laparoscopy Archives - Revista Brasileira de Ginecologia e Obstetrícia
Summary
Rev Bras Ginecol Obstet. 2012;34(6):278-284
DOI 10.1590/S0100-72032012000600007
PURPOSE: To evaluate the anatomical distribution of deep infiltrating endometriosis (DIE) lesions in a sample of women from the South of Brazil. METHODS: A prospective study was conducted on women undergoing surgical treatment for DIE from January 2010 to January 2012. The lesions were classified according to eight main locations, from least serious to worst: round ligament, anterior uterine serosa/vesicouterine peitoneal reflection, utero-sacral ligament, retrocervical area, vagina, bladder, intestine, ureter. The number and location of the DIE lesions were studied for each patient according to the above-mentioned criteria and also according to uni- or multifocality. The statistical analysis was performed using Statistica version 8.0. The values p<0.05 were considered statistically significant. RESULTS: During the study period, a total of 143 women presented 577 DIE lesions: uterosacral ligament (n=239; 41.4%), retrocervical (n=91; 15.7%), vagina (n=50; 8.7%), round ligament (n=50; 8,7%), vesico-uterine septum (n=41; 7.1%), bladder (n=12; 2.1%), and intestine (n=83; 14.4%), ureter (n=11; 1.9%). Multifocal disease was observed in the majority of patients (p<0.0001), and the mean number of DIE lesions per patient was 4. Ovarian endometrioma was present in 57 women (39.9%). Sixty-five patients (45.4%) presented intestinal infiltration on histological examination. A total of 83 DIE intestinal lesions were distributed as follows: appendix (n=7), cecum (n=1) and rectosigmoid (n=75). The mean number of intestinal lesions per patient was 1.3. CONCLUSIONS: DIE has a multifocal pattern of distribution, a fact of fundamental importance for the definition of the complete surgical treatment of the disease.
Summary
Rev Bras Ginecol Obstet. 2012;34(6):278-284
DOI 10.1590/S0100-72032012000600007
PURPOSE: To evaluate the anatomical distribution of deep infiltrating endometriosis (DIE) lesions in a sample of women from the South of Brazil. METHODS: A prospective study was conducted on women undergoing surgical treatment for DIE from January 2010 to January 2012. The lesions were classified according to eight main locations, from least serious to worst: round ligament, anterior uterine serosa/vesicouterine peitoneal reflection, utero-sacral ligament, retrocervical area, vagina, bladder, intestine, ureter. The number and location of the DIE lesions were studied for each patient according to the above-mentioned criteria and also according to uni- or multifocality. The statistical analysis was performed using Statistica version 8.0. The values p<0.05 were considered statistically significant. RESULTS: During the study period, a total of 143 women presented 577 DIE lesions: uterosacral ligament (n=239; 41.4%), retrocervical (n=91; 15.7%), vagina (n=50; 8.7%), round ligament (n=50; 8,7%), vesico-uterine septum (n=41; 7.1%), bladder (n=12; 2.1%), and intestine (n=83; 14.4%), ureter (n=11; 1.9%). Multifocal disease was observed in the majority of patients (p<0.0001), and the mean number of DIE lesions per patient was 4. Ovarian endometrioma was present in 57 women (39.9%). Sixty-five patients (45.4%) presented intestinal infiltration on histological examination. A total of 83 DIE intestinal lesions were distributed as follows: appendix (n=7), cecum (n=1) and rectosigmoid (n=75). The mean number of intestinal lesions per patient was 1.3. CONCLUSIONS: DIE has a multifocal pattern of distribution, a fact of fundamental importance for the definition of the complete surgical treatment of the disease.
Summary
Rev Bras Ginecol Obstet. 2012;34(3):118-121
DOI 10.1590/S0100-72032012000300005
PURPOSE: To report the use of colpotomy for the treatment of ectopic pregnancies. METHODS: This was a retrospective cross-sectional study conducted on all women hospitalized with a clinical-laboratory suspicion of ectopic pregnancy who did not fulfill the criteria for drug treatment with methothrexate, during the period from February 2007 to August 2008. Demographic variables, gynecologic history and characteristics associated with treatment were obtained by reviewing the medical records. RESULTS: Eighteen women were included in the study. Mean age was 27±5.2 years. All patients presented ruptured ectopic pregnancy and all were submitted to partial salpingectomy. Surgical time ranged from 30 to 120 minutes (mean: 64.5 minutes) calculated from the moment when the patient entered the operating room to the moment when she left it. No patient presented postoperative infection. Mean time of hospitalization was 40±14.3 hours. The medications used during the postoperative period were similar in all cases, being based on nonsteroid anti-inflammatory drugs, dipyrone, paracetamol and meperidine, as needed. The diet was reintroduced 8 hours after the end of surgery. CONCLUSIONS: The use of colpotomy in the treatment of ectopic pregnancy showed good results, with the absence of important complications and a short hospitalization time. The basic surgical instruments needed for this procedure are relatively common to all hospitals, and the surgical technique is reproducible.
Summary
Rev Bras Ginecol Obstet. 2012;34(3):118-121
DOI 10.1590/S0100-72032012000300005
PURPOSE: To report the use of colpotomy for the treatment of ectopic pregnancies. METHODS: This was a retrospective cross-sectional study conducted on all women hospitalized with a clinical-laboratory suspicion of ectopic pregnancy who did not fulfill the criteria for drug treatment with methothrexate, during the period from February 2007 to August 2008. Demographic variables, gynecologic history and characteristics associated with treatment were obtained by reviewing the medical records. RESULTS: Eighteen women were included in the study. Mean age was 27±5.2 years. All patients presented ruptured ectopic pregnancy and all were submitted to partial salpingectomy. Surgical time ranged from 30 to 120 minutes (mean: 64.5 minutes) calculated from the moment when the patient entered the operating room to the moment when she left it. No patient presented postoperative infection. Mean time of hospitalization was 40±14.3 hours. The medications used during the postoperative period were similar in all cases, being based on nonsteroid anti-inflammatory drugs, dipyrone, paracetamol and meperidine, as needed. The diet was reintroduced 8 hours after the end of surgery. CONCLUSIONS: The use of colpotomy in the treatment of ectopic pregnancy showed good results, with the absence of important complications and a short hospitalization time. The basic surgical instruments needed for this procedure are relatively common to all hospitals, and the surgical technique is reproducible.
Summary
Rev Bras Ginecol Obstet. 2010;32(9):441-446
DOI 10.1590/S0100-72032010000900005
PURPOSE: to evaluate the contribution of diagnostic laparoscopy to approach the infertile couple. METHODS: retrospective analysis of 86 consecutive cases of patients who were accompanied in the infertility appointments and were submitted to diagnostic laparoscopy from January 2004 to December 2006. Eighty-two of these patients had been submitted to hysterosalpingography (HSG) prior to laparoscopy. The laparoscopic findings were analyzed, as well as the accessory procedures, and the results of the hysterosalpingography and of the laparoscopy were correlated. Statistical analysis was performed by the use of the Statistical Package for the Social Sciences 15. The sensitivity and the specificity of HSG were determined and the confidence intervals were calculated with an alpha error of 0.05 (95%CI). RESULTS: the laparoscopy revealed 21 cases of endometriosis (24.4%), 14 cases of uni/bilateral inflammatory disease of the salpinx (16.3%), and 16 cases of pelvic inflammatory disease (18.6%). Adhesiolysis and ablation of endometrial lesions were performed in eight patients. There were also other accessory procedures: two salpingostomies, two paraovarian cystectomies, two ovarian cystectomies and three ovarian drillings. The tubal patency test during laparoscopy was normal in 44 cases (53%), revealed unilateral obstruction in 21 cases (25.3%) and bilateral obstruction in 17 cases (20.5%). The results of the hysterosalpingography were similar to those of the laparoscopy in 44 out of the 82 cases (53.7%). HSG sensitivity was 0.79 (95%CI=0.62-0.9) and its specificity was 0.58 (95%CI=0.42-0.73) when the disease was defined as any form of tubal occlusion detected with the laparoscopy, wheter this occlusion was one-sided or two-sided. HSG sensitivity and specificity were 0.47 (95%CI=0.24-0.71) and 0.77 (95%CI=0.64-0.86), respectively, when the definition of the disease was limited to two-sided tubal occlusion. In nine cases (15.3%) in which HSG had shown normal findings or only a unilateral occlusion, laparoscopy revealed a two-sided occlusion. And in 15 cases (65.2%) in which HSG had shown a two-sided occlusion, laparoscopy revealed normal findings or one-sided occlusion. CONCLUSIONS: the laparoscopy demonstrated its diagnostic and therapeutic relevance, proving to have fundamental importance for the clarification of the tuboperitoneal status. It has permitted the development of concomitant accessory therapeutic procedures, thus defining the best treatment strategy for the infertile couples.
Summary
Rev Bras Ginecol Obstet. 2010;32(9):441-446
DOI 10.1590/S0100-72032010000900005
PURPOSE: to evaluate the contribution of diagnostic laparoscopy to approach the infertile couple. METHODS: retrospective analysis of 86 consecutive cases of patients who were accompanied in the infertility appointments and were submitted to diagnostic laparoscopy from January 2004 to December 2006. Eighty-two of these patients had been submitted to hysterosalpingography (HSG) prior to laparoscopy. The laparoscopic findings were analyzed, as well as the accessory procedures, and the results of the hysterosalpingography and of the laparoscopy were correlated. Statistical analysis was performed by the use of the Statistical Package for the Social Sciences 15. The sensitivity and the specificity of HSG were determined and the confidence intervals were calculated with an alpha error of 0.05 (95%CI). RESULTS: the laparoscopy revealed 21 cases of endometriosis (24.4%), 14 cases of uni/bilateral inflammatory disease of the salpinx (16.3%), and 16 cases of pelvic inflammatory disease (18.6%). Adhesiolysis and ablation of endometrial lesions were performed in eight patients. There were also other accessory procedures: two salpingostomies, two paraovarian cystectomies, two ovarian cystectomies and three ovarian drillings. The tubal patency test during laparoscopy was normal in 44 cases (53%), revealed unilateral obstruction in 21 cases (25.3%) and bilateral obstruction in 17 cases (20.5%). The results of the hysterosalpingography were similar to those of the laparoscopy in 44 out of the 82 cases (53.7%). HSG sensitivity was 0.79 (95%CI=0.62-0.9) and its specificity was 0.58 (95%CI=0.42-0.73) when the disease was defined as any form of tubal occlusion detected with the laparoscopy, wheter this occlusion was one-sided or two-sided. HSG sensitivity and specificity were 0.47 (95%CI=0.24-0.71) and 0.77 (95%CI=0.64-0.86), respectively, when the definition of the disease was limited to two-sided tubal occlusion. In nine cases (15.3%) in which HSG had shown normal findings or only a unilateral occlusion, laparoscopy revealed a two-sided occlusion. And in 15 cases (65.2%) in which HSG had shown a two-sided occlusion, laparoscopy revealed normal findings or one-sided occlusion. CONCLUSIONS: the laparoscopy demonstrated its diagnostic and therapeutic relevance, proving to have fundamental importance for the clarification of the tuboperitoneal status. It has permitted the development of concomitant accessory therapeutic procedures, thus defining the best treatment strategy for the infertile couples.
Summary
Rev Bras Ginecol Obstet. 2010;32(6):298-307
DOI 10.1590/S0100-72032010000600008
Endometriosis is characterized by the presence of endometrial tissue, localized outside the uterine cavity, such as peritoneal surface, ovaries, and rectum-vaginal septum. The prevalence is about 6 to 10%. Concerning the etiopathogenesis, the retrograde menstruation theory is accepted, although disruption in endometrial molecular biology seems to be fundamental to the development of endometriosis ectopic focuses. Women with endometriosis may be asymptomatic or may present complaints of dysmenorrhea, dispareunia, chronic pelvic pain and/or infertility. Although the definitive diagnosis of endometriosis needs a surgical intervention, mainly by laparoscopy, many findings obtained by physicalexamination and imaging and laboratory tests can predict, with a high degree of reliability, that the patient has endometriosis. The most common current treatments include surgery, ovarian suppression therapy or both. Pharmacological treatments that do not inhibit ovarian function are under investigation.
Summary
Rev Bras Ginecol Obstet. 2010;32(6):298-307
DOI 10.1590/S0100-72032010000600008
Endometriosis is characterized by the presence of endometrial tissue, localized outside the uterine cavity, such as peritoneal surface, ovaries, and rectum-vaginal septum. The prevalence is about 6 to 10%. Concerning the etiopathogenesis, the retrograde menstruation theory is accepted, although disruption in endometrial molecular biology seems to be fundamental to the development of endometriosis ectopic focuses. Women with endometriosis may be asymptomatic or may present complaints of dysmenorrhea, dispareunia, chronic pelvic pain and/or infertility. Although the definitive diagnosis of endometriosis needs a surgical intervention, mainly by laparoscopy, many findings obtained by physicalexamination and imaging and laboratory tests can predict, with a high degree of reliability, that the patient has endometriosis. The most common current treatments include surgery, ovarian suppression therapy or both. Pharmacological treatments that do not inhibit ovarian function are under investigation.
Summary
Rev Bras Ginecol Obstet. 2009;31(12):586-591
DOI 10.1590/S0100-72032009001200002
PURPOSE: to identify the microbial charge present in reusable trocars used in gynecological laparoscopies. METHODS: a descriptive exploratory study. An amount of 57 trocars, 30 with 10 mm of diameter and 27 with 5 mm, have been collected from the surgical unit, immediately after the surgery and placed in a sterilized recipient, in which 250 mL of sterile distilled water was added. Then, the trocars were agitated for the drainage of particles and to obtain a wash-out fluid to be analyzed. After being filtered through 0.22 µm cellulose membrane, the residue was placed on blood agar plates with a sterilized forceps. Following incubation, microbiological analysis has been done to count the number of colonies and further identify the microorganisms, using standard laboratorial techniques. RESULTS: microbial charge was recovered from 47.4% of the trocars analyzed. Among those, 45.6% presented 1 to 100 growing colonies. Fourteen types of microorganisms have been identified, among which the more frequently isolated were coagulase-negative Staphylococcus (28%) and Bacillus sp (21%), Aeromonas hydrophila, Alcaligenes sp, Candida parapsilosis, and enterobacteries were also identified. CONCLUSIONS: the study has demonstrated that the microbial challenge faced by the technician responsible for the cleaning and sterilization of trocars is low, as compared to the challenge imposed by biological markers. Nevertheless, it may be not inferred that the risks for infectious complications for patients are minimal.
Summary
Rev Bras Ginecol Obstet. 2009;31(12):586-591
DOI 10.1590/S0100-72032009001200002
PURPOSE: to identify the microbial charge present in reusable trocars used in gynecological laparoscopies. METHODS: a descriptive exploratory study. An amount of 57 trocars, 30 with 10 mm of diameter and 27 with 5 mm, have been collected from the surgical unit, immediately after the surgery and placed in a sterilized recipient, in which 250 mL of sterile distilled water was added. Then, the trocars were agitated for the drainage of particles and to obtain a wash-out fluid to be analyzed. After being filtered through 0.22 µm cellulose membrane, the residue was placed on blood agar plates with a sterilized forceps. Following incubation, microbiological analysis has been done to count the number of colonies and further identify the microorganisms, using standard laboratorial techniques. RESULTS: microbial charge was recovered from 47.4% of the trocars analyzed. Among those, 45.6% presented 1 to 100 growing colonies. Fourteen types of microorganisms have been identified, among which the more frequently isolated were coagulase-negative Staphylococcus (28%) and Bacillus sp (21%), Aeromonas hydrophila, Alcaligenes sp, Candida parapsilosis, and enterobacteries were also identified. CONCLUSIONS: the study has demonstrated that the microbial challenge faced by the technician responsible for the cleaning and sterilization of trocars is low, as compared to the challenge imposed by biological markers. Nevertheless, it may be not inferred that the risks for infectious complications for patients are minimal.
Summary
Rev Bras Ginecol Obstet. 2009;31(7):349-352
DOI 10.1590/S0100-72032009000700005
PURPOSE: to evaluate the ovarian reserve of infertile patients with severe ovarian endrometriosis, submitted to excisional surgery of endometriomas and attended from February to November, 2008. METHODS: prospective study, including 30 patients with endometriosis grades III and IV, with severe ovarian impairment, submitted to excisional surgery of the endometriomas, and 30 patients with endometriosis grades I and II, allocated as a Control Group. The ovarian reserve was indirectly assessed, through the basal (U/L) follicle stimulating hormone (FSH), between the third and fifth days of the cycle, 12 months after the surgery. The body mass index (BMI) was calculated according to Quetelet's formula [weight (kg)/height(cm²)]. The Mann-Whitney non-parametric U test was used to compare the variables "age", "BMI" and "basal SFH" between the groups. RESULTS: there was no significant difference between the groups about age and BMI. Concerning basal FSH, in the group of patients with severe endometriosis, the average value was 7.0 U/L, while in the Control Group, it was 5.6 U/L (p=0.3), what demonstrates that the difference between the two groups was not significant. CONCLUSIONS: the surgery did not affect the ovarian reserve of patients with severe ovarian endometriosis.
Summary
Rev Bras Ginecol Obstet. 2009;31(7):349-352
DOI 10.1590/S0100-72032009000700005
PURPOSE: to evaluate the ovarian reserve of infertile patients with severe ovarian endrometriosis, submitted to excisional surgery of endometriomas and attended from February to November, 2008. METHODS: prospective study, including 30 patients with endometriosis grades III and IV, with severe ovarian impairment, submitted to excisional surgery of the endometriomas, and 30 patients with endometriosis grades I and II, allocated as a Control Group. The ovarian reserve was indirectly assessed, through the basal (U/L) follicle stimulating hormone (FSH), between the third and fifth days of the cycle, 12 months after the surgery. The body mass index (BMI) was calculated according to Quetelet's formula [weight (kg)/height(cm²)]. The Mann-Whitney non-parametric U test was used to compare the variables "age", "BMI" and "basal SFH" between the groups. RESULTS: there was no significant difference between the groups about age and BMI. Concerning basal FSH, in the group of patients with severe endometriosis, the average value was 7.0 U/L, while in the Control Group, it was 5.6 U/L (p=0.3), what demonstrates that the difference between the two groups was not significant. CONCLUSIONS: the surgery did not affect the ovarian reserve of patients with severe ovarian endometriosis.
Summary
Rev Bras Ginecol Obstet. 2008;30(8):400-405
DOI 10.1590/S0100-72032008000800005
PURPOSE: to evaluate the sensitivity, specificity, positive and negative predictive value of double contrast barium enema (DCBE) for the diagnoses of rectum and sigmoid endometriosis. METHODS: prospective transversal study including 37 patients with suspicion of deep endometriosis. Patients were submitted to DCBE, according to the standard technique described in the literature, and then, to laparoscopy. The results of laparoscopy and the DCBE images were interpreted and compared, based on the histological evaluation. Statistical analysis was done by association (χ2 test) and agreement analyses (Kappa's test). RESULTS: patients' average age was 35.8±4.4 years old (age group from 28 to 48 years), 85.6% of them being white and 14.4%, black women. Deep endometriosis was confirmed by laparoscopy and histological exam in all the studied patients. Intestinal endometriosis was confirmed by histological exam in 27 women (72.9%) of them. DCBE demonstrated suggestive radiologic signs of intestinal infiltration by endometriosis in 24 women (64.9%) and no signs in 13 women (35.1%). The method sensitivity was 67.5%, specificity 53.8%, positive predictive value, 77.8% and negative predictive value, 70%. Among the 24 abnormal exams, 16 (43.2%) presented radiologic speculum-type image, 16 (43.2%), an image compatible with stenosis, and four (10.8%), double contour. CONCLUSIONS: the DCBE presents high sensitivity and high positive predictive value, in the diagnosis of the rectum and sigmoid endometriosis. Radiologic images speculum and stenosis-type present high sensitivity and positive predictive value for the intestinal infiltration by endometriosis.
Summary
Rev Bras Ginecol Obstet. 2008;30(8):400-405
DOI 10.1590/S0100-72032008000800005
PURPOSE: to evaluate the sensitivity, specificity, positive and negative predictive value of double contrast barium enema (DCBE) for the diagnoses of rectum and sigmoid endometriosis. METHODS: prospective transversal study including 37 patients with suspicion of deep endometriosis. Patients were submitted to DCBE, according to the standard technique described in the literature, and then, to laparoscopy. The results of laparoscopy and the DCBE images were interpreted and compared, based on the histological evaluation. Statistical analysis was done by association (χ2 test) and agreement analyses (Kappa's test). RESULTS: patients' average age was 35.8±4.4 years old (age group from 28 to 48 years), 85.6% of them being white and 14.4%, black women. Deep endometriosis was confirmed by laparoscopy and histological exam in all the studied patients. Intestinal endometriosis was confirmed by histological exam in 27 women (72.9%) of them. DCBE demonstrated suggestive radiologic signs of intestinal infiltration by endometriosis in 24 women (64.9%) and no signs in 13 women (35.1%). The method sensitivity was 67.5%, specificity 53.8%, positive predictive value, 77.8% and negative predictive value, 70%. Among the 24 abnormal exams, 16 (43.2%) presented radiologic speculum-type image, 16 (43.2%), an image compatible with stenosis, and four (10.8%), double contour. CONCLUSIONS: the DCBE presents high sensitivity and high positive predictive value, in the diagnosis of the rectum and sigmoid endometriosis. Radiologic images speculum and stenosis-type present high sensitivity and positive predictive value for the intestinal infiltration by endometriosis.
Summary
Rev Bras Ginecol Obstet. 2007;29(6):297-302
DOI 10.1590/S0100-72032007000600004
PURPOSE: to identify the main characteristics of the diagnostic and surgical gynecological laparoscopies carried out in patients with reproductive difficulties at a teaching hospital in Recife, from 2000 and 2004. METHODS: a hospital based descriptive case-series study was carried out with 295 patients who had undergone gynecological laparoscopy for either infertility or tube recanalization in the Mother and Child Health Professor Fernando Figueira Institute. Information was obtained from the surgical records of the laparoscopies carried out from January 2000 to December 2004. The inclusion criteria was infertility or pre-recanalization study as a surgical indication. The information was typed twice into a data bank. Tables with central measurements and dispersion tendency were created for the quantitative variables and frequency distribution for the categorical variables. The statistical program, Epi Info 3.3.2., was used to analyze the data. RESULTS: along the study, 462 gynecological laparoscopies were analyzed, 295 (63.8%) of them having as an indication either infertility (41.1%) or the study of possible tube recanalization (18.8%). The patients’ average age in both groups was from 30 to 34 years old. Among the 87 patients with desire of tube recanalization, 55.2% had one or both tubes inadequate for the procedure, and from those, 52.1% was diagnosed with tube amputation (fimbrectomy). In the infertility cases, the most observed findings were adherences (60.6%), tube obstruction (40.9%) and endometriosis (36.1%). Among the procedures carried out, lysis of adherences (34.2%) and biopsies (21%) were the most frequent, followed by endometriosis treatment (10.8%) and salpingostomy (10.8%). CONCLUSION: videolaparoscopy is an important tool in the study and treatment of patients with infertility and before tube recanalization, especially in those hospitals where advanced reproductive techniques are not available.
Summary
Rev Bras Ginecol Obstet. 2007;29(6):297-302
DOI 10.1590/S0100-72032007000600004
PURPOSE: to identify the main characteristics of the diagnostic and surgical gynecological laparoscopies carried out in patients with reproductive difficulties at a teaching hospital in Recife, from 2000 and 2004. METHODS: a hospital based descriptive case-series study was carried out with 295 patients who had undergone gynecological laparoscopy for either infertility or tube recanalization in the Mother and Child Health Professor Fernando Figueira Institute. Information was obtained from the surgical records of the laparoscopies carried out from January 2000 to December 2004. The inclusion criteria was infertility or pre-recanalization study as a surgical indication. The information was typed twice into a data bank. Tables with central measurements and dispersion tendency were created for the quantitative variables and frequency distribution for the categorical variables. The statistical program, Epi Info 3.3.2., was used to analyze the data. RESULTS: along the study, 462 gynecological laparoscopies were analyzed, 295 (63.8%) of them having as an indication either infertility (41.1%) or the study of possible tube recanalization (18.8%). The patients’ average age in both groups was from 30 to 34 years old. Among the 87 patients with desire of tube recanalization, 55.2% had one or both tubes inadequate for the procedure, and from those, 52.1% was diagnosed with tube amputation (fimbrectomy). In the infertility cases, the most observed findings were adherences (60.6%), tube obstruction (40.9%) and endometriosis (36.1%). Among the procedures carried out, lysis of adherences (34.2%) and biopsies (21%) were the most frequent, followed by endometriosis treatment (10.8%) and salpingostomy (10.8%). CONCLUSION: videolaparoscopy is an important tool in the study and treatment of patients with infertility and before tube recanalization, especially in those hospitals where advanced reproductive techniques are not available.
