisition of gastrointestinal bacterial flora in infants have never been studied. We collected stool samples from 3-day-old infants born to mothers who received intrapartum amoxicillin (antibiotic-exposed group; n = 25) and to untreated mothers (non-antibiotic-exposed group; n = 25). The groups were matched for factors known to affect intestinal microbial colonization: gestational age, type of delivery, and type of feeding. Qualitative and quantitative differential analyses of the bacterial flora in stool samples were performed. Similar numbers of infants in the non-antibiotic-exposed and antibiotic-exposed groups were colonized by aerobic bacteria and amoxicillin-resistant enterobacteria (75 and 77%, respectively) ( P = 0.79). In contrast, significantly fewer infants in the antibiotic-exposed group than in the non-antibiotic-exposed group were colonized by anaerobic bacteria, especially Clostridium (12 and 40%, respectively) ( P < 0.05). Regarding intestinal bacterial colonization, the differences between antibiotic-exposed and non-antibiotic-exposed infants were remarkably few. The only statistically significant effect was the reduced initial bacterial colonization by Clostridium in the antibiotic-exposed group. In our study, the use of IAP did not favor colonization by β-lactam-resistant bacteria. However, further evaluations are required to highlight the potential risks of the widespread use of antibiotics to prevent early-onset GBS infection.

International audience; Background: Pelvic inflammatory disease (PID) is often responsible for acute pelvic pain, yet its clinical diagnosis is difficult. The aim of this study was to develop and validate prediction rules for the diagnosis of PID in patients seen for acute pelvic pain, based solely on a self-assessed questionnaire. Methods: From September 2006 to April 2008, 499 consecutive patients presenting at the gynecology emergency departments of 5 hospitals for acute pelvic pain completed a Self-Assessment Questionnaire for Gynecological Emergencies. Seventy-three were identified as having a PID. Two-thirds of the database was randomly selected for the derivation of the prediction rules, and the other third was used for internal validation. We developed 2 scores, one that rules out a diagnosis of PID and one that predicts PID, based on multiple logistic regression with jackknife estimates. These scores were then validated with the validation data set. Results: Four variables were independently associated with PID: scattered pain radiation and/or diffuse pain, insidious pain, peritoneal irritation, and abnormal vaginal discharge. They were used to create a sensitive prediction model that rules out PID. Four other variables were used to build another model that predicted PID with high specificity: abnormal vaginal discharge, bilateral pelvic pain, constipation, and presence of an intrauterine device. The probability of PID for the patients in the low-risk group was 1.1% (95% confidence interval, 0.03-5.8), and the probability of PID in the high-risk group was 55% (95% confidence interval, 31.5-76.9). Conclusion: These 2 prediction rules that classify patients in low risk or high risk of PID, based on simple items collected by a self-assessed questionnaire that are composed only of case history and autodescription of the pain, may prove useful for diagnosing or ruling out PID in patients with acute pelvic pain.

We report the 1st case of primary peritonitis caused by Streptococcus pyogenes with a reduced susceptibility to fluoroquinolones in a healthy woman, leading to a clinical and microbiological treatment failure. DNA sequencing of parC and gyrA revealed the association of the following 3 substitutions in ParC: Ser80Pro, Asp91Asn, and Ser140Pro.

Hysterectomy is the most effective treatment for symptomatic myoma with no possible recurrence. Hysterectomy for myoma is associated with a high rate of patient satisfaction (95%). Quality of life is globally improved by hysterectomy, as is sexuality with less pelvic pain, asthenia, urinary symptoms and impaired mental health. Vaginal and laparoscopic routes should be preferred to diminish blood loss, hospital stay and postoperative pain. Patients with hysterectomy are at twice as much risk of requiring surgical treatment for incontinence later on. Stress urinary incontinence must be looked for during the preoperative history-taking.

The medical management of symptomatic non-submucosal uterine fibroid tumors (leiomyomas or myomas) is based on the treatment of abnormal uterine bleeding by any of the following: progestogens, a levonorgestrel-releasing intrauterine device, tranexamic acid, nonsteroidal anti-inflammatory drugs, or GnRH analogs. Selective progesterone receptor modulators are currently being evaluated and have recently been approved for fibroid treatment. Neither combined estrogen-progestogen contraception nor hormone treatment of the menopause is contraindicated in women with fibroids. When pregnancy is desired, whether or not infertility is being treated by assisted reproductive technology, hysteroscopic resection in one or two separate procedures of submucosal fibroids less than 4 cm in length is recommended, regardless of whether they are symptomatic. Interstitial, also known as intramural, fibroids have a negative effect on fertility but treating them does not improve fertility. Myomectomy is therefore indicated only for symptomatic fibroids; depending on their size and number, and may be performed by laparoscopy or laparotomy. Physicians must explain to women the potential consequences of myomas and myomectomy on future pregnancy. For perimenopausal women who have been informed of the alternatives and the risks, hysterectomy is the most effective treatment for symptomatic fibroids and is associated with a high rate of patient satisfaction. When possible, the vaginal or laparoscopic routes should be preferred to laparotomy for hysterectomies for fibroids considered typical on imaging. Because uterine artery embolization is an effective treatment with low long-term morbidity, it is an option for symptomatic fibroids in women who do not want to become pregnant, and a validated alternative to myomectomy and hysterectomy that must be offered to patients. Myolysis is under assessment, and research on its use is recommended. Isolated laparoscopic ligation of the uterine arteries is a potential alternative to uterine artery embolization; it also complements myomectomy by reducing intraoperative bleeding. It is possible to use second-generation techniques of endometrial ablation to treat submucosal fibroids in women whose families are complete. Subtotal hysterectomy is a possible alternative to total hysterectomy for fibroid treatment, given that by laparotomy the former has a lower complication rate than the latter, while by laparoscopy, these rates are the same. In each case, the patient is informed about the benefit and risk associated with each therapeutic option.

Physical examination, ultrasonography, and laboratory tests fail to reliably establish the preoperative diagnosis of tubal rupture in patients with ectopic pregnancy (EP), leading to a high rate of diagnostic laparoscopy. The aim of this study was to construct and to evaluate a clinical prediction rule for tubal rupture screening based on a self-assessment questionnaire, among patients with EP.A standardized questionnaire was constructed via semistructured interviews of patients with acute pelvic pain. Features associated with tubal rupture were then identified in 141 prospectively included patients with tubal pregnancy, including 30 with tubal rupture, in five hospitals. Multiple logistic regression was used to select the best combination of independent features for predicting tubal rupture. Cross-validation was with the jackknife method. The main outcome measure was diagnostic accuracy of the questionnaire for ruling out tubal rupture.Eighty-nine items characterizing acute pelvic pain were identified. Among them, four contributed independently to the diagnosis of tubal rupture: vomiting during pain, diffuse abdominal pain, acute pain for longer than 30 minutes, and flashing pain. The presence of one or more of these features had 93% sensitivity (95% confidence interval [CI] = 84% to 100%) and 44% specificity (95% CI = 35% to 53%) for tubal rupture, with a negative likelihood ratio for ruling out tubal rupture of 0.16.These results suggest that a standardized questionnaire may contribute to ruling out tubal rupture in patients with EP.

To assess face and construct validity of a new virtual reality (VR) training simulator for hysteroscopic placement of tubal sterilization implants.Nonrandomized, controlled trial comparing responses and performance of novices and experts on the simulator.Canadian task force II-1.Forty-six gynecologists were personally invited or recruited at the 33rd Conference of the French National College of Gynecologists and Obstetricians (CNGOF) from December 9 to 12, 2009, grouped as 20 experts and 26 novices. They all performed the defined sequence of virtual procedures on the simulator (case 1 for familiarization, case 4 for study assessment) and finally completed the study questionnaire.Responses to realism, educational potential, and general opinion were excellent, proving face validity. Significant differences between novices and experts were assessed for 7 of the 15 metrics analyzed, proving construct validity.We established face and construct validity for EssureSim, an educational VR simulator for hysteroscopic tubal sterilization implant placement. The next steps are to investigate convergent and predictive validity to affirm the real capacity of transferring the skills learned on the training simulator to the patient in the operating room.

Objective To assess a new hysteroscopic method of tubal sterilization; specifically, to examine the factors associated with placement failure of Essure ® implants. Design Observational, multicenter, 6-month study. Setting Seven gynecology clinics, including five public hospitals and two private clinics, in France. Patient(s) A total of 495 women who provided informed consent. Intervention(s) All procedures were done by a vaginoscopic approach with a 5-mm operating hysteroscope. Main Outcome Measure(s) Data collected were age, parity, type of anesthesia, premedication, endometrial aspect, ostia visualization, duration of the procedure, pain during the procedure, and associated procedures. Unilateral and bilateral placement rates were assessed. Adverse events at 3 months (expulsion, migration, perforation) were also recorded. Result(s) Mean parity was 2.45; 20 women were nulliparous. In 56.3% of cases (n = 277), none or local anesthesia was used for the placement procedure. Overall, 86% of the women (n = 423) had nonsteroidal anti-inflammatory drug (NSAID) premedication, and 8.1% (n = 40) had another intrauterine surgical procedure performed at the same time. In 24 cases, at least one of the tubal ostia could not be visualized well during hysteroscopy. Conclusion(s) The failure rate for Essure ® micro-insert placement was 6% at first attempt and 3.3% after two attempts. Success rate was not significantly associated with parity, mode of analgesia, NSAID premedication, or combination with another procedure. The only factor significantly associated with the failure rate was poor visualization of the tubal ostia.