| Role of laparohysteroscopy in women with normal pelvic imaging and failed ovulation stimulation with intrauterine insemination | ||
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Article in Journal of Human Reproductive Sciences - Women with primary infertility and no obvious pelvic pathology on clinical evaluation and imaging are either treated empirically or further investigated by laparoscopy. AIMS: The role of diagnostic laparoscopy in women who fail to conceive after empirical treatment with ovulation induction and intrauterine insemination was evaluated. SETTINGS AND DESIGN: Retrospective study at a private infertility center. MATERIALS AND METHODS: A study of patients who underwent diagnostic laparoscopy between 1st January 2001 and 31st December 2008 was performed. Those patients who had no detectable pathology based on history, physical examination, and ultrasound and had treatment for three or more cycles in the form of ovulation induction and IUI were included in the study. Moderate and severe male factor infertility and history of any previous surgery were exclusion criteria. STATISTICAL ANALYSIS USED: Data were statistically analyzed using Statistics Package for Social Sciences (ver. 16.0; SPSS Inc., Chicago). RESULTS: Of the 127 women who underwent diagnostic laparoscopy and hysteroscopy, 87.4% (n 5 111) of patients had positive findings. Significant pelvic pathology (moderate endometriosis, pelvic inflammatory disease, and tubal pathology) was seen in 26.8% of cases. CONCLUSION: One in four women had significant pelvic pathology where treatment could possibly improve future fertility. Diagnostic laparoscopy has a role in infertile women with no obvious abnormality before they proceed to more aggressive treatments. |
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| Endometrial carcinoma in a young subfertile woman with polycystic ovarian syndrome | ||
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Adenocarcinoma of the endometrium is a morbid condition in women under 40 years of age with an incidence of 25%. However, patients with anovulatory polycystic ovarian syndrome are at risk of developing endometrial carcinoma. The disease is often advanced when diagnosed, thereby depriving the woman of the option for fertility sparing conservative approach. In young women with menstrual abnormalities and polycystic ovarian disease and/or infertility, an endometrial evaluation should be performed. Carcinoma endometrium should be kept in mind while evaluating young women with polycystic ovary syndrome for abnormal uterine bleeding. Only strictly selected patients should, therefore, be indicated for long-term progestogen treatment and careful evaluation before and after treatment should be performed. |
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| Endometrial stromal sarcoma mimicking a myoma | ||
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K. Jayakrishnan, M.D., D.G.O., D.N.B.,a Aby K. Koshy, M.S., D.N.B.,a Pochiraju Manjula, M.B.B.S., D.G.O.,a Anitha M. Nair, M.B.B.S.,a Anupama Ramachandran, D.G.O., D.N.B.,a and Jayasree Kattoor, M.D.b a KJK Hospital, Fertility Research and Gynaec Centre, Trivandrum, Kerala, India; and b Department of Pathology, Regional Cancer Centre, Trivandrum, Kerala, India Uterine malignancies are not uncommonly misdiagnosed for the more ubiquitous leiomyoma. A case of endometrial stromal sarcoma with ultrasound and color Doppler imaging is described. (Fertil Steril 2009;92:1744–6. 2009 by American Society for Reproductive Medicine.) |
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| KJK report in prestigious Fertility Sterlity Nov 2009 journal | ||
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KJK Hospital reported Endometrial stromal sarcoma mimicking Fibroid uterus and it was published in prestigious Fertility Sterlity journal November 2009 |
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| KJK Hospital introduces Fellowship in Reproductive Medicine from January 2010 | ||
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KJK Hospital introduces Fellowship in Reproductive medicine from Jan 2010 for aspirants planning to pursue a career in Reproductive Medicine Course duration- 12 months No of candidates per year -2 Qualification Post graduate- M.D, or DNB in Obstetrics and Gynaecology Details can be obtained from website;www.kjkhospital.com Or contact Dr K Jayakrishnan by e mail. Email- kjkhospital@gmail.com,kjkhospital@vsnl.com |
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| 38th Global Congress at Orlando ,USA,Nov 2009 | ||
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| AAGL Congress at Orlando with Dr Harry Reich,who did the first Laparoscopic Hysterectomy in 1989 | ||
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| Presenting his work at AAGL meet ,Orlando,USA | ||
| Dr Jayakrishnan presented a paper on Outcome of septal resection in Primary Infertility at AAGL meet,Orlando Nov 2009. | ||
| Dr K Jayakrishnan at ESHRE 2009,June 28-July 1st 2009 | ||
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| ESHRE 2009 | ||
| Dr K Jayakrishnan attended the European Soceity of Human Reproduction meeting held at Amsterdam from June 28th till July 1st 2009 | ||
| XV th World Congress at Geneva April 2009 | ||
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| Dr Jayakrishnan presented KJK Hospitals work on Septal Incision in primary Infertility over a period of 8 years. | ||
| Dr Jayakrishnan at 15th World Congress Geneva April 2009 | ||
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| Septal incision in primary infertility-Poster based on 8 years experience at KJk Hospital | ||
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| Presenting paper on Role of Laparoscopy in failed IUI at 15th World Congress ,Geneva | ||
| Dr K Jayakrishnan was invited to present his work at 15th World Congress held at Geneva from April 19th-22nd 2009.He presented his work on Role of septal incision in primary infertility as poster.The oral presentation on Role of Laparoscopy in failed IUi was appreciated by all. | ||
| A noble gesture from a couple who was successful by IVF | ||
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| Dr jayakrishnan after handing over the cheque to the couple | ||
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An Indian couple based at UK decided to donate a hefty amount needed for the medicines for a needy patient .KJK hospital identified a needy couple who conceived after IVF This cheque was Handed over at a function held at KJK Hospital in June 2008. KJK salutes the kind gesture of the couple based at UK for this noble gesture.May this be a eyeopener for many who conceive by IVF and ready to help the needy and poor patients. |
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| ESHRE 2008 July Dr K Jayakrishnan at Barcelona,Spain | ||
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| Dr Jayakrishnan attended the ESHRE coference at Spain in July 2008 | ||
| Dr Jayakrishnan at World Congress in Endometriosis,Australia,March 2008 | ||
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| Dr jayakrishnan presented his work on Endometriosis comparing cystectomy with ablation at World Congress on Endometriosis,Melbourne March 2008 | ||
| Laparoscopic Treatment of Endometriosis Focusing on Fertility Outcomes | ||
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Abstract Most endometriosis patients have fertility complaints and, in spite of the improvement of assisted reproduction procedures, outcomes remain unsatisfactory. This suggests that there are unknown ethiopathogenic influences that adversely affect fertility. Laparoscopic treatment of endometriosis is of questionable efficiency with regard to achieving better fertility results, with controversies mainly surrounding ovarian residual reserve. However, the laparoscopic approach follows good practice principles and is considered a minimally invasive procedure, with the advantage of being diagnostic and therapeutic. Decision to excise endometriomas must be taken cautiously, considering factors such as patient's age, previous ovarian reserve, previous pelvic surgery, presence of pain or malignancy suspicion, disease extension and the mean diameter of the lesions. Introduction Infertility complaints occur in almost 60% of women with endometriosis Mechanical interference is the most accep phenomenon but there is an increasing role attributed to immunological, genetic and hormonal factors, which is still under investigation and certainly contributes to the etiopathogeny of this enigmatic disease Although the etiopathogeny of endometriosis and also its causal relationship with infertility remain unclear, the advent of assisted reproduction techniques (ART) allowed an important advance on infertility treatment. However, the outcomes of ART in endometriosis remain unsatisfactory, revealing impaired pregnancy and implantation rates in comparison with infertility due to tubal and male factors according to the metanalysis of Barnhart et al. in 2002 even though other studies do not support this affirmative Medical treatment with gonadotropin-releasing hormone (GnRH) agonists prior to ART is associated with an increase in pregnancy rates but clinical therapy alone is considered inefficient for treating endometriosis-associated infertility. Owing to its high rates of recurrence (approximately 50% after 5 years of therapy cessation ]), we are frequently presented with a dilemma between performing ART or adopting a surgical approach as the first choice to achieve better results when treating infertile couples. Undoubtedly, the best approach must be individualized to each infertile couple, combining improvement of pregnancy rates, reduction of morbidity and following good practice principles. The evaluation must be undertaken in a global manner and the essential factors to be considered are patient's age, grade and type of endometriosis (ovarian, peritoneal or deep infiltrating) and clinical symptoms of the disease. Besides this, performing randomized, placebo-controlled studies regarding surgical treatment of endometriosis is difficult, resulting in a lack of evidence or reliable data. The aim of this review is to analyze the laparoscopic surgical procedure for infertility treatment in endo-metriosis in its different phenotypics presentations: peritoneal, ovarian and deep infiltrating disease Deep Infiltrating Endometriosis Deep endometriosis of rectovaginal septum represents a separate chapter in this disease. Its characteristics are so unique that it seems inappropriate to consider it together with peritoneal and ovarian forms of the disease. The differences of deep endometriosis begin in its lesion characteristics, histology and hormonal behavior, and also its clinical parameters, such as severity of the symptoms and therapeutic response Deep endometriosis, in general, is defined as peritoneal invasion of over 5 mm Its real incidence is unknown but the estimative is suggested to be one of each five endometriosis patient. In decreasing order, it affects the uterosacral ligaments, rectosigmoid colon, vagina and urinary bladder In spite of scores two- to eight-times higher for deep endometriosis classified by revised American Society for Reproductive Medicine Classification pelvic pain has poor correlation with this classification This fact is especially important when analyzing rectovaginal endometriosis, which shows an exuberant clinical presentation New classification criteria have been proposed for this type of endometriosis. The Adamyan classification, for example, divides rectovaginal endometriosis into three types: • Retrocervical endometriosis (in which the rectum is usually free of disease) • Rectovaginal septum • Bowel endometriosis (with infiltrative characteristics over the bowel thickness) This type of classification may be more compatible with the surgical approach of this disease The diagnosis of rectovaginal endometriosis is also essentially surgical, but clinical and image exams must be performed to help plan surgical strategies. At clinical examination, vaginal exam is extremely useful to reveal fibrosis or nodularity in cul-de-sac and uterosacral ligaments Regarding image scanning exams, even transvaginal ultrasound can suggest rectovaginal endometriosis through visualization of a hypoecogenic lesion between rectum and vagina In fact, it has been given particular importance to transvaginal ultrasound in the detection of rectovaginal septum endometriosis, showing high sensitivity and good correlation with laparoscopic findings However, it is MRI, in association with rectum ecoendoscopy, that emerged as the best examination to identify deep endometriosis. When considering bowel endometriosis, the sensitivity is similar (90 vs 83%, respectively); however, in rectovaginal and uterosacral disease, the sensitivity is extremely different (77.7 vs 7.4% and 84.8 vs 45.6%, respectively There is a consensus that surgical treatment is the best option for deep endometriosis, due to high incidences of recurrence when clinical treatment is used alone Feasibility and advantages of laparoscopy as a surgical route for endometriosis treatment has already been proven An important aspect may also be considered: deep endometriosis can be missed even during laparoscopy if the surgeon is not warned about it. During inspection of the peritoneal surface the depth of invasion may not be initially noticed; therefore, the surgeon must perform a careful palpation of any suspect lesion to check if there is infiltration of this nodule or not. The introduction of rectal and vaginal probes during the surgery also improves the exposition and excision of the lesions Regarding fertility outcomes, pregnancy rates after laparoscopic procedure for rectovaginal endometriosis treatment varies from 44.4 to 72%. As a matter of fact, there is no homogeneity among the studies when referring to: classification of superficial versus deep endometriosis, or American Society for Reproductive Medicine (ASRM) classification; time of follow-up; if topic or ectopic pregnancy after treatment; and if spontaneous or after ART pregnancy. In spite of these differences among the studies, the pregnancy rates achieved after surgery were at least similar to pregnancy rates shown in ART. The analysis of a prospective, randomized and placebo-controlled study for laparoscopic treatment of endometriosis, in all grades by ASRM classification, revealed spontaneous pregnancy in 12 out of 39 patients. It also showed a significant improvement of life quality after excisional surgery for grades III and IV of endometriosis in comparison with the control group.[54] However, the relationship between fertility rates after laparoscopy and ASRM classification appears to be unsatisfactory. Chapron et al. evaluated 30 patients submitted to laparoscopy due to deep endometriosis affecting uterosacral ligaments. The spontaneous pregnancy rate was 48.5% 12 months after surgery, with only one pregnancy by IVF. There was no positive correlation between endometriosis ASRM scores and pregnancy rates In spite of its low incidence (5.4-12% of all endometriosis patients), bowel endometriosis is the most frequent extragenital site of endometriosis Thus, this form of the disease must be searched preoperatively in all patients evidencing deep endometriosis ] approximately 9% of these patients require bowel segmental resection The main localizations are rectum and rectosigmoid junction, responsible for 93% of all lesions. Several studies have demonstrated feasibility of laparoscopic route also for the treatment of this kind of endometriosis Radical excision of these lesions can provide an improvement of 91-100% of the bowel endometriosis The impact of laparoscopic excision of colorectal endometriosis on fertility outcomes has also been studied Hyster-ectomy or oophorectomy are not usually necessary in this surgery. The laparoscopic excision of bowel endometriotic lesions appears to be highly efficient in reducing pelvic pain and also restoring fertility Darai et al. revealed pregnancy rates of 45.5% after 24 months of follow-up in 22 women who were submitted to laparoscopic resection of bowel endometriosis. Of these 22 women, ten became pregnant (two twice), nine pregnancies were spontaneous and three occurred after one cycle of IVF. The average time for conception was 8 months after the surgery and the newborn rate was 82%.[ Redwine and Wright also demonstrated a fertility rate of 43% after en bloc resection of complete cul-de-sac obliteration due to endometriosis.[ ] Other studies focusing the same goal showed pregnancy achievement in three out of seven ] and eight of 15[ patients. In this last study, six of these women were already submitted to IVF previously to laparoscopic procedure. Therefore, when bowel resection is necessary, the segmental colorectal resection appears to be the best option, but women must be warned about this type of surgery and mainly about its complications, once rectovaginal fistula occurs in 10% of the cases Ovarian Endometrioma Although we do not know the specific role of the endometriomas over the reduction of fertility potential, vascular compression is markedly observed in compromised gonads ] and studies have already demonstrated that 17-44% of the patients with endometriosis-related infertility present ovarian endometriotic cysts ] Therapeutic choice for infertile patients with endometriomas remains a great challenge in the assisted reproduction scenario. Once the limited efficacy of drug therapy is known laparoscopic management may be considered as a complementary approach, with satisfactory long-term fertility results whether for spontaneous pregnancies or ART, in this last one improving transvaginal accessibility and, sometimes, ovarian stimulation response. Regardless of the absence of a definitive conclusion for the ideal therapeutic management, there is a trend to indicate laparoscopy for all infertile patients presenting with endometriomas The surgical decision in these cases must be taken cautiously, considering factors that may influence results, such as the patient's age and ovarian reserve markers, previous pelvic surgery, presence of pain or malignancy suspicion, disease extension and the mean diameter of the lesions ] The mean diameter of the endometriotic cyst is an important issue in the decision process. Some authors have already attributed low success rates in ART cycles to large endometriomas We believe that ART could minimize endometriosis interference over fertility in patients with superficial ovarian lesions or cysts with mean diameter of less than 4 cm and proceed cystectomy for ovarian endometriomas of over 4 cm to possibly improve the gonad response to exogenous stimulation and access to follicles, and to confirm histologically the diagnosis, as previously stated by the European Society for Human Reproduction and Embryology Regarding spontaneous pregnancies and recurrence of the cysts and symptoms, Hart et al. systematically reviewed the issue and concluded that laparoscopic cystectomy appears to be the best therapeutic choice if compared with drainage or coagulation Alborzi et al. prospectively evaluated 52 patients submitted to laparoscopic cystectomy and observed spontaneous pregnancy rates of nearly 60% in the first year after surgery, which were statistically significant when compared with the 23.3% obtained after endometrioma fenestration and coagulation.[26] Beretta et al. had already compared such techniques in 64 patients with endometriomas and shown 24-month cumulative pregnancy rates of 66.7% for exeresis versus 23.5% when the other techniques were performed Thus, expectant management after surgery, with the aim of achieving spontaneous pregnancy, appears to be a good choice, especially for those patients under 35 years of age. Littman et al. observed that, in a period of 8 months after endometrioma excision, almost 50% of pregnancies were obtained spontaneously or after ovulation induction with clomiphene citrate in patients previously submitted to ART ] However, patients over 35 years old or presenting signs of impaired ovarian function may not be encouraged to decide on expectant management, as they usually present a lower ovarian response. In these cases, ART may be considered as the first-choice treatment, being the laparoscopic procedure dispensable, unless there is no transvaginal access to the ovarian follicles for oocytes pick-up. Regarding ART results after endometriomas excision, Garcia-Velasco et al. retrospectively evaluated 189 women who had undergone IVF treatment following laparoscopic approach to excise lesions and observed no differences between the groups, whatever variety analyzed. They obtained 25.4% of pregnancies among operated women and 22.7% among patients with intact cysts, with no statistical significance, and concluded that no additional benefits were provided by cystectomy Despite the large number of studies over the theme, consequences of endometrioma excision to the remaining ovarian tissue still hinder the surgical therapeutic decision. The possibility of normal ovarian tissue resection during endometriomas excision and occurrence of vascular damage give reason to such a dilemma[ ] and, although no answer has been given, some researchers attempt to demystify this theory. Muzii et al. confirmed that excision provides a complete treatment to the problem and, even if ovarian adjacent tissue is being excised with the cyst, there were morphologic, and supposed physiologic, changes in this adjacent tissue in more than 80% of the 70 endometriomas obtained by laparoscopic cystectomy ] This implicates that the permanence of such tissue should not contribute to real ovarian reserve. Even Garcia-Velasco et al. found no difference between the numbers of oocytes retrieved following endometrioma excision, advocating the surgical option As a matter of fact, controversy was created by Ragni et al. who demonstrated a significantly reduced number of dominant follicles and oocytes among operated gonads after gonadotropic stimulation in 38 patients who were previously submitted to unilateral endometrioma laparoscopic enucleation.[ ] Several studies have already evaluated ovarian function after endometrioma exeresis and demonstrated that there were no significant differences between normal and cystectomized ovaries, with satisfactory pregnancy rates. Loh et al. demonstrated a 73.3% pregnancy rate in up to 42 months after surgery, a quarter of them submitted to IVF.[ ] Similarly, other studies obtained equivalent pregnancy rates, from 30.5 to 38% per cycle, between women submitted to laparoscopic cystectomy and tubal infertility control group, after induced ovarian cycles ] Nevertheless, individualization of each case is the prerogative for the most adequate approach. Based on the current literature, we believe that, in general terms, laparoscopic exeresis of ovarian endometriomas in infertile patients should be considered a good practice. It is important to consider the couple's opinion after clarifying the pros and cons, stimulating the patient and her partner to participate in the decision considering the distinct possible strategies. Cyst recurrences should also be criteriously evaluated and successive excisions are strongly discouraged owing to their potential risk of diminishing follicles population. |
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| What we have done at KJK Hospital in 2007 | ||
| Click here to view what has been done at KJK Hospital in 2007 | ||
| iffs World Congress on Fertility and Sterlity | ||
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| Dr K Jayakrishnan presenting his paper on Mullerian anomalies at World Congress in Fertility and Ste | ||
| Dr K Jayakrishnan presenting his paper on Mullerian anomalies at World Congress 2007 at Durban,S Africa May 1st 2007 | ||
| Secondary Amenorrhoea due to Virilizing Ovarian Tumour | ||
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Introduction: Virilizing tumours of the ovary are extremely rare and account for less than 0.2% of ovarian cancers frequently seen in the third and fourth decades of life. About 75% of the lesions are seen in women younger than 40yrs. The tumours typically produce androgens and clinical virilization is noted Ni 70-85% of the patients. Case report: Here is a case reported from our hospital who is a 27yr old para1 (married for 7yrs) who attended our center with history of secondary amenorrhea of 3yrs duration following regular menstrual cycles. She had one full term FTND, 6yrs back. She had no medical or surgical illnesses. There was no significant family history O/E. The patient had features of virilization which including amenorrhea hirsuitism and hoarseness of voice. USS showed normal sized uterus with thin endometrium of 4mm, right ovary was normal in size with small follicles. Left ovary was enlarged to 4.3x3x4cm with multiple anechoic areas with internal echoes, size varying between 9-10mm with increased vascularity. Routine blood investigations, thyroid function tests, serum prolactin, serum insulin levels were all in normal range. Serum FSH was 1.3miu/ml (lower than normal), DHEAS 8ng/ml (normal), serum testosterone 5.5ng/ml (increased), CA125 5.2units/ml (normal).Diagnosis of left ovarian cyst of 4cm with virilizing features was made. Laparoscopic surgery was done. Uterus and both fallopian tubes normal, right ovary volume decreased, left ovary enlarged to 4cm with intact capsule, partly solid and partly cystic, liver sub diaphragmatic space paracolic gutters and other abdominal organs were normal. Left salpingo ovariotomy was done. Endometrial sampling was taken. Intra and post operative period was uneventful. Laparoscopy Picture/Video to be inserted HPR: Leydig cell tumor of ovary, intermediate grade. Endometrial sampling: Composed of endometrial stroma with occasional glands and non secretary epithelium Discussion: Sertoli leydig cell tumours are most frequently low grade malignancies although occasionally a poorly differentiated variety may behave more aggressively because these low grade lesions are only rarely bilateral. The incidence of malignance transformation is higher than with feminizing tumours. The diagnosis is usually made on the basis on the endocrine behavior of the tumoue. The usual treatment is unilateral salpingo ovariotomy and evaluation of the contra lateral ovary for patients who are in their reproductive years. For older patients, hysterectomy and bilateral salpingo-oophorectomy are appropriate. Prognosis: The 5yr survival rate is 70-90% and recurrences thereafter are uncommon. |
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| AICOG 2007 Dr k jayakrishnan presenting his paper | ||
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| Presentation on saline Infusion sonography at AICOG 2007,Kolkata | ||
| Dr H Carp receiving the book on Infertility from Dr K Jayakrishnan | ||
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| Dr H Carp receiving the book on Infertility from Dr K Jayakrishnan | ||
| Practical insights in Fertility management | ||
| USG workshop at KJK Hospital Dec 5th 2004 | ||
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| Dr Santha Madhavan,Dr K Jayakrishnan and Dr Indrani Suresh at USG workshop inaugural ceremony. | ||
