performed the procedures over a period of 8 years. All procedures were per-formed under general anesthesia and under transabdominal ultrasound guid-ance. Adhesions were due to induced abortion or postpartum or postabortalcurettage in 79.6% of the patients. All patients received postoperative highdose estrogen and progesterone treatment. While in the majority of the pa-tients no intrauterine adjuvants were used balloon and hyaluronic acid gelwere used in others.

RESULTS: Complete restoration of the cavity was achieved in 67 (33.3%)and partial restoration in 82 (40.8%) patients. In 52 patients (25.9%) there wasonlyminimal or no change in the configuration of the uterine cavity despite re-petitive hysteroscopic interventions. There were 2 cases of uterine rupture. Ofthe patients not lost to follow-up 75.8% with complete restoration, 43.6% ofpatients with partial restoration, and 13.7% with minimal or no change of theuterine cavity achieved an intrauterine pregnancy. Therewas one ectopic preg-nancy. There were 8 cases of placenta previa and 4 cases of placenta accreata.

CONCLUSION: Results from this large series of severe intrauterine adhe-sions show that serial office hysteroscopic interventions result in satisfactoryanatomic and reproductive outcomes.

O-238 Tuesday, October 15, 2013 04:15 PM

SIGMOIDAL ADHESIONS ARE A RISK FACTOR FOR IRRITABLEBOWEL SYNDROME. G. Patounakis, G. T. Fossum. Obstetrics and Gy-necology, Thomas Jefferson University, Philadelphia, PA.

OBJECTIVE: To determine if sigmoidal adhesions are a risk factor for ir-ritable bowel syndrome (IBS).

DESIGN: Retrospective cohort study.MATERIALS AND METHODS: All procedures performed by a single

surgeon at our institution from January 2008 to December 2012 werequeried. Subsequently, all patients with sigmoidal adhesions to either thepelvic sidewall or the uterus were identified. The remaining patientswere without sigmoidal adhesions and served as controls. A subset of thesecontrols was randomly chosen by computer program. Age, race, and bodymass index (BMI) were tabulated. Medical conditions present at the time ofsurgery were determined by diagnosis codes, patient intake forms, and thepre-operative history form. These conditions were IBS, hypertension, dia-betes, gastroesophageal reflux disease (GERD), pelvic pain, and endometri-osis. The Student t-test and Fisher’s Exact test were used to compare thepatients with sigmoidal adhesions versus controls. P-values<0.05 wereconsidered statistically significant.

RESULTS: A total of 968 patient records were reviewed who had surgery.Sigmoidal adhesions were found in 111 patients. Of the remaining 857 con-trols, 189 were randomly selected for further review. The two groups did notdiffer in demographics including hypertension, diabetes and GERD. IBS was5 times more prevalent in the adhesion group. As expected, there was moreendometriosis and pelvic pain in the adhesion group.

Sigmoidal Adhesions?

p-valueYes (n¼111) No (n¼189)

Age (y) 40�9.6 39�8.4 NSBMI (kg/m2) 31�7.8 31�7.5 NSRace African American 55 (49%) 94 (50%) NS

Caucasian 23 (21%) 35 (19%)Other 3 (3%) 6 (3%)Unknown 30 (27%) 53 (28%)

IBS 21 (19%) 7 (4%) <0.0001Hypertension 35 (32%) 50 (26%) NSDiabetes 10 (9%) 13 (7%) NSGERD 29 (26%) 34 (18%) NSPelvic Pain 60 (54%) 40 (21%) <0.0001Endometriosis 21 (19%) 5 (3%) <0.0001

Mean�standard deviation; NS¼not statistically significant.

CONCLUSION: Sigmoidal adhesions were found in patients with IBS,endometriosis, and pelvic pain. Lysis of sigmoidal adhesions may improveIBS.

FERTILITY & STERILITY�

O-239 Tuesday, October 15, 2013 04:30 PM

FLEXIBLE CO2 LASER VS. ULTRASONIC SCALPEL IN ROBOT-ASSISTED LAPAROSCOPIC MYOMECTOMY. S. Choussein,S. S. Srouji, S. A. Missmer, A. R. Gargiulo. Center for Infertility and Repro-ductive Surgery, Department of Obstetrics, Gynecology and ReproductiveBiology, Brigham and Women’s Hospital, Harvard Medical School, Boston,MA.

OBJECTIVE: Photonic and ultrasonic energy provide highly effective cut-ting and coagulation with a lesser extent of collateral thermal damagecompared to electrosurgery. We aim to compare the effectiveness and safetyof a flexible CO2 laser fiber to the ultrasonic scalpel when employed througha robotic surgical system.DESIGN: Retrospective cohort study.MATERIALS AND METHODS: Operative outcomes of patients under-

going robot-assisted myomectomy with a flexible laser fiber (BeamPath Ro-botic, Omniguide) or ultrasonic scalpel (Harmonic ACE Curved Shears,Intuitive Surgical) were compared. Statistical differences in surgical outcomemeans were calculated using the Wilcoxon rank sum test.RESULTS: 82 patients were included in the study (n¼41 per laser

and scalpel group). Characteristics of the patients in the two instrumentgroups were similar, with overall mean age�SD¼38.1�6.5 years andBMI¼27.3�5.8 kg/m2. In total, 164 intramural, 90 subserosal, 36 peduncu-lated, 11 submucosal, 1 cervical and 7 broad ligament myomas wereremoved. There was also similar tumor characteristics between instrumentgroups, with mean number of tumors removed¼3.8�3, mean largest tumorsize¼6.4�2.2 cm, and mean specimen weight¼153.8�137.3 gm. All proce-dures were successfully completed without conversion to conventional lapa-roscopy or open surgery. Comparison of operative outcomes is shown in theTable.

CO2 Laser Ultrasonic scalpel

p-value

Mean�SD Mean�SD

Operative time (min)

194.5�72.3 183.4�65.2 0.15 Estimated blood loss (mL) 111.6�122.5 119.2�163.5 0.74 Length of stay (days) 0.22�0.5 0.78�2.0 0.03

CONCLUSION: Robot-assisted laparoscopic myomectomy with flexibleCO2 laser fiber is safe and has comparable operative outcomes to ultrasonicscalpel. The small size and flexibility of this device represent a majoradvancement in terms of laser ergonomics as they allow robotic surgeonsto employ safe focal energy without sacrificing operative ergonomics.

O-240 Tuesday, October 15, 2013 04:45 PM

THE FUNDAMENTALS OF LAPAROSCOPIC SURGERY: A VALI-DATED CURRICULUM TO TEACH LAPAROSCOPIC SKILLSAND KNOWLEDGE IN OBSTETRICS AND GYNECOLOGYRESIDENTS. K. M. Braun,a C. Palladino,b B. A. Parnell,a C. B. Ray,a

L. Evans.b aObstetrics and Gynecology, Georgia Regents University, Au-gusta, GA; bEducational Innovation Institute, Georgia Regents University,Augusta, GA.

OBJECTIVE: The Fundamentals of Laparoscopic Surgery (FLS) programis a validated curriculum to teach basic laparoscopic knowledge and skill;passage of the FLS examination is now required for General Surgery boardcertification. Our goal was to assess the FLS curriculum as a model to teachbasic laparoscopic skills and knowledge for Obstetrics and Gynecology (Ob-Gyn) residents.DESIGN: A pre- and post-test pilot study of the FLS curriculum from

August 2012-April 2013 at a single academic medical center Ob-Gyn resi-dency program located in the southeastern US.MATERIALS AND METHODS: The FLS program was adopted as a

replacement curriculum for all residents in the program (PGY 1-4, n¼15).It is a two-part program consisting of five online modules related to cognitiveknowledge in laparoscopic surgery and technical training in five manualskills (e.g., ligating loop). Residents accessed and studied the online modulesat their own pace, and the manual skills training was taught during monthlytraining sessions with faculty. Residents practiced to attain time and accuracystandards for each task per protocol. For testing, all tasks were summed togive a maximum of 500 points. Residents completed a pre- and post-test

S73

on the manual skills training and a post-test only on the cognitive knowledgemodules.

RESULTS: All residents completed the manual skills training; only 27%completed the online cognitive knowledge modules. Pre-test scores of 138� 73 increased 228% following manual training to 453 � 29, (p<0.001),with all residents attaining manual skills scores equivalent to FLS certifica-tion (>270) at post-test (vs. one resident at pre-test). Despite low onlinecognitive module completion, the mean score on the cognitive knowledgepost-test was 82.4, with a 100% pass rate.

CONCLUSION: The results of this study suggest that the FLS programholds promise as a curricular initiative for developing laparoscopic skillsand knowledge in Ob-Gyn residents.

O-241 Tuesday, October 15, 2013 05:00 PM

THECLINICAL EFFECTIVENESS OFMODIFIEDLAPAROSCOPICFIMBRIOPLASTYFORTHETREATMENTOFMINIMALENDOME-TRIOSIS AND UNEXPLAINED INFERTILITY. S. E. Franjoine,a

J. H. Liu,a C. Geng,b M.A. Bedaiwy.a aObstetrics and Gynecology, UniversityHospitals Case Medical Center, Cleveland, OH; bEpidemiology and Biostatis-tics, Case Western Reserve University, Cleveland, OH.

OBJECTIVE: Modified laparoscopic fimbrioplasty (MLF) is a surgicaltechnique that takes place during diagnostic laparoscopy and is designed toincrease the working surface area of the fimbriated end of the fallopiantube to optimize ovum pickup. We propose that an improvement in fimbrialfunction through MLF increases pregnancy rates and reduces time to preg-nancy in women with minimal endometriosis or unexplained infertility.

DESIGN: This is a retrospective cohort study comparing the reproductiveoutcomes of women who underwent MLF (n¼50) to women who underwentdiagnostic laparoscopy alone (n¼87).

MATERIALS AND METHODS: MLF involves gentle dilation of thefimbriae, lysis of adhesions crossing or blocking the lumen, and expansionof the working surface area of the fimbriae. The reproductive history, opera-tive information and outcomes were collected from pre-existing records. Thedemographic and reproductive characteristics of patients who achieved preg-nancy were compared to those who did not achieve pregnancy. The time topregnancy was analyzed via Kaplan-Meier curve, and the number neededto treat was determined.

RESULTS: The demographics and surgical variables were comparable forthe two groups. The MLF group had a higher percentage of women achievepregnancy (40% vs. 28.7%, p¼0.13) and a shorter mean time to pregnancy(13 vs. 18 weeks, p¼0.27). The percent pregnant was significant for womenless than 35 years old (51.5% vs. 28.8%, p¼0.02), but not for women greaterthan 35 years old (17.6% vs. 28.6%, p¼0.45). The inverse number needed totreat, an assessment of the number needed to initiate pregnancy, was deter-mined to be 8.

CONCLUSION:Modified laparoscopic fimbrioplasty is a surgical techniquethat may be an effective alternative to IVF for women withminimal endometri-osis or unexplained infertility who undergo laparoscopy for infertility. In thisretrospective study, more women who had MLF become pregnant, and thetime to pregnancy was significantly shorter for patients less than 35 years old.

O-242 Tuesday, October 15, 2013 05:15 PM

HIGHER INCIDENCEOF UTERINEMALFORMATIONS IN INFER-TILE PATIENTS COMPARED TO CONTROL WOMEN AS AS-SESSED BY THREE DIMENSIONAL ULTRASOUND. M. Carrasco,a

R. Garcia-Guzman,a M. Puopolo,b J. Hernandez,a A. Palumbo.a aCentrode Asistencia a la Reproduccion Humana de Canarias, La Laguna, Sta.Cruz de Tenerife, Spain; bCell Biology and Neurosciences, Istituto Superioredi Sanit�a, Rome, Italy.

OBJECTIVE: To assess the incidence of uterine malformations in infertilepatients compared to the general population.

DESIGN: Retrospective case control study based on a computerized data-base including three dimensional ultrasound (3D US) images.

MATERIALS AND METHODS: This study included 529 consecutivewomen attending our clinic with chief complaint of infertility and 466 con-trols seen in our clinic for gynecologic care or as prospective egg donors. Ofcontrols, 123 had proven fertility (at least 1 liveborn). Cases and controls at-tended our clinic from January 2009 to November 2011. Uterine morphologywas evaluated by 3D US using a voluson E8 or a voluson 720 Pro (GE,Austria). The Viewpoint database and the 3D View program were used.Descriptive statistics are reported with 95% confidence intervals (CI).

S74 ASRM Abstracts

RESULTS: Of the 529 infertile patients 73 [13.8 % (11.0-17.0 CI)] pre-sented uterine anomalies including: complete septate uterus (n¼1; 0.2%);subseptate uterus (n¼45; 8.5 %); arcuate uterus (n¼25; 4.7 %); unicornuateuterus (n¼1; 0.2 %); bicornuate uterus (n¼1; 0.2 %). Of the 466 controls,representing our general gynecologic population 18 [3.9% (2.3-6.0) CI)]had uterine malformations including: complete septate uterus (n¼2; 0,4%);subseptate uterus (n¼2; 0.4%); arcuate uterus (n¼14; 3%). Two of the 123fertile controls had an arcuate uterus [1.6% (0.0-5.7 CI)].CONCLUSION: The hereby reported difference in the incidence of uter-

inemalformations between infertile and control subjects suggests that uterineanomalies might be considered a risk factor for infertility that warrants accu-rate investigation. For this purpose 3D US is a useful screening and diag-nostic tool. A limitation of this study is the unblinded assessment ofuterine anomalies in cases and controls.

O-243 Tuesday, October 15, 2013 05:30 PM

USE OF AN IN VITRO MOUSE MACROPHAGE MODEL TODETECT THE ADHESION FORMING POTENTIAL OF MATE-RIALS USED IN PELVIC SURGERY. J. Hice, L. Penrose,A. Loveless, S. Prien. Department of Obstetrics and Gynecology, TexasTech University Health Sciences Center, Lubbock, TX.

OBJECTIVE: Even with significant precaution, pelvic surgery carries arisk of adhesion formation and its associated infertility issues. While thecomplete pathway is not illuminated, basic science implicates the macro-phage as the main player in the inflammatory response. Activated macro-phages secrete inflammatory cytokines and fibrous factors noted tocontribute to adhesion formation. Therefore, cultured macrophages mightprove a good model to assess materials prior to their use in pelvic surgery.The goal of the current study was to identify which suture materials causedthe least peritoneal macrophages activation as an indicator of inflammatoryresponse and predictor of adhesion formation.DESIGN: Cell culture based study.MATERIALS ANDMETHODS: Mice peritoneal macrophages were har-

vested and placed in culture for 24 hrs prior to exposure to suture. The cul-tures were then rinsed with fresh media and cells exposed to 0.5 cmlengths of the assigned suture: 3-0 Vicryl, 3-0 Plain gut, 3-0, or 3-0Monocryl,or a non-exposed control group. At 24 hrs and 72 hrs the cultures were as-sessed visually for macrophage activation by a panel of trained experts.Each observer ranked 100 cells per culture as activated, partially activatedor non-activated based on cell morphology. All treatments were performedin duplicate.RESULTS: All cultures demonstrated at least partial activation of the

macrophage population by 72 hrs. However, the cultures exposed to PlainGut and Vicryl demonstrated significantly more activation than the controlor Monocryl cultures (P < 0.001). Further Monocryl exposed samplesdemonstrated no more activation than the control (P ¼ 0.365).CONCLUSION: The data suggest the magnitude of inflammatory

response, mediated by macrophage activation, may be minimized by sutureselection in peritoneal exposure. Further, the data suggest the macrophageculture model might provide a means of assessing materials prior to theiruse in fertility surgeries. Further study is needed to confirm themodel efficacy.

O-244 Tuesday, October 15, 2013 05:45 PM

LARGE OVARIAN ENDOMETRIOMA: THREE – STEP PROCE-DURE OR COMBINED EXCISIONAL AND ABLATIVESURGERY. H. A. M. Salem, M. Z. E. Moustafa, E. A. Abd Elnaby. Ob-stetrics and Gynecology, Faculty of Medicine, Tanta University, Tanta, Ghar-beya, Egypt.

OBJECTIVE: To evaluate the effect of two different laparoscopic tech-niques: three–step procedure versus combined excisional and ablative sur-gery on the ovarian reserve in women with large ovarian endometriomas.DESIGN: Prospective randomized clinical trial.MATERIALS AND METHODS: Patients:Forty women, between 23-37 years of age, with large ovarian endometrio-

mas (a mean diameter > 3cm). Main exclusion criteria were: previousovarian surgery, previous surgery for endometriosis, presurgical evidenceof poor ovarian reserve, and morbid obesity.Interventions:Patients were randomized into 2 groups:Group 1: the endometriomas were management with the three–step proce-

dure. The 1st laparoscopy for diagnosis, ovariolysis, endometrioma incision,

Vol. 100, No. 3, Supplement, September 2013