Pregnancy and perinatal outcomes of early vs late selective termination in dichorionic twin pregnancy: systematic review and meta-analysis

OBJECTIVE

To evaluate outcomes of dichorionic twin pregnancies undergoing early vs late selective termination of pregnancy (ST).

METHODS

MEDLINE, EMBASE, CINAHL and the Web of Science databases were searched electronically up to March 2022. The primary outcome of this study was pregnancy loss prior to 24 weeks' gestation. The secondary outcomes included preterm birth (PTB) before 37, 34, and 32 weeks, preterm prelabor rupture of membranes (PPROM), gestational age (GA) at delivery, Cesarean delivery, mean birth weight, 5-min Apgar score < 7, overall neonatal morbidity and neonatal survival. Only prospective or retrospective studies reporting data on the outcome of early (before 18 weeks) vs late (at or after 18 weeks) ST in dichorionic twin pregnancies were considered suitable for inclusion. Quality assessment of the included studies was performed using the Newcastle-Ottawa scale for cohort studies. Random-effects head-to-head meta-analysis was used to analyze the data.

RESULTS

Seven studies reporting on 649 dichorionic twin pregnancies were included in this systematic review. The risk of pregnancy loss prior to 24 weeks was significantly lower in dichorionic twin pregnancies undergoing early compared with late ST (1% vs 8%; odds ratio (OR), 0.25 (95% CI, 0.10-0.65); P = 0.004). The risk of PTB was significantly lower in dichorionic twin pregnancies undergoing early compared with late ST when considering PTB before 37 weeks (19% vs 45%; OR, 0.36 (95% CI, 0.23-0.57); P < 0.00001), before 34 weeks (4% vs 19%; OR, 0.24 (95% CI, 0.11-0.54); P = 0.0005) and before 32 weeks (4% vs 20%; OR, 0.21 (95% CI, 0.05-0.85); P = 0.03). The mean birth weight was significantly greater in the early-ST group (mean difference (MD), 392.2 g (95% CI, 59.1-726.7 g); P = 0.02), as was the mean GA at delivery (MD, 2.47 weeks (95% CI, 0.04-4.91 weeks); P = 0.049). There was no significant difference between dichorionic twin pregnancies undergoing early compared with late ST in terms of PPROM (P = 0.27), Cesarean delivery (P = 0.38), 5-min Apgar score < 7 (P = 0.35) and neonatal survival of the non-reduced twin (P = 0.54).

CONCLUSIONS

The risk of pregnancy loss prior to 24 weeks and the rate of PTB before 37, 34 and 32 weeks were significantly higher in dichorionic twin pregnancies undergoing late vs early ST, thus highlighting the importance of early diagnosis of fetal anomalies in twin pregnancies. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Use of oral GnRH antagonists combined therapy in the management of symptomatic uterine fibroids

Uterine fibroids have an impact on women’s lives due to their high prevalence, physical symptoms, their consequences on patients’ emotional and psychological well-being and loss of work productivity. The choice of therapeutical approaches varies depending on several factors, and therefore should be applied individually. Currently, there is an unmet need for good, reliable, uterine-sparing options. The oral GnRH antagonists (Elagolix, Relugolix, Linzagolix) represent a new alternative for the medical management of hormone-dependent gynaecological diseases such as uterine fibroids or endometriosis. They rapidly bind to the GnRH receptor, block endogenous GnRH activity and directly suppress LH and FSH production, avoiding unwanted flare-up effects. Some GnRH antagonists are marketed in combination with hormone replacement therapy add-back to counteract hypo-oestrogenic side effects. According to the registration trials, once-daily GhRH antagonist combination therapy results in a significant reduction in menstrual bleeding, as compared with placebo, and preserves bone mineral density, for up to 104 weeks. Further studies in the long term are needed to evaluate the whole impact of medical treatment of uterine fibroids on the management of this common women’s disease.

P-717 Trends in the incidence of major birth defects after Assisted Reproductive Technologies (ART) in Lombardy Region, Northern Italy

Study question

Does the association between Assisted Reproductive Technologies (ART) and birth defects change over time?

Summary answer

The increased incidence of birth defects in ART pregnancies is not steady over time. A decline of this risk emerged in most recent years.

What is known already

The incidence of birth defects is increased in pregnancies after ART. The latest meta-analysis showed that infants born following IVF-ICSI have a 40% increased risk (Zhao et al., 2020). Even if infertile women are exposed to higher risk per se, some ART related factors may also contribute. To note, ART procedures are continuously evolving, and it cannot be excluded that the magnitude of the association of ART and birth defects may have changed in recent years. We failed to identify in the literature studies reporting on the trends of birth defects in IVF-ICSI pregnancies over time.

Study design, size, duration

This is a population-based study using the automated system of healthcare utilization databases from Lombardy, a region located in Northern Italy accounting for about 10 million inhabitants. We identified deliveries occurring between January 2014 and December 2020 from women beneficiaries of the public health system using the standard discharge form and the certificate of delivery assistance. We excluded cases with incomplete information and pregnancies obtained by intrauterine insemination or ovarian hyperstimulation alone.

Participants/materials, setting, methods

The rate of newborns affected by major defects was calculated among natural and IVF-ICSI pregnancies. A logistic regression model was used to adjust for maternal sociodemographic features (i.e., age, nationality, marital status, education, and employment). Data are presented as adjusted odd ratio (aOR) and corresponding 95% Confidence Interval (CI) of major defects among IVF-ICSI pregnancies compared to natural conceptions. Analyses were repeated for every calendar year.

Main results and the role of chance

A total of 508,421 live births were included, of whom 14,067 (2.8%) were achieved with IVF-ICSI. The proportion of non-spontaneous conceptions per year progressively increased over the years, being 2.1%, 2.3%, 2.6%, 2.8%, 3.2%, 3.4% and 3.2% in 2014, 2015, 2016, 2017, 2018, 2019, and 2020, respectively (p &lt; 0.0001). Overall, 13,080 birth defects were recorded, of whom 412 occurred among ART newborns (3.1%). The risk of birth defects is increased in women undergoing ART (aOR 1.13; 95%CI:1.02-1.25), but a decreasing trend over time was highlighted. Indeed, the aOR dropped from 1.40 (95%CI: 1.04-1.91) in 2014 to 0.7 (95%CI: 0.73-1.28) in 2020 (p &lt; 0.001). During the study period, a statistically significant reduction in multiple pregnancies (p-value for trend &lt;0.0001) and in the ratio of ICSI to conventional IVF (p-value for trend &lt;0.0001) was also observed, potentially explaining the positive trend observed for birth defects.

Limitations, reasons for caution

The diagnosis of malformation is based on information detected at the time of delivery, and not during the subsequent infant’s hospitalization, or later in lifetime. Further, we have no information on pregnancies terminated early. Finally, data was collected from registries and this modality may expose the findings to some inaccuracies.

Wider implications of the findings

The increased risk of birth defects in IVF-ICSI pregnancies is not steady over time. A decline of this risk emerged in our region. Policy changes in ART may explain this beneficial effect. Evidence obtained more than one decade ago may not be valid in the modern era of IVF.

Trial registration number

not applicable

When more is not better: 10 'don'ts' in endometriosis management. An ETIC * position statement

A network of endometriosis experts from 16 Italian academic departments and teaching hospitals distributed all over the country made a critical appraisal of the available evidence and definition of 10 suggestions regarding measures to be de-implemented. Strong suggestions were made only when high-quality evidence was available. The aim was to select 10 low-value medical interventions, characterized by an unfavorable balance between potential benefits, potential harms, and costs, which should be discouraged in women with endometriosis. The following suggestions were agreed by all experts: do not suggest laparoscopy to detect and treat superficial peritoneal endometriosis in infertile women without pelvic pain symptoms; do not recommend controlled ovarian stimulation and IUI in infertile women with endometriosis at any stage; do not remove small ovarian endometriomas (diameter <4 cm) with the sole objective of improving the likelihood of conception in infertile patients scheduled for IVF; do not remove uncomplicated deep endometriotic lesions in asymptomatic women, and also in symptomatic women not seeking conception when medical treatment is effective and well tolerated; do not systematically request second-level diagnostic investigations in women with known or suspected non-subocclusive colorectal endometriosis or with symptoms responding to medical treatment; do not recommend repeated follow-up serum CA-125 (or other currently available biomarkers) measurements in women successfully using medical treatments for uncomplicated endometriosis in the absence of suspicious ovarian cysts; do not leave women undergoing surgery for ovarian endometriomas and not seeking immediate conception without post-operative long-term treatment with estrogen-progestins or progestins; do not perform laparoscopy in adolescent women (<20 years) with moderate-severe dysmenorrhea and clinically suspected early endometriosis without prior attempting to relieve symptoms with estrogen-progestins or progestins; do not prescribe drugs that cannot be used for prolonged periods of time because of safety or cost issues as first-line medical treatment, unless estrogen-progestins or progestins have been proven ineffective, not tolerated, or contraindicated; do not use robotic-assisted laparoscopic surgery for endometriosis outside research settings. Our proposal is to better address medical and surgical approaches to endometriosis de-implementing low-value interventions, with the aim to prevent unnecessary morbidity, limit psychological distress, and reduce the burden of treatment avoiding medical overuse and allowing a more equitable distribution of healthcare resources.

Endometriosis: seeking optimal management in women approaching menopause

The incidence of endometriosis in middle-aged women is not minimal compared to that in the reproductive age group. The treatment of affected women after childbearing age to the natural transition toward menopause has received considerably poor attention. Disease management is problematic for these women due to increased contraindications regarding hormonal treatment and the possibility for malignant transformation, considering the increased cancer risk in patients with a long-standing history of the disease. This state-of-the-art review aims for the first time to assess the benefits of the available therapies to help guide treatment decisions for the care of endometriosis in women approaching menopause. Progestins are proven effective in reducing pain and should be preferred in these women. According to the international guidelines that lack precise recommendations, hysterectomy with bilateral salpingo-oophorectomy should be the definitive therapy in women who have completed their reproductive arc, if medical therapy has failed. Strict surveillance or surgery with removal of affected gonads should be considered in cases of long-standing or recurrent endometriomas, especially in the presence of modifications of ultrasonographic cyst patterns. Although rare, malignant transformation of various tissues in endometriosis patients has been described, and management is herein discussed.

Radiation effects on male fertility

BACKGROUND

Spermatogenesis is a process of dynamic cell differentiation. Ionizing radiation impairs spermatogenesis, and spermatogonia are more radiosensitive than spermatocytes or spermatids. Consistent with this assumption and due to improvement in tumor curability, nowadays, fertility preservation represents a public health need.

OBJECTIVES

To discuss radiotherapy-induced risk to male fertility and raise oncologic awareness of male fertility in daily clinical practice.

MATERIALS AND METHODS

PubMed and Clinicaltrials.gov databases were searched for papers in English.

RESULTS

We provide an overview of clinical landscape. Four main issues were proposed: (i) spermatogenesis and radiobiological general concepts; (ii) impairment of spermatogenesis; (iii) impairment of testosterone-producing Leydig cells; (iv) clinical radiotherapy evidence in oncology.

CONCLUSION

This review can be useful in daily clinical work and offer some directions for future research.

Treatment of the Mayer-Rokitansky-Küster-Hauser syndrome with autologous in vitro cultured vaginal tissue: descriptive study of long-term results and patient outcomes

OBJECTIVE

Evaluating sexual function and quality of life (QoL) in patients treated with a modified Abbé-McIndoe technique using in vitro cultured autologous vaginal mucosa.

DESIGN

Descriptive study.

SETTING

Policlinico Umberto I, Sapienza University of Rome.

POPULATION

From 2006 to 2016, 39 women affected by Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) underwent vaginoplasty at our centre using a modified Abbé-McIndoe technique with in vitro cultured autologous vaginal tissue.

METHODS

For each patient, vaginal tissue was obtained by full-thickness biopsy of the vaginal vestibule. Following enzymatic dissociation, cells were cultured for 2-3 weeks before the transplant.

MAIN OUTCOME MEASURES

Each patient completed two validated questionnaires to quantify sexual function and QoL: the Female Sexual Function Index (FSFI), administered at 12, 36, and 60 months, and the Psychological General Well Being Index (PGWBI) administered at 0, 6, and 36 months after surgery.

RESULTS

Twelve months after surgery, 29 patients were engaging in regular sexual activity. The FSFI test results showed a satisfactory sexual function compared to the general population, with median values of 25.85 (range 4.6-30.5) at 12 months, 27.2 (range 4.4-33.6) at 36 months, and 29.6 (range 23.9-33.6) at 60 months. The PGWBI questionnaire showed a median score of 420.5 (range 108-540) before surgery, and 459 (range 252-533) at the 60-month follow-up.

CONCLUSIONS

Vaginoplasty performed with the use of autologous vaginal tissue, besides ensuring a long-term satisfying sex life, helps in achieving an improvement in QoL that is maintained over time.

TWEETABLE ABSTRACT

Vaginoplasty using in vitro vaginal tissue ensures a satisfactory sexual function and improves quality of life.

Dose-dense weekly chemotherapy in advanced ovarian cancer: An updated meta-analysis of randomized controlled trials

OBJECTIVE

The use of dose-dense weekly chemotherapy in the management of advanced ovarian cancer (OC) remains controversial. The aim of this meta-analysis was to evaluate the efficacy of dose-dense regimen to improve clinical outcomes in OC patients with the inclusion of new trials.

METHODS

For this updated meta-analysis, PubMed Medline and Scopus databases and meeting proceedings were searched for eligible studies with the limitation of randomized controlled trials, comparing dose-dense chemotherapy versus standard treatment. Trials were grouped in two types of dose-dense chemotherapy: weekly dose-dense (both paclitaxel and carboplatin weekly administration) and semi-weekly dose-dense (weekly paclitaxel and three weekly carboplatin administration). Data were extracted independently and were analyzed using RevMan statistical software version 5.3 (http://www.cochrane.org). Primary end-point was progression-free survival (PFS).

RESULTS

Four randomized controlled trials comprising 3698 patients were identified as eligible. Dose-dense chemotherapy had not a significant benefit on PFS (HR 0.92, 95% CI 0.81-1.04, p = 0.20). When the analysis was restricted to both weekly and semi-weekly dose-dense data, a no significant interaction between dose-dense and standard regimen was confirmed (HR 1.01, 95% CI 0.93-1.10 and HR 0.82, 95% CI 0.63-1.08, respectively).

CONCLUSIONS

In the absence of PFS superiority of dose-dense schedule, three weekly schedule should remain the standard of care for advanced OC.

A medical device containing purified bovine colostrum (Monurelle Biogel) in the treatment of vulvovaginal atrophy in postmenopausal women: Retrospective analysis of urinary symptoms, sexual function, and quality of life

OBJECTIVE

This study assessed the effectiveness and safety of a medical device containing purified bovine colostrum (Monurelle Biogel; Zambon, Bresso, Italy) in improving vulvovaginal atrophy (VVA), sexual function, urinary symptoms, and quality of life (QoL) in postmenopausal women.

METHODS

In all, 172 postmenopausal women with VVA were included in the study. All women were treated with vaginal Monurelle Biogel daily for 12 weeks. Patients underwent clinical examinations, completed a 3-day voiding diary, and had VVA graded using the Vaginal Health Index (VHI) at baseline and 12 weeks. Patients also completed the Female Sexual Function Index (FSFI), overactive bladder questionnaire (OAB-Q), and the Urogenital Distress Inventory (UDI-6), among others.

RESULTS

After 12 weeks, there were significant increases in mean (± SD) VHI (12.53 ± 3.67 vs. 19.31 ± 3.49; P < .0001), the number of patients engaging in regular sexual activity 102 (59.3%) vs. 144 (83.7%), and in the total FSFI score (21.64 ± 2.99 vs. 28.16 ± 1.93; P < .0001) compared with baseline. In addition, there were significant reductions in the mean number of 24-hour voids (9.57 ± 2.12 vs. 7.13 ± 1.22; P < .0001), urgent micturition episodes per 24 hours (1.75 ± 0.76 vs. 1.14 ± 0.87; P = .001), nocturia episodes (1.58 ± 0.85 vs. 0.97 ± 1.18; P = .0002), and urinary incontinence episodes per 24 hours (0.74 ± 0.59 vs. 0.28 ± 0.52; P = .003). Finally, after 12 weeks treatment, there were significant differences in UDI-6 (7.85 ± 0.81 vs. 5.56 ± 1.40), OAB-Q symptom (53.60 ± 12.57 vs. 22.08 ± 9.63), and OAB-Q health-related QoL (21.75 ± 8.51 vs. 69.34 ± 14.59) scores compared with baseline (P < .0001 for all). The Patient Impression of Global Improvement scale revealed global improvement in 143 women (83.14%).

CONCLUSIONS

Monurelle Biogel is an effective treatment for VVA in postmenopausal women, improving sexual life, urinary symptoms, and QoL.

Risk-reducing salpingo-oophorectomy in BRCA1 and BRCA2 mutated patients: An evidence-based approach on what women should know

This review is focused on the ovarian cancer risk reduction management in BRCA mutation carriers and is intended to assist with clinical decision-making. Obviously, treatment decisions must be based on the available evidence. Despite risk-reducing salpingo-oophorectomy is firmly recommended, several separate questions can be raised to address the variety of intense controversy of this approach. A special emphasis lies in the effective preventive surgical measure against ovarian cancer risk, in an attempt to detect the optimal timing and mitigate the impact on patients. The long term implications of risk-reducing salpingo-oophorectomy as well as hormone replacement therapy are also actively debated. This is expected to represent an opportunity for improved management modelling of BRCA mutated patients.

Clinical outcomes after resectoscopic treatment of cesarean-induced isthmocele: a prospective case-control study

OBJECTIVE

Isthmocele represents a reservoir on the anterior wall of the uterine isthmus or of the cervical canal at the site of a previous cesarean delivery scar. Recently, it has been clarified that it might be the cause of several gynecologic symptoms, as most common abnormal uterine bleeding. Hysteroscopy and trans-vaginal ultrasound are considered the gold standard for the diagnosis of this defect. Resectoscopic treatment can be considered effective in small size defects, but no randomized clinical trials are available. This is a prospective controlled study to assess feasibility and efficacy of surgical hysteroscopic treatment of cesarean-induced isthmocele on symptom relief.

PATIENTS AND METHODS

Diagnostic hysteroscopy was performed as an office procedure in all 47 patients included in the study to confirm and identify the size of the defect. Surgical hysteroscopic treatment was performed in a selected group of patients (n = 23) having no more desire to conceive. Outcomes were measured three months later and compared in the operative hysteroscopy versus diagnostic hysteroscopy group.

RESULTS

The duration of periods shortened significantly (p = 0.0003) compared with the duration of menses before operative hysteroscopy in the treated group. Moreover, symptom relief was significantly better in treated patients compared with controls (p < 0.0001).

CONCLUSIONS

Resectoscopic treatment of isthmocele offers the possibility of an effective, safe and well-tolerated resolution of associated bleeding symptoms, having an excellent impact on the length of menses. To our knowledge, this is the first prospective controlled trial demonstrating better outcomes of resectoscopic treatment of isthmocele in solving symptoms compared with expectant management.

D-mannose: a promising support for acute urinary tract infections in women. A pilot study

OBJECTIVE

Urinary tract infections still represent a significant bother for women and result in high costs to the health system. D-mannose is a simple sugar; it seems able to hinder bacteria adhesion to the urothelium. The present study aimed to determine whether D-mannose alone is effective in treating acute urinary tract infections in women and its possible utility in the management of recurrences.

PATIENTS AND METHODS

This is a pilot study, performed between April 2014 and July 2015 at Department of Gynaecological Obstetrics and Urologic Sciences of "Sapienza" University of Rome. A D-mannose compound was administered twice daily for 3 days and then once a day for 10 days. Changes in patients' symptoms, the therapeutic effects and changes in quality of life (QoL) were evaluated clinically and using a specifically validated questionnaire (UTISA). After described treatment, patients were randomized in receiving or not prophylaxis in the next 6 months.

RESULTS

Mean UTISA scores recorded after completing the treatment, compared with baseline scores, showed a significant improvement of the majority of symptoms (p < 0.05). D-mannose seemed to have had a significant positive effect on UTIs' resolution and QoL improvement (p = 0.0001). As prophylactic agent administered for 6 months, it showed promising results (4.5% vs. 33.3% recurrences in treated and untreated patients respectively).

CONCLUSIONS

The results of this study suggest that D-mannose can be an effective aid in acute cystitis management and also a successful prophylactic agent in a selected population; however, more studies will certainly be needed to confirm the results of our pilot study.

The impact of chorionicity and type of conception on maternal-neonatal outcome in twin pregnancies

PURPOSE OF INVESTIGATION

To evaluate the maternal and neonatal outcomes in twin pregnancies according to chorionicity (monochorionic (MC) versus dichorionic (DC) and type of conception [spontaneously conceived (SC) versus assisted reproduction technology (ART)].

MATERIALS AND METHODS

A retrospective study of 196 twin pregnancies admitted to the Department of Gynecology, Obstetrics and Urology of the University of Rome Sapienza, from January 2008 to April 2013.

RESULTS

There were 55 MC and 141 DC twin pregnancies (82 SC and 59 ART). MC twin pregnancies had a higher incidence of preterm birth (p < 0.008), twin-twin transfusion syndrome (TTTS) (p < 0.021), and intrauterine growth restriction (IUGR) (p < 0.05). MC pregnancies had lower neonatal birth weight (p < 0.05), and lower Apgar score. ART DC pregnancies had a higher incidence of preterm delivery (p < 0.05).

CONCLUSIONS

MC twin pregnancy is associated with higher risk of adverse maternal and perinatal outcomes. In the DC subgroup, ART is associated to a higher incidence of preterm delivery.

Erythropoiesis-stimulating agents in gynecological malignancies: A study-level meta-analysis

This meta-analysis was planned to define the role of erythropoiesis-stimulating agents (ESAs) in gynecological cancer patients, receiving myelosuppressive treatment. Pubmed, Medline and Scopus were searched to select English-language articles. Only randomized controlled trials (RCTs) were included. Endpoints were incidence of transfusions, thrombotic events (TE), deaths, and failures. Odd ratio (OR) with 95% confidence interval (CI) was calculated using fixed or random effects model. In seven RCTs ESAs studies of 892 patients under treatment, use of ESAs correlates with a significant reduction of transfusions rate (OR=0.35; 95% CI: 0.19-0.65; p=0.008). OR for overall mortality was 1.10 (95% CI 0.82-1.49; p=0.53). ESAs OR for disease failure in 5 studies was 1.71 (95% CI: 0.90-3.24; p=0.1). This meta-analysis, even if limited by few RCTs, suggests that ESAs reduce transfusions without increasing mortality or disease progression in gynecological cancer patients receiving treatment.

Tyrosine-kinases inhibitors in recurrent platinum-resistant ovarian cancer patients

For many decades, ovarian cancer (OC) has been one of the most common gynecological cancer. Despite advances in OC diagnosis and treatment, the risk of recurrence is ever present and approximately 85% of patients will experience relapse. Recurrent OC after first-line therapy is almost always incurable. Multiple novel therapies, including tyrosine-kinases inhibitors (TKI), have shown promising results, but their role needs to be clarified. In this review we describe the rationale and the clinical evidence regarding the use of TKI for the treatment of recurrent platinum-resistant OC patients.

PARP inhibition: A promising therapeutic target in ovarian cancer

Ovarian cancer is burdened by the highest mortality rate among gynecological cancers. Gold standard is represented by the association of platinum-taxane -based chemotherapy and radical surgery. Despite several adjustments occurred in cytotoxic drug in last decades, most patients continue to relapse, and no significant enhancement has been reached in the overall survival. The development of drug resistance and the recurrence of disease have prompted the investigations of other targets that can be used in the treatment of ovarian cancers. Among such targets, polyadenosine diphosphate-ribose polymerase (PARP) represents a novel way to target specific patways involved in tumor growth. PARP accelerates the reaction of the polyADP-ribosylation of proteins implicated in DNA repair. PARP inhibitors have shown activity in cancers with BRCA mutations, with other deficient DNA repair genes or signaling pathways that modulate DNA repair, or in association with DNA damaging agents not involved in DNA repair dysfunction. A number of inhibitors for PARP has been developed, and such drugs are under investigation in clinical trials to identify their impact in the treatment of ovarian cancers. This review aims to summarize the recent researches and clinical progress on PARP inhibitors as novel target agents in ovarian cancer.

Management of hydrosalpinx before IVF: a literature review

Hydrosalpinx has a detrimental effect on the outcome of in vitro fertilization (IVF). Surgical intervention such as salpingectomy or tubal occlusion before IVF improves the outcome of IVF, but these procedures are often contraindicated in women with dense pelvic adhesions. Thus, it is worthwhile to search minimally invasive alternative therapies. The main objective of this review is to assess and compare the value of all the therapeutic options for hydrosalpinx before IVF. The results of the following procedures were compared: the laparoscopic treatments (salpingectomy/proximal tubal occlusion), the hysteroscopic insertion of device achieving tubal occlusion, the tuberous sclerosis and the aspiration of hydrosalpingeal fluid at the time of IVF procedure. Laparoscopic surgical treatment should be considered for all women with hydrosalpinx before IVF. Whenever laparoscopy is not recommended, hysteroscopic insertion of device seems the most effective option for management of hydrosalpinx before IVF.

[Tubo-peritoneal factor of infertility: diagnosis and treatment]

Infertility, defined as the inability to conceive despite regular unprotected sexual intercourse over 12 years, affects approximately 10% of the fertile population. The commonest cause of tubal damage is pelvic inflammatory disease (PID), which in the developed world is caused mainly by Chlamydia trachomatis infection. The incidence of tubal damage after one episode of pelvic infection is approximately 12%, 23% after two episodes and 54% after three episodes. Other causes of tubal damage include postsurgical adhesions or endometriosis. Tubal patency can be diagnosed by hysterosalpingography (HSG) or laparoscopy with chromopertubation. Surgery represents the best therapeutic approach for tubal pathology, with a term pregnancy rate of 70% after surgery in selected patients, while the latest results in Italy of assisted reproductive technology (ART) report a live birth rate per cycle of 13.8%. In conclusion, tubal reconstructive surgery remains an important option for many couples and surgery should be the fi rst line approach for a correct diagnosis and treatment of tubal infertility.

[Prevention of postoperative adhesions]

Postoperative adhesions represent a common consequence in patients who underwent abdominal or pelvic surgery. Such adhesions can be asymptomatic, but they can cause complications such as chronic abdomino-pelvic pain, secondary infertility, an increase in bowel obstruction risk and more complexity for future surgery, including longer surgery times and an increase in morbidity. Normally, adhesions appear after offences against the peritoneum, causing flogosys, and develop both in new sites, previously not involved, and in sites already interested in adhesiolysis. Previous laparotomy is an important risk factor, as after laparatomy a minimum of 93% of patients present adhesions during a following surgery. Furthermore, the rate of recurrence after adhesiolysis is 85%. Among several strategies employed, valid prevention methods are: using minimally invasive surgery techniques, reducing the incision area, containing tissue dehydration during surgery and an accurate hemostasis. Also, for preventing and reducing adhesions, the usage of NSAIDs, fibrinolytics and anticoagulants, as well as the application of substances acting as a physical barrier, have been proposed. Recently, crystalloid solutions have been introduced, using the hydro-flotation principle for intraperitoneal organs. This research aims to analyze causes and epidemiology for postoperative adhesions, with particular regard to gynecological operations and to describe and compare the means available to prevent them.

[The role of laparoscopy in ovarian carcinoma]

The role of minimally invasive surgery in the management of gynecologic cancers is continuously expanding. Although few trials have focused on the safety of laparoscopy in oncology, laparoscopy is now widely used for most gynecological malignancies. Laparoscopy is widely used to manage benign ovarian masses, but its role in managing ovarian cancer still needs to be defined. The role of laparoscopy in ovarian cancer surgery may be divided into three following categories: 1) laparoscopic staging of apparent early ovarian cancer; 2) laparoscopic assessment of disease extent and potential for resectability; 3) laparoscopic reassessment, or second-look operation, or rule out recurrence. Laparoscopic approach has shown several advantages like a reduction in operating time, blood loss, hospital stay, and total hospital charges. The limitations of laparoscopic practice include inadequate port-site metastasis, tumour dissemination due to cyst rupture and incomplete staging. In addition, there were limitations in performing extensive laparoscopic sampling of areas of tumor persistence including retroperitoneal lymph nodes. In literature there are no randomized studies assessing the use of laparoscopy in the management of ovarian cancer. Moreover, most of the studies in literature comparing laparoscopy and laparotomy are carried out by surgeons specialized in one of two approaches, so that the results can not be compared.

[Cognitive research about the use of virtual worlds among the students enrolled to the faculty of medicine and surgery "Campus Bio-Medico University" in Rome]

BACKGROUND AND AIMS

The main difference between a virtual reality and a generic representation is to be directly involved into the action you are performing. As a matter of fact, within the shift from real to virtual world, our biological physique does not mutate but is amplified and connected to the virtual world by technological interfaces. Training using a virtual reality simulator is an option to supplement (or replace) standard training. One of the two main goals of our study is to test, at first, how much students enrolled to the Faculty of Medicine at "University Campus Bio-Medico of Rome" are familiar with synthetic worlds, how long they have been using them and how they would like their Avatar to look like. Moreover, the second aim is to collect students' opinion about the use of virtual, interactive environments to enable learning and participation in dynamic, problem based, clinical, virtual simulations. Simulations might be used to allow learners to make mistakes safely in lieu of real life situations, learn from those mistakes and ultimately to improve performances by subsequent avoidance of those mistakes.

MATERIALS AND METHODS

The selected approach to the study is based on a semi-structured questionnaire made of 14 questions administered to all the medical students.

RESULTS

Most of the students appear not to be very confident with virtual worlds mostly because of a lack of interest. However, a large majority of them are likely to use a virtual world for fun or escaping from reality. Students would select and customize their Avatar by giving her/him the same sexual identity, same figure, same social class but different employment.

CONCLUSIONS

It is important to notice that a wide majority of the students is interested in practicing on a virtual world in order to manage new experiences and being able to face them; their willing is to get benefits from the ability to make mistakes in a safe environment as well as to record a positive impact on their understanding.

[Use of bulking agents in urinary incontinece]

Urinary incontinence consist in voluntary urine leakage. Female affected in the world are about 200 thousand. Urinary incontinence affect severely women quality of life. There are different kinds of urinary incontinence that can be treated in different ways. We can use pelvic floor rehabilitation, drug therapy, invasive and non-invasive surgical treatment. Different treatments are used for different incontinence types. Periurethral injection is the most common procedure between non-invasive surgery. The most recent bulking agents occasionally determine severe adverse reaction or complication. Frequently we can have just pain during injection and a temporary urine retention. During the latest years we used a lot of bulking agents: bovine collagen, autologous fat, carbon particles, macroplastique, calcium hydroxylapatite, ethylene vinyl alcohol copolymer, dextranomer. Urethral injection have success in 40-90%. We can assert that macroplastique is the most efficacy and safe on the basis of literature data and of our experience data. This surgical procedure, in fact, has good percentage of success in accurately selected patients. In our experience Macroplastique can also be used in oncological patients, in elderly women, in patients with important comorbidity and with high surgical risk with good objective and subjective results.

Hemoglobin variation and blood transfusion rates in patients affected by locally advanced cervical cancer undergoing neo-adjuvant chemotherapy followed by radical surgery: the role of erythropoietic growth factors

BACKGROUND

The objectives of the present study were to evaluate hemoglobin levels and consequent clinical behaviors related to anemia developed in patients affected by locally advanced cervical cancer treated with neo-adjuvant chemotherapy in the last decade and to evaluate the impact that the introduction of erythropoietic growth factors had in the clinical practice.

PATIENTS AND METHODS

Blood chemistries, prospectively recorded from 98 cervical cancer patients, treated with neo-adjuvant chemotherapy and, if necessary, erythropoietic growth factors, were compared with matched historical controls before the introduction of growth factors in clinical practice.

RESULTS

Hemoglobin level in the study group did not differ significantly during chemotherapy. At the third cycle of chemotherapy and at the end of chemotherapy, hemoglobin level was significantly higher in the study group compared with the control group. Transfusion rates in the study group were significantly lower. The analysis within the study group revealed that hemoglobin level in patients who suffer at diagnosis from anemia tends to increase whereas hemoglobin level in nonanemic patients tends to decrease.

CONCLUSIONS

Erythropoietic growth factors increase hemoglobin level and reduce blood transfusions in cervical cancer patients undergoing neo-adjuvant chemotherapy followed by radical surgery. An appropriate autologous blood donation program can noticeably reduce homologous blood transfusions.

[Laparoscopic treatment of adnexal cystic masses]

Operative laparoscopy has become the gold standard for the surgical treatment of numerous gynecological benign conditions. In the case of ovarian cysts, however, the use of the laparoscopic approach has been debated due to the possibility of encountering an unexpected ovarian malignancy at the time of surgery. This would upstage a IA or IB ovarian malignancy to IC. In this review, the authors evaluate the preoperative parameters that could help in the selection of the patients who are candidate to a laparoscopic approach. In particular, the authors consider the age related risk of the patients, the use of sonography and color-Doppler velocimetry, the use of CA 125, and as a last diagnostic step, the findings at laparoscopy. In a personal series of 1.584 cysts in patients under 40 years of age, the first author encountered 7 unexpected borderline tumors and 1 mucinous G1 adenocarcinoma, while no malignancy was found in a group of strictly selected postmenopausal patients. These data have been compared with those found in scientific literature. There is no sound evidence that the stripping procedure determines a reduction of the ovarian reserve when performed with strict microsurgical principles. Recent evidence in the literature suggests that the decreased ovarian responsiveness reported by some authors following ovarian cystectomy may not be a consequence of surgery. The concern of a possible reduction of the ovarian reserve needs to be balanced with the benefits obtained with surgery. Finally, it should always be kept in mind the risk of an unexpected malignancy, even in cysts apparently benign, malignancy that can only be diagnosed through surgery obtaining a specimen for pathology.

The role of neoadjuvant chemotherapy followed by radical surgery in the treatment of locally advanced cervical cancer

In 1984 the first pilot study on neoadjuvant chemotherapy in cervical cancer was reported. Since then, many investigators have studied the possible role that this therapeutic strategy could achieve in patients. Different chemotherapic combinations are constantly being attempted in order to obtain the maximum tumour response. At the same time few randomised studies have demonstrated the superiority of this treatment when adopted before radical surgery, in terms of overall survival compared to radiotherapy alone. Recently a detailed meta-analysis has been performed and the results confirmed what previously was achieved by the randomised trials. Since the beginning of all the phase III trials, the standard treatment of locally advanced disease has been modified from radiotherapy alone to concomitant radio-chemotherapy. For this reason the EORTC group has launched a trial with the objective of comparing neoadjuvant chemotherapy followed by radical surgery versus concomitant chemo-radiotherapy.