The endogenous oxytocin after manipulative osteopathic treatment in full-term pregnant women

OBJECTIVE

The aim of this study is to assess whether the touch of osteopathic manipulative treatment (OMT) can affect the endogenous production of oxytocin in full-term pregnant women and the assessment of well-being following the treatment.

PATIENTS AND METHODS

In this study have been enrolled 57 pregnant women at full-term pregnancy (37th-41st week) for evaluation of the concentration of salivary oxytocin 2 minutes before and 2 minutes after a single session of OMT by an osteopath lasting for 30 minutes. Pre-OMT and post-OMT saliva samples were collected with the use of Salivette® salivary swabs. 7 salivary swabs were excluded from the analysis. 50 samples were analyzed with an appropriate ELISA kit.

RESULTS

The mean OT salivary concentration pre-OMT was 89.98±16.39, and post-OMT was 100.60±19.13 tends to increase with p=0.0000051. In multivariate analysis, two subgroups show interesting data in the mean difference in OT salivary concentration post-OMT: women with painful contractions (p=0.06) and women under 35 years (p=0.09).

CONCLUSIONS

The results of this study demonstrate that the effectiveness of OMT-increasing endogenous oxytocin is statistically significant in full-term pregnant women. The sensation of well-being found in most women indicates that there has been a predominantly central rather than peripheral oxytocin release after OMT.

The role of peritoneal lavage in benign gynecologic laparoscopic surgery

OBJECTIVE

Laparoscopic surgery offers many advantages compared to invasive surgery but one of the main problems is postoperative pain, partially resulting from the peritoneal inflammatory process mediated by inflammatory cytokines. The rationale of this study is that intraperitoneal washing could remove inflammatory mediators that are the cause of postoperative pain and could help in the removal of CO2 from the abdominal cavity. This article aims to analyze the effects of peritoneal lavage in the reduction of postoperative shoulder pain.

PATIENTS AND METHODS

277 patients enrolled to undergo laparoscopic gynecologic surgery were included in the study. Women are randomized into two groups, according to the use or non-use of peritoneal lavage with saline solution at the end of laparoscopic gynecological major procedures.

RESULTS

Data show that the peritoneal lavage can significantly reduce postoperative pain in the first 36 hours after surgery, as well as patients' requests for analgesics: during the first 3 postoperative days, requests for paracetamol were lower in the YW (Yes Washing) group than the NW (No Washing) group (77 vs. 101; p<0.05); similar results are obtained considering ketorolac administration (62 vs. 71; p<0.05).

CONCLUSIONS

Peritoneal lavage after gynecological laparoscopic procedures may be effective in the reduction of postoperative pain and use of analgesics.

O-050 Virtual reality applications in ultrasound

Surgical simulation has been introduced in surgical training since 1920 following the example of airline and military industry. Recently, the Association of American Medical Colleges commented on the increased use of simulation in different medical specialties, recognizing its potential ability to improve patients safety and to enhance healthcare in general. Historically, graduating obstetrics and gynecology residents have been expected to learn following the adage ‘see one, do one, teach one’, which required a high volume experience. Nowadays, as the complexity of procedures increases and surgical volume decreases, in order to acquire surgical skills rapidly there is the need to integrate surgical and ultrasound virtual simulation into modern residency training alongside traditional teaching methods. In addition, recent changes in the field (e.g. workhours restrictions, decreased bedside teaching) have high lightened these necessities.

Ultrasonography is a skill that requires a complex interplay of motor skills and visual-cognitive skill. The learning process include two steps: an initial global assessment followed by a focal search for pathology and key landmarks. Recently more attention has been paid to design increasingly sophisticated simulators for ultrasound in obstetrics and gynecology. These are broadly divided into to major categories: physical mannequins and virtual reality simulators. The physical mannequins practically consist in low cost silicon dummies that enable learners to discover basic anatomical and pathological findings using real ultrasound equipment. This type of simulators allows the trainees to learn haw to use the equipment in order to obtain proper scans. However, the case complexity is limited due to the low fidelity of the physical mannequins. In addition there is no automated feedback and a supervisor is always needed during the practice.

The virtual reality simulators usually rely on haptic devices or physical mannequins that record probe movements during transabdominal or transvaginal scans and combined them with computer-animated/real ultrasound images. Instructions and automated feedback are provided during the practice. They often contains multiple cases allowing the trainees to be exposed to different clinical scenarios.

In the field of Reproductive Endocrinology and Infertility some ultrasound and surgical skills are required for independent practice including transvaginal oocyte pick-up, hysterosalpingocontrastsonography (HyCoSy) and embryo-transfer. Considering advantages and disadvantages of both apprenticeship models (traditional training and simulator-based training), a blended approach which combines simulator-based training with didactic and more traditional training on real patients could be introduced. So far the use of simulation-based training has shown promising results in terms of moderate effects on patient outcomes and large effects on trainee behavior in the clinical setting. It could be useful especially in the initial part of a structured training for novices, enabling them to acquire basic skills and to reach a predefined level of performance in a safe and controlled environment, before applying the procedure to real patients.

Impact of a new carrageenan-based vaginal microbicide in a female population with genital HPV-infection: first experimental results

OBJECTIVE

The objective of this study was to assess safety, satisfaction, and anti-viral effect of a new carrageenan-based vaginal microbicide in a population of fertile female patients with genital human papillomavirus (HPV) infection.

PATIENTS AND METHODS

Forty healthy and sexually active women aged 18-45 years with genital HPV infection were enrolled. Each subject was treated with a gel formulated with 0.02% carrageenan and Propionibacterium extract (CGP) (Carvir, Depofarma SpA, Mogliano Veneto, Treviso, Italy). The subjects were evaluated at baseline, after the I cycle of therapy and after the II cycle. At final status, treatment acceptability and satisfaction were evaluated using a 5-point Likert scale. Furthermore, the rate of HPV genital infection clearance at final follow-up was evaluated. These data were compared with the HPV genital infection clearance rate in a control group of patients not subjected to any therapy.

RESULTS

Overall, 68 HPV infections were detected at baseline, among 40 subjects enrolled. The HPV 16 genotype was the most frequent (12%) followed by HPV 18 (10%), and HPV 53 (9%). At the end of the study, 22 (55%) patients were very satisfied, 14 (35%) were satisfied, 3 (7.5%) were uncertain, and only 1 (2.5%) was dissatisfied, with 0 very dissatisfied. Only 2 patients complained of a local adverse event. Analysing infection clearance at the end of the study, 60% of patients became HPV negative. Among these, 13 cases were high-risk HPV infection. There were 16 patients with persistent infection ("non-responders"). No patient developed a "de novo" genital lesion. After controlling for age, the intervention had an adjusted OR of 4.9 (95% CI 1.6-15.1) to clear HPV.

CONCLUSIONS

The results of this work suggest that Carvir vulvovaginal microbicide gel is safe and well-tolerated. Furthermore, this experience supports the hypothesis that CG has a role in accelerating the normal clearance of genital HPV infection in women with a positive HPV-DNA test.

Surgery and out-patient data collection and reporting using Filemaker Pro

OBJECTIVE

The application of an electronic database in clinical practice is used widespread in every field of medicine. The aim of the present study is to illustrate our experience to use a database software for documentation of two of our clinical activities, outpatient hysteroscopy and inpatient gynaecological surgery.

PATIENTS AND METHODS

In 2004, we designed two databases, the first one to document surgical procedures in the operating theatre, the second to document outpatient hysteroscopy procedures using FileMaker v.8.5. The data entry interface contains free text fields for patient demographic data and the description of the surgical procedure, supplemented by drop-down lists for items such as clinical findings, procedures, instrumentation, technique, and complications. Copies were filed in the main hospital notes, sent to General Practitioners, and also given to our patients.

RESULTS

Since August 2004, we have used our two databases to document 2766 gynaecological operations and 3777 outpatient hysteroscopies. All users particularly liked the dropdown lists as their use greatly reduced the time taken to enter each patient's data. The databases were regularly used to select patients for audit projects and research data collection for prospective studies.

CONCLUSIONS

FileMaker is an user-friendly and easily configured software, extremely valuable in everyday clinical work.

Non-steroidal anti-inflammatory drugs increase MRP4 expression in an endometriotic epithelial cell line in a PPARa dependent manner

OBJECTIVE

Endometriosis is a debilitating disease characterized by chronic inflammation. The transporter multidrug resistance-associated protein 4 (MRP4/ABCC4) is expressed in human endometrial tissue; it is overexpressed in ectopic endometrial tissue, and is modulated by the anti-inflammatory lipid Lipoxin A4 (LXA4). Recently, it was demonstrated that aspirin induces platelet MRP4 over-expression, through genomic modulation in megakaryocytes. Since patients with endometriosis frequently use aspirin or other non-aspirin Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), the aim of this study was to verify whether aspirin and other NSAIDs enhance MRP4 expression in 12Z human endometriotic epithelial cells and whether this was peroxisome proliferator-activated receptor alpha (PPARa) dependent.

MATERIALS AND METHODS

MRP4 and PPARa expression was analyzed by Q-RT-PCR using TaqMan® Master Mix and TaqMan® Assay Reagents (Life Technologies, Monza, Italy) and Western blot.

RESULTS

In 12Z cells, aspirin and other NSAIDs enhanced MRP4 mRNA and protein expression; these treatments also induced PPARa expression. Aspirin and diclofenac-induced increases in MRP4 expression were not observed in cells where PPARa was knocked down using siRNA. NSAIDs-induced MRP4 expression was correlated with augmented PGE2 secretion, indicating functional relevance.

CONCLUSIONS

MRP4 expression was increased in cells treated with NSAIDs and the nuclear receptor PPARa is involved. Elevated PGE2 levels in cell supernatants correlate with its increased transport by MRP4 after NSAID treatment. More importantly, we provide evidence that in endometriotic epithelial cells aspirin and non-aspirin NSAIDs treatments alter gene expression.

Preterm birth: incidence, risk factors and second trimester cervical length in a single center population. A two-year retrospective study

OBJECTIVE

To report the incidence and the major risk factors (RFs) associated with preterm birth (PTB), combining both maternal RFs and cervical length (CL), and to understand if cervical length measurement is really useful in all the patients.

PATIENTS AND METHODS

The study population consisted of 2048 women admitted to the Department of Obstetrics and Gynecology, University Hospital of Messina, over a 2-year period. Preterm cases represented approximately 8.64% of our total population and, exactly, 65% were late preterm, 32% were preterm, and 3% were extremely preterm.

RESULTS

An analysis of PTB sub-categories based on gestational age showed a stronger correlation between gestational age and CL among preterm and extremely preterm, while no correlation was found among late preterm. Between preterm cases and controls, there was a significant difference in pre-pregnancy weight and Body Mass Index (BMI). Moreover, a significant association between PTB and uterine anomalies, poli-oligodramnios and hypertension was found.

CONCLUSIONS

We strongly suggest adding a transvaginal ultrasound CL universal screening to all pregnant women at the time of the second trimester ultrasound. We encourage further studies to identify new RFs of PTB and to define the mechanisms by which risk factors are related to PTB.

High progesterone levels during the luteal phase related to the use of an aromatase inhibitor in breast cancer patients

OBJECTIVE

To evaluate the hormonal profile in three breast cancer patients who underwent controlled ovarian stimulation in the presence of the aromatase inhibitor letrozole.

PATIENTS AND METHODS

In IVF University referral center, a case series of three breast cancer patients who underwent controlled ovarian stimulation (COS) with recombinant FSH and letrozole were investigated. Ovulation was induced with hCG (case No. 1) or with GnRH agonist (case No. 2-3). The primary outcome of our study was the detection of progesterone levels in the luteal phase.

RESULTS

Very high progesterone values (mean 186.6 ± 43.6 ng/mL) during the luteal phase were recorded in all three cases.

CONCLUSIONS

High progesterone levels can be related to the use of letrozole independently of the most commonly used trigger regimen. Although progesterone has long been considered a protective factor against breast cancer, several studies have demonstrated that progesterone could expand a transformation-sensitive stem cell population in the mammary glands. The estrogen negative feedback effect on the hypothalamus-pituitary axis and the disruption of steroid biosynthesis and could represent an intriguing reason behind this phenomenon. Our results highlight the need to evaluate further the increase in progesterone levels in the luteal phase in women with breast cancer undergoing COS with letrozole.

Occiput-spine relationship: shoulders are more important than head

OBJECTIVE

To understand the role of fetal spine position in determining a fetal head position at the time of birth and modality of delivery.

PATIENTS AND METHODS

This was a multicenter prospective observational study. Fetal occiput and spine position were evaluated by intrapartum ultrasound. Eighty-six women were eligible for inclusion in the study. Occiput rotational movements and modality of delivery in relation to the fetal spine position were investigated.

RESULTS

At the beginning of labor, fetal occiput was in a posterior position in 52.3% of cases and, in 81.5% of cases the spine was in an anterior transverse position. At birth, occiput and spine were both in an anterior position in 90.4% of cases. The rate of cesarean sections in the SP group was significantly higher than the rate in the SAT group (50% vs. 8%, p < 0.0007). Instead, the rate of vaginal deliveries without intervention in the SP group was significantly lower than the rate in the SA group (14% vs. 71%, p < 0.0001).

CONCLUSIONS

Fetal spine position could have an important role in determining fetal occiput position at birth. Spine position might play a crucial role in the outcome of delivery.

The efficacy of modified luteal phase support with intramuscular progesterone in IVF/ICSI cycles: a retrospective observational study

OBJECTIVE

The use of gonadotropin-releasing hormone agonist for ovulation triggering has become an intriguing topic in the last few years. As long as adequate luteal phase support is provided, it may be a valuable alternative to standard hCG triggering, associated with a significant reduction in OHSS incidence. Several luteal phase support options have been proposed, but few studies have addressed the issue of the appropriate route for progesterone administration to women triggered with GnRHa. The aim of the study was to evaluate the effect of GnRHa triggering on IVF/ICSI outcomes, using modified luteal phase support with intramuscular progesterone.

PATIENTS AND METHODS

A retrospective study was carried out between January 2014 and December 2015, comparing the reproductive outcome in GnRHa triggered women given modified luteal phase support with intramuscular progesterone (Group A) with the outcome in women triggered with standard hCG (Group B) in IVF/ICSI cycles.

RESULTS

200 (Group A n = 100; Group B n = 100) consecutive normoresponder women were included. No differences with respect to Age, BMI, basal FSH, basal Estradiol and infertility diagnosis were observed between groups. Increased numbers of retrieved oocytes (8.1 ± 3.3 versus 6.8 ± 3.5, p = 0.009) and mature oocytes (5.8 ± 2.6 versus 5.1 ± 2.7, p = 0.03) were detected in Group A compared with Group B. Implantation, biochemical pregnancy and ongoing pregnancy rates were similar.

CONCLUSIONS

Our findings confirmed that the GnRHa triggering strategy is associated with increased number of oocytes retrieved and of mature oocytes even in normoresponder women. Moreover, in these patients, the use of intramuscular progesterone during luteal phase support achieved satisfactory IVF outcomes.

Is vaginal fractional CO2 laser treatment effective in improving overactive bladder symptoms in post-menopausal patients? Preliminary results

OBJECTIVE

To evaluate the role of vaginal fractional CO2 laser treatment in the relief of Overactive Bladder (OAB) symptoms in post-menopausal women.

PATIENTS AND METHODS

Post-menopausal women who complained of one or more symptoms related to vulvo-vaginal atrophy (VVA), who experienced symptoms of OAB and who underwent vaginal treatment with fractional CO2 laser were enrolled in the study. At baseline (T0) and 30 days post-treatment T1), vaginal status (using Vaginal Health Index - VHI), subjective intensity of VVA symptoms (using a visual analog scale - VAS) and micturition diary were evaluated. OAB symptoms were also assessed using a validated questionnaire.

RESULTS

Thirty patients were enrolled. A statistically significant improvement in VVA symptoms was observed and in VHI at T1 (p < 0.0001). A significant improvement was also identified in the micturition diary, in number of urge episodes and OAB-q (p < 0.0001). Nine of the 30 patients suffered from incontinence episodes and had improved at T1.

CONCLUSIONS

We showed that fractionated CO2 laser vaginal treatment has proved to be effective in improving OAB symptoms in post-menopausal women. Moreover, it is a safe and efficacious measure for the relief of VVA related conditions. Further long-term studies are needed to confirm these preliminary results.

Laparoscopic versus laparotomic surgery for adnexal masses: role in elderly

BACKGROUND

The purpose of this study is to compare laparoscopy (LPS) and laparotomy (LPT), in terms of surgical outcomes, in elderly patients (>65 years) with adnexal masses.

METHODS

We retrospectively reviewed a series of women older than 65 who had a diagnosis of adnexal masses. Then, all patients were divided into two different groups according to the type of surgery: 27 who underwent LPS (LPS group) and 24 who underwent LPT (LPT group). We took into consideration: age, comorbidity, histological diagnosis, surgery approach, and surgical outcome. Then, we calculated the percentages of all of these data and then χ (2) test and t-Student test were used to calculate the p value, to compare the two surgical techniques. A p value lower than 0.05 was considered to be statistically significant.

RESULTS

At first, we evaluated the relation between the diagnosis and the surgery approach, and we obtained statistically significant results for serous cyst, adenocarcinoma serous/mucinous, and others, and the table highlights that some of the benign masses were mostly treated with LPS, while borderline and malignant masses were treated with LPT. Then, we evaluated the comorbidities of the patients, and we found that those cases had a significantly higher prevalence of cardiovascular disease and metabolic diseases. Finally, we compared the surgery outcome of LPS versus LPT surgeries for adnexal masses in elderly women, and there were statistically significant results for postoperative complications, number of patients who needed drainage, and number of days of hospitalization after surgery.

CONCLUSIONS

Our results demonstrated that the patients who underwent LPS, compared to the patients who underwent LPT, have better outcomes in terms of postoperative complications (7.4 % with LPS and 37 % with LPT), number of patients who needed drainage (11.1 % with LPS and 62.5 % with LPT), and number of days of hospitalization after surgery, in term of mean (5 for LPS and 10.9 in term of LPT).

Myoma migration: an unexpected "effect" with Ulipristal acetate treatment

OBJECTIVE

Uterine myomas are one of the most common benign tumours, occurring in 20-40% of women of reproductive age. Ulipristal acetate (UPA) is a possible option for medical treatment of myomas. It induces amenorrhea and can reduce myoma volume before surgical treatment. Since its introduction in our department, we uncovered an unknown effect: migration of myoma.

CLINICAL CASE REPORTS

We describe three clinical case of myoma migration following three months UPA pre-operative treatment. The first woman presented with a FIGO 2 myoma, which migrated in FIGO 3. A previously planned hysteroscopy converted into a laparoscopy. The second woman also presented with a FIGO 2 myoma, which migrated in FIGO 3. Initially, a hysteroscopy was planned, but ultimately surgery was no longer required. The third woman presented with a FIGO 2-5 myoma, which migrated in FIGO 1. The previously planned laparoscopy converted into a vaginal myomectomy.

CONCLUSIONS

UPA induces a proapoptotic and anti proliferative effect of leiomyoma cells. It reduces expression of VEGF and reduces collagen deposition in the extracellular matrix. These mechanisms could induce migration of myoma. UPA as pre-operative treatment can induce migration of myoma and, therefore, can lead to perioperative conversion of surgery.

Ulipristal acetate prior to in vitro fertilization in a female patient affected by uterine fibroids: a case report

OBJECTIVE

Uterine leiomyomatosis and especially submucosal myomas hamper the outcomes of Assisted Reproductive Techniques (ART). Even though surgical treatment eliminates gross anatomical anomalies, medical treatment should be encouraged to improve the overall structure of the uterus, thereby enabling ART.

CASE PRESENTATION

We report the case of an infertile female patient suffering from symptomatic uterine fibromatosis, who received 5 mg/day ulipristal acetate (UPA), a selective progesterone receptor modulator (SPRMs), for three months before and after hysteroscopic myomectomy. Uterine bleeding reduced on the eight days of treatment, with a subsequent improvement of pelvic pain. Under transvaginal ultrasound the uterus appeared globally enlarged with a diffuse leiomyomatosis of the myometrial layer. Saline infusion showed a markedly distorted cavity due two submucosal myomas (sized 31 × 24 mm and 21 × 19 mm, respectively) and one intramural myoma (37 × 34 mm). After three months the size of the myomas was reduced by 30-40%, allowing the hysteroscopic removal of the submucosal fibroids and the bigger intramural one. The smaller fibroids involving the myometrial layer were instead too diffused to be removed. At the conclusion of the subsequent cycle of UPA, the overall appearance of the cavity had improved, and the endometrial layer was regular, allowing the patient to undergo in vitro fertilization (IVF). There was no adverse effect related to treatment, and the endometrial biopsy did not reveal any histologic change.

CONCLUSIONS

UPA seems to have a triple effect: it ensures prompt symptom relief, it reduces the size of the myomas enabling surgery and it improves the morphology of the uterus.

Analysis of persistence of human papillomavirus infection in men evaluated by sampling multiple genital sites

OBJECTIVE

Although human papillomavirus (HPV) infection has been studied extensively in women, data on male infection are limited. The purpose of this study was to investigate persistence of HPV infection at multiple genital sites in men and to define potential associations with socio-behavioural characteristics.

PATIENTS AND METHODS

Penile, urethral and seminal specimens were tested by the INNO-LiPA HPV system (Innogenetics) and a PCR assay. Persistence was defined as the detection of same HPV type at ≥ 2 consecutive visits. The Kaplan-Meier method and the log-rank test were applied to estimate the likelihood of persistence.

RESULTS

A total of 50 men (median age: 33 years) were followed for a median of 14.7 months. Altogether, 49%, 36%, 26% and 11% of baseline HPV-positive men had 6-, 12-, 18- and 24-month persistent infection with any HPV type, respectively. The 6-, 12- and 18- month persistence was more common for oncogenic HPV infections; 24-month persistence was similar. The median duration of persistence was 21.7 months for any HPV. The median duration of persistence for any HPV type was significantly longer in the penile sample (22.5 months, 95% CI: 18.3-26.7) than the semen sample (15.3 months, 95% CI: 14.5-16.1).

CONCLUSIONS

Over a third of type-specific HPV infections in men remained persistent over a 24-month period. The median duration of HPV infection was longer in penile samples compared to seminal samples. As being increasing the attention of HPV vaccination as a potential preventive approach also for men, it is imperative to obtain additional insight on natural history of HPV infection in men, particularly as far as incidence and duration are concerned.

Diagnostic findings in adenomyosis: a pictorial review on the major concerns

Adenomyosis is a benign pathology with a marked impact on women in reproductive age. The prevalence of adenomyosis ranges from 5 to 70%. Dysmenorrhea, metrorrhagia, chronic pelvic pain, dyspareunia and infertility often occur, while a third of the women is asymptomatic. This pictorial review focuses on the peculiar patterns of presentation in adenomyosis. They are identified by means of non-invasive or minimally invasive techniques, with particular reference to 2D- and 3D-transvaginal sonography, sonohysterosalpingography, magnetic resonance imaging, and endoscopic techniques (i.e. hysteroscopy and laparoscopy).

Environment and Endometriosis: a toxic relationship

Endometriosis is a common, benign, estrogen-dependent gynecological disease that represents one of the main causes of hospitalization in industrialized countries. It is well established that a large amount of natural and man-made chemicals are present in the environment and both humans and animals are exposed to them. Dioxin and dioxin-like compounds have long biological half-life, can accumulate within the organism and could negatively affect several physiological processes. The purpose of this review is to provide an overview of the possible relationship between these chemicals and the pathogenesis of endometriosis.

The behaviour of the peripheral natural killer cells in the foetal growth restriction

AIM

To study the behaviour of the peripheral lymphocyte subsets in foetuses affected by growth restriction.

PATIENTS AND METHODS

Thirty consecutive pregnant women with an ultrasound diagnosis of foetal growth restriction were included in this study (group A) while 30 women with a physiologic pregnancy were recruited as control group (group B). The diagnosis was performed during the ultrasound of the third trimester and confirmed at birth. Blood samples were drawn after the ultrasound of the third trimester for all patients. The analyzed populations were: WBC, total lymphocytes, CD2+, CD3+, CD4+, CD5+, CD8+, CD19+, CD56+, HLA-DR+, CD45+, CD3+HLA-DR+, CD4+CD3+, CD3+CD8+, CD2+CD56+, CD19+CD5+, ratio (CD4+CD3+)/(CD3+CD8+).

RESULTS

The percentage and absolute value of the NK cells was higher in the group A [(20.90 vs. 15.09)%, p = 0.0005; (419.55 vs. 341.40) UI/μl, p = 0.0005]. This trend was confirmed by the CD2+CD56+ natural killer (NK) subset [(18.84 vs. 13.42) UI/μl, p = 0.0005]. Instead, the CD4+ percentage value was lower in the group A [(41.15 vs. 44.84)%, p = 0.03] through the CD4+CD3+/CD3+CD8+ ratio was not significantly different.

CONCLUSIONS

Our findings reinforce the concept of pregnancy as a controlled systemic inflammatory state that if altered can have adverse consequences for the mother and the foetus.

Ovarian stimulation in patients in risk of OHSS

Ovarian hyperstimulation syndrome (OHSS) represents an exaggerated response to controlled ovarian stimulation (COS) that in some cases could be life-threatening. Assuming that complete prevention of OHSS is not possible, several strategies could be carried out to reduce the risk and early identification of risk factors represents the first step of a multi-stage process. Some well-established risk factors that could rise the risk of OHSS include young age, polycystic ovary syndrome, prior hyper-response/OHSS. In recent years research has focus on identifying biomarkers/hormonal markers that could represent potential predictors of OHSS (anti-Mullerian hormone and antral follicle count). The possible prevention strategies available for the clinician could be divided into primary and secondary. Primary prevention includes personalized stimulation protocols in order to suit patients' characteristics (individually tailored COS, use of GnRH antagonist stimulation protocols, in vitro maturation). Secondary prevention includes all strategies directed to counteract an excessive ovarian response (cycle cancellation, coasting, trigger ovulation by low doses of hCG or by alternative agents, cryopreservation of oocytes/embryos, adequate luteal phase support). So far, the combined use of a GnRH antagonist protocol with GnRH agonist triggering and oocyte and embryo freezing could not be recommended as a standard preventive measure, but it surely represents a promising one.

Fertility preservation in female cancer patients: an emerging challenge for physicians

Fertility preservation has become an issue of great importance in female cancer patients due to increasing survival rates and delayed childbearing. It is an emerging challenge for physicians, cause of several related issues (multidisciplinary approach, doctor-patient communication, ethical, religious and legal problems) and many unresolved questions. This review aims to update the latest literature data, summarizing the effects of cancer treatments on female fertility and the various options currently available to offer cancer patients the opportunity of future pregnancies. Many strategies exist for fertility preservation in young women and they should be assessed according to the patient's age, type of cancer, partner status and time available. Some techniques are well established, others are still experimental. The established methods include embryo cryopreservation, transposition of ovaries prior to radiation therapy, radiation shielding of gonads and conservative surgical approaches. The experimental methods include oocyte cryopreservation, in vitro maturation of oocytes, ovarian tissue cryopreservation and transplantation, and ovarian suppression. Improvement of these techniques as well as better characterization of their success rates and risks, await further investigation. Oocytes donation and gestational surrogacy represent the last options. Thus, the care of these patients is challenging, complex and requires a multidisciplinary approach. A close collaboration between Oncologists, Specialists in Reproductive Medicine, Gynecologic Oncologists and Endocrinologists is crucial for always offering the best possible option.

Low dose of betamethasone throughout the whole course of pregnancy and fetal growth: a clinical study

AIM

To assess the eventual influence of low dose betamethasone throughout pregnancy on fetal growth.

PATIENTS AND METHODS

320 patients - admitted to the Section of Obstetrics and Gynecology of Ferrara University from January 2005 to December 2010 - were subdivided in two groups: 160 patients affected by recurrent spontaneous abortion (Group A), treated by low dose of betamethasone (0.5 mg/daily) throughout pregnancy for preventive purposes, 160 patients with physiological pregnancy as control group (Group B). Primary measured outcomes were neonatal biometric parameters such as birth weight, head circumference and neonatal length. Unpaired t-test was used to compare the neonatal biometric parameters.

RESULTS

Birth weight, length and circumference head resulted significantly lower in groups treated by GCs. However, excluding bias as pregnancy complicated by diseases, which could affect fetal growth, biometric neonatal parameters were not different between two groups. Furthermore, analyzing the distribution of the value of birth weight we observed that in the group A there were 44 newborns with a weight even higher than fiftieth percentile.

CONCLUSIONS

Betamethasone seems not to influence fetal growth. Our analysis demonstrates that fetal growth is influenced by several factors, therefore, homogeneous study population is essential to have convincing results.

Luteal phase support for assisted reproductive technologies: between past, present and future

The luteal phase is defined as the period between ovulation and either the establishment of a pregnancy or the onset of menses two weeks later. Assisted reproductive technologies (ART), and in particular controlled ovarian stimulation (COS), negatively interfere with the endocrine mechanisms normally regulating the luteal phase. Up to now, there is no generally accepted opinion as to the most appropriate therapeutic schemes for luteal phase support in ART cycles. Progesterone-based protocols are the most frequently adopted, while alternative regimens including human chorionic gonadotropin (hCG) and GnRH agonists (GnRH-a) are controversial. A GnRH-a can be used instead of hCG for ovulation triggering and the effectiveness of luteal phase support in such new protocols is the object of a growing number of experimental studies. Currently, vaginal progesterone is considered as the first line therapy for luteal phase support (LPS). The starting-time and the duration of luteal phase supplementation after the onset of pregnancy are still debated. Despite the lack of clinical or biological evidence supporting the efficacy of luteal phase support in intrauterine insemination cycles, the use of progesterone has become a well-established practice.

[Administration of micronized palmitoylethanolamide (PEA)-transpolydatin in the treatment of chronic pelvic pain in women affected by endometriosis: preliminary results]

AIM

Aim of the study was to evaluate the effectiveness of micronized palmitoylethanolamide (PEA)-transpolydatin in the treatment of chronic pelvic pain in women affected by endometriosis.

METHODS

Twenty-four patients with suspected endometriosis affected by severe pelvic pain were enrolled. All patients received two tablets a day of PEA 400 mg and 40 mg polydatin for 90 days consecutively. A Visual Analogic Scale was used for the assessment of the severity of global pain, dysmenorrhea, dyspareunia, dysuria and dischezia. A second questionnaire was submitted to patients to assess the quality of life. The compilation of a diary lead us to evaluate the monthly assumption of any painkillers. Patients were evaluated at the begin of the treatment and then monthly until the end of the study (90 days). The statistical analysis was performed by using the ANOVA for the analysis of variance.

RESULTS

Statistically significant results were found in relation to pelvic pain, dysmenorrhea and dyspareunia compared to the initial evaluation of patients. Results related to dysuria and dischezia were not statistically significant (P>0.05). The decrease in pelvic pain leads to an improvement of the quality of life of patients. A decreased assumption of nonsteroidal anti-inflammatory drugs (NSAIDs) was also observed.

CONCLUSION

PEA could be considered an effective supplement to conventional analgesic therapies in the management of pelvic pain related to endometriosis.

The addition of GnRH antagonists in intrauterine insemination cycles: a pilot study

AIM

This prospective study was designed to assess whether the use of GnRH antagonists can improve the success rate of controlled ovarian stimulation (COS) in intrauterine insemination (IUI) treatments.

PATIENTS AND METHODS

Eighty patients were divided into two groups: GnRH antagonist group (Group A, n=40) and control group (Group B, n=40). Patients in Group B underwent COS with recombinant Follicle Stimulating Hormone (r-FSH, 50-75 IU/d) only, while patients in Group A were administered r-FSH (50-75 IU/d) plus cetrorelix (0.25 mg/d, starting when ≥ 2 follicles ≥ 14 mm were detected on ultrasound scan). In both groups a single insemination was performed 36 hours after human Chorionic Gonadotropin (hCG, 250 mcg) administration. The primary outcome was clinical Pregnancy Rate (PR). Secondary outcomes were ongoing PR, incidence of Premature Luteinization (PL), number of follicles with mean diameter ≥ 16 mm and between 11 and 15 mm on the day of hCG administration, miscarriage rate, cycle cancellation rate, total amount of r-FSH used and duration of treatment. Student's t test and Chi-square test were used (p < .05 statistically significant).

RESULTS

A total of 146 cycles were performed (Group A: n=72; Group B: n=74). A trend towards higher PR in Group A was detected, although it was not statistically significant (Clinical PR: 18.05% vs 10.81%). The number of follicles ≥ 16 mm was significantly increased in Group A. The incidence of both premature LH surge and premature luteinization (PL) was significantly higher in Group B. No significant differences were found in the duration of the stimulation protocol, and in the total amount of r-FSH administered.

CONCLUSIONS

The addition of GnRH antagonist in COS/IUI protocol significantly increases the number of mature follicles. However, this multifollicular recruitment is not linked to a significantly higher PR.

GnRH antagonists in assisted reproductive techniques: a review on the Italian experience

Current Controlled Ovarian Stimulation (COH) for Assisted Reproductive Techniques (ART) pursues three main objectives: hypophyseal activity suppression, multiple follicle growth stimulation, and ovulation induction. By suppressing hypophyseal activity, it is possible to prevent untimely LH surge and allow the appropriate development of the leading follicle. The classical GnRH agonist long protocol is the most widely used in COH for ART. However, an alternative regimen based on GnRH antagonist has been recently introduced in clinical practice. As competitive antagonists, these drugs display an immediate and quickly reversible effect and they avoid hormonal withdrawal side effects. Moreover, this protocol shows undeniable advantages, including the shorter duration of the treatment, the lower amount of gonadotropin required, the shorter hormonal and ultrasound monitoring of patients, milder physical and emotional stress, and a lower risk of Ovarian Hyperstimulation Syndrome (OHSS). The use of GnRH antagonists was traditionally restricted to selected patients, as "poor responders" and women at high-risk of developing OHSS such as Polycystic Ovary Syndrome (PCOS) and patients who had previously experienced OHSS. These findings could prompt a trend to change from the standard agonist protocol to the antagonist protocol in all categories of patients. This review provides a comprehensive overview of the use of GnRH antagonist protocols applied both to IVF techniques and to IUI procedures in the Italian experience.

[Administration of MICRONIZED PALMITOYLETHANOLAMIDE (PEA)-transpolydatin in the treatment of chronic pelvic pain in women affected by endometriosis: preliminary results.]

Aim: Aim of the study was to evaluate the effectiveness of micronized palmitoylethanolamide (PEA)-transpolydatin in the treatment of chronic pelvic pain in women affected by endometriosis. Methods: Twenty-four patients with suspected endometriosis affected by severe pelvic pain were enrolled. All patients received two tablets a day of PEA 400 mg and 40 mg polydatin for 90 days consecutively. A Visual Analogic Scale was used for the assessment of the severity of global pain, dysmenorrhea, dyspareunia, dysuria and dischezia. A second questionnaire was submitted to patients to assess the quality of life. The compilation of a diary lead us to evaluate the monthly assumption of any painkillers. Patients were evaluated at the begin of the treatment and then monthly until the end of the study (90 days). The statistical analysis was performed by using the ANOVA for the analysis of variance. Results: Statistically significant results were found in relation to pelvic pain, dysmenorrhea and dyspareunia compared to the initial evaluation of patients. Results related to dysuria and dischezia were not statistically significant (P>0.05). The decrease in pelvic pain leads to an improvement of the quality of life of patients. A decreased assumption of nonsteroidal anti-inflammatory drugs (NSAIDs) was also observed. Conclusion: PEA could be considered an effective supplement to conventional analgesic therapies in the management of pelvic pain related to endometriosis.

Tubal endometrioma within a twisted fallopian tube: a clinically complex diagnosis

BACKGROUND

Endometriotic lesions affect the fallopian tubes in 6% of patients with endometriosis and adhesions involve the salpinges in 26%. Different studies report that 45%-70% of adolescents with chronic pelvic pain have endometriosis diagnosed at the time of laparoscopy.

CASE

We report a case of an 18-year-old girl with a tubal torsion due to a tubal endometrioma. The endometriotic nodule before laparoscopy appeared to be located in the rectovaginal septum. At laparoscopy, a right fallopian tube torsion was visible and several adhesions were connecting the lesion to the pouch of Douglas' walls.

SUMMARY AND CONCLUSION

The tenacious adhesions, which welded the nodule to the walls of the pouch of Douglas, did not allow to distinguish at the MRI a tubal endometrioma from a rectovaginal endometriotic mass, justifying the false diagnosis.

In vitro fertilization stimulation protocol for normal responder patients

The aim of this prospective observational study is to determine the different outcomes of IVF/ICSI treatments after using antagonists or agonists of gonadotrophin-releasing hormone (GnRH) for controlled ovarian hyperstimulation (COH) in normal responder patients. Two hundred forty-seven patients undergoing IVF treatment at the Centre of Reproductive Medicine, Rome (CERMER), from January 2005 to December 2008, were included in the study. Patients were stimulated either with a standard long protocol with GnRH agonists (n = 156) or with GnRH antagonists (n = 91). The use of GnRH antagonists resulted in a significant reduction in the duration of the stimulation (Agonist Group 14.10 ± 2.25 vs Antagonist Group 11.34 ± 2.11; p < 0.001) and in the amount of gonadotrophin (IU of r-FSH) needed (Agonist Group 1878 ± 1109 vs Antagonist Group 1331 ± 1049; p = 0.0014). Moreover a lower number of cycles were cancelled with the antagonist protocol (4.39 vs 6.41%). The GnRH antagonist protocol, when compared to the GnRH agonist one, is associated with a similar clinical pregnancy rate, similar implantation rate, significantly lower gonadotrophin requirement and shorter duration of stimulation. For this reason, GnRH antagonists might be a good treatment even for normal responder patients undergoing IVF.

Fertility-sparing treatment of endometrial cancer precursors among young women: a reproductive point of view

BACKGROUND

Early-stage endometrial cancer and complex atypical hyperplasia are treated with hysterectomy and bilateral salpingo-oophorectomy. An emerging issue among younger women affected is the possibility of a fertility-sparing treatment with progestative therapy and close follow-up.

AIM

To assess the possibility of conceiving after a diagnosis of atypical endometrial hyperplasia among women younger than 40 years old, in term of delaying definitive treatment and achieving pregnancy.

MATERIALS AND METHODS

15 women younger than 40 years old with complex CAH or early carcinoma of the endometrium and a wish to preserve fertility. Progestins were administered orally for at least a 12 weeks period. Endometrial biopsies were used at follow-up.

RESULTS

In 11 women, a complete pathological remission of the disease was observed. 4 pregnancies were attained in 4 women. 3 showed progression and underwent definitive surgery at 18 months. 1 showed no response at 24 months and 3 cycles and was counseled to receive a hysterectomy.

CONCLUSIONS

A conservative approach in patients younger than 40 years appears a valid option, and a progestative therapy trial should be attempted whether a valid consensus is attained. Considering the risk to find AEH at biopsies and eventually a carcinoma at hysterectomy (25% of cases) a careful management is strictly required.

Methylenetetrahydrofolate reductase gene promoter hypermethylation in semen samples of infertile couples correlates with recurrent spontaneous abortion

STUDY QUESTION

Is the methylation status of the methylenetetrahydrofolate reductase (MTHFR) promoter region in semen samples associated with 'recurrent spontaneous abortion' (RSA)?

SUMMARY ANSWER

MTHFR promoter hypermethylation is more frequent in semen samples from RSA couples than in semen samples from infertile couples with no history of RSA (NRSA) and affects the whole sperm population significantly more often.

WHAT IS KNOWN ALREADY

Modifications to the MTHFR gene such as polymorphisms and promoter methylations are associated with male infertility.

STUDY DESIGN, SIZE AND DURATION

Retrospective cohort study of semen samples from 20 RSA couples, 147 NRSA couples and 20 fertile men between 2011 and 2012.

MATERIALS, SETTING AND METHODS

DNA from the semen samples of RSA, NRSA and fertile men were analyzed by methylation-specific PCR amplification using primers which anneal to the methylated or unmethylated cytosine-phosphodiester bond guanine (CpG) islands within the promoter region of MTHFR. The specificity of the PCR products was assessed by DNA sequencing.

MAIN RESULTS AND THE ROLE OF CHANCE

The methylated MTHFR epigenotype (including samples where it co-existed with unmethylated MTHFR epigenotypes) was detected in 75% of RSA men, 54% of NRSA men and 15% of fertile men. MTHFR methylation was observed in the whole sperm population in semen samples from 55% of RSA men compared with 8% in NRSA men (P < 0.05) and 0% in fertile men (P < 0.05). DNA sequencing analysis was fully concordant with the PCR results and revealed that when MTHFR methylation occurred, CpG islands within the promoter region were 100% methylated (hypermethylation of MTHFR promoter).

LIMITATIONS, REASONS FOR CAUTION

The relatively small sample size of RSA infertile couples.

WIDER IMPLICATIONS OF THE FINDINGS

The hypermethylation of the MTHFR gene promoter should be taken into consideration as a novel putative risk factor in RSA etiology.

STUDY FUNDING/COMPETING INTEREST(S)

Our institution has received an FAR research grant from the University of Ferrara, Ferrara, Italy. No competing interests declared.

Recombinant luteinizing hormone priming in multiple follicular stimulation for in-vitro fertilization in downregulated patients

Follicle development is controlled amongst other factors by pituitary gonadotropins follicle-stimulating hormone (FSH) and luteinizing hormone (LH) that act in synergy in completing follicle maturation. Exogenous gonadotropins, combined with gonadotropin-releasing hormone agonists, have been successfully used in patients with ovulatory disorders undergoing assisted reproduction. There is some evidence of a beneficial role of androgens or LH administration before FSH stimulation. This study was designed to verify whether the addition of LH in the early follicular phase, in downregulated patients undergoing follicular stimulation for assisted reproduction, would add benefits in terms of general outcomes and pregnancy rates. We compared two groups of patients one of which was treated with recombinant FSH (rFSH) alone and the other with rFSH plus recombinant LH (rLH), in the early follicular phase only. The number of eggs recovered was higher in the group treated with FSH only; however, the number of embryos available at transfer was similar in the two groups and, more importantly, the number of Grades I and II embryos was higher in the group pretreated with LH. Similarly, although biochemical pregnancy rate and clinical pregnancy rates were similar in both groups, a beneficial role of LH priming was demonstrated by the higher implantation rate achieved in these patients.

Pancreatic cancer with liver metastases in a pregnant patient: case report and review of the literature

In this case report, the authors discuss clinical presentation, surgical procedure and early results of chemotherapy of pancreatic carcinoma with liver metastases diagnosed a few days after delivery. Pancreatic adenocarcinoma occurs infrequently in pregnant and childbearing women: only ten cases have been reported in the literature. The early diagnosis of pancreatic cancer is difficult because symptoms appear when cancer is about to reach an advanced stage. In pregnancy, it is even more difficult because symptoms like dyspepsia, vomiting and epigastric pain may result confusing. The authors outline the difficulties in diagnosis and treatment of this kind of disease during pregnancy.

[Endometriosis: review of the literature and clinical management]

Despite numerous studies, endometriosis remains unclear concerning the etiopathogenesis, the natural history and optimal treatment. It occurs preferentially in young women and may be associated with a series of painful symptoms very disabling, together with infertility and significant psychological problems. Because of the multiple consultations, operations and disability it can cause, endometriosis takes an increasing part in health costs. Delays between onset and diagnosis are still long, and it is important to diagnose as early as possible to stop this disease so as to maintain or restore fertility and quality of life for patients. That is why a careful listening and clinical examination with appropriate investigations will improve our global care.

Impact of endocrine disruptor chemicals in gynaecology

The potential hazardous effects that estrogen- and androgen-like chemicals may have both on wildlife and human health have attracted much attention from the scientific community. Endocrine disruptors (EDCs) are chemicals that have the capacity to interfere with normal signalling systems. EDCs may mimic, block or modulate the synthesis, release, transport, metabolism and binding or elimination of natural hormones. Even though potential EDCs may be present in the environment at only very low levels, they may still cause harmful effects, especially when several different compounds act on one target. EDCs include persistent pollutants, agrochemicals and widespread industrial compounds. Not all EDCs are man-made compounds; many plants produce substances (phytoestrogens) that can have different endocrine effects either adverse or beneficial in certain circumstances. Natural substances such as sex hormones from urban or farm wastes can become concentrated in industrial, agricultural and urban areas; thus, such wastes may be considered potential 'EDCs' for humans and/or wildlife. Much attention has focussed on changing trends in male reproductive parameters in relation to EDC exposure; however, studies on the female reproductive system have been less comprehensive. We have focussed this article on four major aspects of female reproductive health: fertility and fecundability, endometriosis, precocious puberty and breast and endometrial cancer.

Age-dependent changes in the expression of superoxide dismutases and catalase are associated with ultrastructural modifications in human granulosa cells

Limited knowledge exists about changes in follicle quality associated with age. The aim of this work was to investigate whether ageing may cause oxidative stress-mediated alterations in human granulosa cells (GCs) from periovulatory follicles. GCs employed in this study were obtained from follicular aspirates of 20 younger women (range 27-32 years) and 20 older women (range 38-41 years) undergoing an IVF treatment. Results obtained from comparative RT-PCR analysis revealed that the mean relative levels of mRNAs coding for superoxide dismutases, Cu, ZnSOD (SOD1), MnSOD (SOD2) and catalase were significantly decreased in women > or =38 years (P < 0.05, Student's t-test). These changes were associated with a reduced expression of SOD1, SOD2 and catalase at the protein level. When examined at an ultrastructural level, most of the GCs from this group showed defective mitochondria and fewer lipid droplets than those observed in the younger group. These results indicate that GCs from older patients suffer from age-dependent oxidative stress injury and are taken as an evidence for reduced defence against reactive oxygen species (ROS) in GCs during reproductive ageing.

Oocytes cryopreservation: state of art

In the present review article we sought to analyze, on the basis of a systematic review, the indications, rationale of oocytes cryopreservation, as well as the techniques that improved the aforementioned procedure in order to higher the pregnancy rate in women undergoing that procedure. Moreover, we pointed out the importance of oocytes cryopreservation in the research field as oocyte banking may be of utmost importance to increase the availability of oocytes for research applications such as genetic engineering or embryo cloning. Oocyte freezing has 25 year of history alternating successes and setbacks. Human oocytes have a delicate architecture but are freezable. Clinical efficiency remains low, but healthy children have been born, indicating that chromosomally normal embryos can originate from frozen oocytes. Freezing protocols are not yet optimal and it is now desirable to combine empirical and theoretical knowledge.

Serum CA125 level modifications in women undergoing repeated IVF cycles

In the present paper, serum CA125 modifications in patients undergoing their first IVF cycle were compared with those of patients in their second attempt. A significant increase of this marker was detected in each group of patients at day 14 after embryo transfer. However, the level of CA125 monitored in the patients in their second attempt was significantly higher than that determined in patients undergoing their first ovarian stimulation. This condition does not influence either ovarian response or oocyte and embryo quality. Moreover similar IVF outcome was obtained. Therefore we propose that patients undergoing repeated assisted reproductive technology (ART) cycles may suffer from ovarian surface epithelial damage and/or altered cellular growth rate.

Antioxidant enzymatic defences in human follicular fluid: characterization and age-dependent changes

The aim of this work was to study the antioxidant enzymatic defences in human follicular fluid and investigate their possible changes during reproductive ageing. To this end, we tested the specific activities and protein expression of enzymes involved in reactive oxygen species (ROS) scavenging and in detoxification of ROS byproducts in follicular fluid from young (range 27-32 years, n = 12) and older (range 39-45 years, n = 12) women participating in an IVF programme. Results show that all the tested enzymes [superoxide dismutase (SOD), catalase, glutathione peroxidase, glutathione transferase, glutathione reductase] were significantly expressed in human follicular fluid. However, when the two age groups were compared, we found that follicular fluid from older women exhibited a reduced level of glutathione transferase and catalase activities and a higher level of SOD activity. Immunoblot analysis revealed that ageing was associated with decreased protein expression of GST Pi isoform and did not affect SOD and catalase protein expression. Taken together, these findings indicate that reproductive ageing is accompanied by a change in the antioxidant enzymatic pattern that could impair ROS scavenging efficiency in the follicular environment.

Pelvic relapses in ovarian cancer. Role of CA-125, transvaginal ultrasound and color Doppler

From January 1995 to January 2001, 40 patients with epithelial ovarian cancer were treated at our Institution. Fourteen of these, with a clinical CR after surgery and platinum-based chemotherapy, were evaluated monthly by gynecological examination, Ca-125 RIA assay, pelvic ultrasound with transabdominal and transvaginal probe and color Doppler. Six pelvic relapses, from 1.5 to 3.0 cm, were detected by transvaginal ultrasound (US). They showed a rich neovascularization with low resistance, high flow, PI from 0.3 to 1.0 and RI < 0.5 in all cases. US did not reveal any sign of relapse in the remaining eight patients. In all cases of pelvic relapses ultrasonic signs of recurrence preceded the increase of Ca-125 by one to six months (average 3.8).

A new molecular and cytogenetic approach to sterility. A review of the literature

In the therapeutic procedure of conjugal fertility, the use of intracytoplasmic sperm injection (ICSI) has opened new possibilities when conventional in vitro fertilization (IVF) techniques are unsuccessful. Cytogenetic studies showed the presence of genetic anomalies in foetuses conceived with this technique. Starting from these considerations, through a data collection of the literature, the authors report the latest scientific findings on this problem. They show the limits of the knowledge about genetic risks linked to these techniques, increasingly imposing rigorous medical behavior and conscious choices of the couple.

[Ectopic pregnancy after in vitro fertilization and embryo transfer. Analysis of literature]

The incidence of ectopic pregnancy has dramatically increased in the last decade. The triggering factors may be different and among them there is the introduction of medical assisted procreation techniques. Tubal pathologies in 80% of women undergoing artificial insemination techniques, the transfer in the womb of more than one embryo and the method of the same embryo-transfer may influence the onset of an ectopic pregnancy. This study aims to detect the factors that can prevent or reduce thc incidence of this pathology, after a close examination of the literature.

A low-dose stimulation protocol using highly purified follicle-stimulating hormone can lead to high pregnancy rates in in vitro fertilization patients with polycystic ovaries who are at risk of a high ovarian response to gonadotropins

OBJECTIVE

To study the benefits of a low-dose stimulation (LDS) protocol with purified urinary follicle-stimulating hormone in patients with polycystic ovaries who have presented previously with a very high ovarian response to a standard hMG stimulation.

DESIGN

Cohort study.

SETTING

Fertility center in a university hospital.

PATIENT(S)

Sixty-one patients involved in an IVF/ICSI program from January 1995 to December 1996.

INTERVENTION(S)

The patients were first stimulated with a standard protocol using hMG and presented with a very high ovarian response. These patients were then stimulated a second time using a low-dose protocol. Cryopreserved embryos were transferred in later artificial or natural cycles until to December 1999.

MAIN OUTCOME MEASURE(S)

Number of gonadotropin ampules; estradiol level on the day of ovulation induction; follicles, oocytes, and cryopreserved zygotes; fertilization, implantation, and pregnancy rates; and number of ovarian hyperstimulation syndromes (OHSS).

RESULT(S)

The number of ampules used, the estradiol level reached, and the number of oocytes obtained were significantly lower under the LDS than the standard protocol. High implantation (21.8%) and clinical pregnancy (38.4%) rates were obtained after LDS. The cumulated deliveries per cycle started and per patient were, respectively, 41.6% and 52.5%. Five patients suffered OHSS with the standard protocol, and none with the LDS.

CONCLUSION(S)

The LDS protocol offers a safe and efficient treatment for patients who present with echographic polycystic ovaries and are at risk of an excessive ovarian response to standard IVF stimulation protocols.

[Urinary incontinence in pregnancy and prevention of perineal complications of labor]

BACKGROUND

Female urinary incontinence often manifests itself for the first time during pregnancy in a great number of women (23-50%). In many cases it is transitory in nature, the result of the stress induced by the pregnancy on the pelvic floor. In this study the authors discuss the frequency of urinary incontinence on the basis of a questionnaire administered to a limited sample group of obstetrics patients in order to identify the potential risk factors and to plan protective and rehabilitative strategies for the pelvic floor both during pregnancy and before and after delivery.

METHODS

From November 1998 until June 1999 at the Obstetrics and Gynecology Clinic of the University of L'Aquila (Italy) 150 women were surveyed by written questionnaire both before delivery and on the second day following delivery. Those who were identified as having urinary incontinence during pregnancy were readministered the questionnaire at three months following delivery.

RESULTS

Urinary incontinence was reported during pregnancy by 48% of the women under examination, which appeared, for the most part, during the third trimester of the pregnancy (in 43% of the women). No differences related to age were discovered, while a cesarean section played a protective role. For women with preexisting IUS the new pregnancy was an aggravating factor. Of the women with IUS during pregnancy who did not demonstrate preexisting symptoms only 9.4% reported persistent urinary incontinence at three months following delivery. Among women pregnant for the first time with persistent symptoms all had received episiotomies by the third month following delivery.

CONCLUSIONS

The authors of this study wish to direct their attention to the identification of women with IUS during pregnancy so that damage from delivery can be reduced to a minimum and rehabilitation strategies for the functioning of the pelvic floor can be imitated as soon as possible.

Follow-up of 32 hypothalamo-hypopituitary patients treated with pulsatile gonadotropin-releasing hormone or human menopausal gonadotropin

In a clinical retrospective study, a follow-up of hypothalamo-amenorrheic patients treated firstly with gonadotropin-releasing hormone (GnRH) pump stimulation and secondly with human menopausal gonadotropin (hMG) was performed. Thirty-two hypothalamo-amenorrheic patients, 24-38 years old, were submitted to 103 GnRH stimulation cycles. Seven, with polycystic ovaries (PCO) on ultrasound, were stimulated with hMG after one or several unsuccessful pump cycles. Ovulation was confirmed by a luteinizing hormone (LH) surge or triggered by human chorionic gonadotropin in 80 out of 103 cycles (77.7%/cycle) leading to 62 timed sexual intercourses and 17 intrauterine inseminations (IUI). Twenty-one pregnancies (26.3%/cycle) terminated in eight abortions (38.1%/pregnancy) and 13 deliveries (40.6%/patient). hMG stimulation, in the seven PCO patients (six IVF, one IUI), led to four additional deliveries in three patients. Five patients became pregnant spontaneously after pump failure (n = 2) or unsuccessful IVF (n = 3). Combining all cycles, 17 deliveries were obtained in 16 patients. No case of ovarian hyperstimulation syndrome (OHSS) was observed. GnRH is an efficient and safe treatment of hypothalamo-amenorrheic-induced anovulation. Following GnRH or hMG ovarian stimulation, spontaneous ovulation and conception may be restored in certain hypothalamo-amenorrheic patients.