Giant recurrent perineal endometriosis in an episiotomy scar--a case report.

The occurrence of perineal endometriotic lesions can be explained by mechanical dissemination and transplantation of endometrial cells. Viable decidual endometrial cells are likely to be transplanted into the episiotomy wounds or perineal tears during normal vaginal delivery and subsequent growth may occur A case of a 33-year old woman with a medical history of recurrent perineal endometriosis was described. An endometriotic giant mass (8 centimeter in diameter) was wide-excised, together with the episiotomy scar. The recovery was uneventful. Three years after the surgery, the patient is symptom-free and with no signs of recurrence or discomfort. According to the literature and our own experience, a complete excision of endometriotic tissue is the treatment of choice. We can conclude that a wide excision is mandatory as it is the only way to prevent tumor recurrence.

Is mid-gestational cervical length measurement as sensitive prediction factor of preterm delivery in IVF as in spontaneous singleton pregnancies?

OBJECTIVES: To verify the relation between pregnancy duration and cervical length (CL) at 22-24 wks of spontaneous and IVF singleton gestations and to assess its predictive value for preterm delivery (< 37 wks). MATERIAL & METHODS: CL at 22-24 wks was performed according to FMF recommendations in 344 women who conceived spontaneously and in 107 IVF singleton pregnancies. The results of CL in both groups were divided into subgroups: ≤ 29 mm, 30-34 mm; 35-39 mm; 40-44 mm; 45-49 mm and ≥ 50 mm. They were subsequently correlated with mean durations of gestation within subgroups and parameters of accuracy were calculated. Correlation and regression analysis was performed. RESULTS: The average age of women in both groups was 28.1 y.o. (SD=4.2 years) and 33.4 y.o. (SD=4.1 years), respectively. The mean gestation age at delivery was 38.9 wks (SD=2.1 wks) vs. 37.9 wks (SD=2.3 wks) and the rate of prematurity equaled 7% vs. 15%, respectively. Regardless the method of conception there is a positive correlation between the CL and the duration of gestation. The regression analysis showed that the significant increase in pregnancy duration was correlated with CL ≥ 35 mm (correlation coefficient greater for spontaneous vs. IVF: rxy=0.418 vs rxy=0.341; p<0.001). All CL parameters of accuracy were better for spontaneous in comparison to IVF pregnancies. CONCLUSIONS: IVF singleton pregnancy carries additional risk factors for preterm delivery. Therefore mid-gestational cervical length is less sensitive predictor than in spontaneous singleton gestations.

Patterns of infertility in Poland - multicenter study.

OBJECTIVE: Infertility seems to be a great worldwide problem. Many publications present the epidemiology of infertility, but the percentage distribution of factors responsible for infertility varies significantly. The objective was to define infertility profiles in Poland assessed according to the information provided by 4 large infertility centers: Bialystok, Poznan, Szczecin and Warsaw. MATERIAL AND METHODS: Multicenter study was performed. Couples with primary infertility, attending one of the four centers in Poland, were asked to fulfill a questionnaire. Overall 1517 questionaires were analysed: Bialystok - 468, Poznan - 325, Szczecin - 341, Warsaw - 383. Only semen analyses fulfilling WHO Manual 1999 criteria were used in the study and were afterwards compared with 2010 WHO standards. RESULTS: Results from 4 Polish centers showed that the average age of infertile women was 31.41 years and of infertile men 33.2 years. The mean duration of infertility equaled 3.31 years. Among 1517 surveyed women, no pathological findings concerning reproductive abilities were observed in 1088 cases (71.72%). In the remaining patients the following were diagnosed: uterine factor in 26 (6.02%) women, ovulation disorders in 134 (31.33%), including 70 (16.27%) of PCOS patients, tubal factor in 165 (38.55%) and endometriosis in 145 (33.73%). The average of 18.9% of couples had a mixed cause of infertility, while idiopathic factor was assigned to 15.99%. In the study male factor accounted for 55.73% of cases. Change of reference values for semen analysis implemented in 2010 caused an increase in the number of normal results and asthenozoospermia. CONCLUSIONS: According to the data provided by Polish infertility centers the rate of male factor as a reason of infertility has reached 55.73%. However, the implementation of new reference values for semen analysis in 2010 led to the decrease in male factor frequency and the increase in the rate of idiophatic infertility. Anovulatory cycles and endometriosis are the main reasons affecting the female reproductive potential.

Congenital adrenal hyperplasia due to 21-hydroxylase deficiency - management in adults.

Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is one of the most common autosomal recessive hereditary diseases. The impairment of cortisol synthesis leads to excessive stimulation of the adrenal glands by adrenocorticotropic hormone (ACTH), adrenal hyperplasia, and excessive androgen synthesis. The syndrome is characterised by a considerable correlation between the genotype and the phenotype with the type of CYP21A2 gene mutation affecting the severity of 21-hydroxylase deficiency. The clinical manifestations of CAH in adults result from adrenocortical and adrenomedullary insufficiency, hyperandrogenism, and the adverse effects of glucocorticosteroids used for the treatment of the condition. Non-classic CAH may sometimes be asymptomatic. In patients with classic CAH obesity, hyperinsulinaemia, insulin resistance, and hyperleptinaemia are more often seen than in the general population. These abnormalities promote the development of metabolic syndrome and its sequelae, including endothelial dysfunction, and cardiovascular disease. Long-term glucocorticosteroid treatment is also a known risk factor for osteoporosis. Patients with CAH require constant monitoring of biochemical parameters (17a-hydroxyprogesterone [17-OHP] and androstenedione), clinical parameters (body mass, waist circumference, blood pressure, glucose, and lipids), and bone mineral density by densitometry. The principal goal of treatment in adults with CAH is to improve quality of life, ensure that they remain fertile, reduce the manifestations of hyperandrogenisation in females, and minimise the adverse effects of glucocorticosteroid treatment. Patients with classic CAH require treatment with glucocorticosteroids and, in cases of salt wasting, also with a mineralocorticosteroid. Radical measures, such as bilateral adrenalectomy, are very rarely needed. Asymptomatic patients with non-classic CAH require monitoring: treatment is not always necessary. Medical care for patients with CAH should be provided by reference centres, as the management of such patients requires collaboration between an endocrinologist, diabetologist, gynaecologist, andrologist, urologist, and psychologist.

Pregnancy after organ transplantation.

Ovarian function with regular menstrual cycles is usually restored in women of reproductive age after solid organ transplantation. The number of pregnancies reported in these patients increases gradually. Pregnancy is always considered high risk, and not properly planned may lead to serious complications. The best for the patient is to conceive in a period of good general health and good stable graft function, after appropriate preparation and not later than five years after transplantation. Immunosuppressive regimen should be modified before conception. Sirolimus and mycophenolate mofetil should be excluded. The blood levels of immunosuppressive agents should be regularly controlled during the whole pregnancy. The rate of successful pregnancies isn approximately 95% in graft recipients. Increased incidence of preterm labor, anemia and intrauterine growth restriction is observed compared with general population. Organ transplantation itself is not an indication for cesarean section and vaginal delivery is recommended as the best for the patient, the graft and the newborn. Breast feeding is believed to be contraindicated in women on immunosuppressive therapy, however no adverse effects were reported in children of graft recipients who decided to breast feed. The rate of congenital malformations in newborns is approximately 3-4% and does not differ from the rate seen in general population. The rate of perinatal deaths decreased beneath 0.8% in recent reports. Jaundice, hyperglycemia and hyperkalemia, observed more frequently in newborns of graft recipients, are mild and in most cases do not have any clinical implications.

Cancer of the urinary bladder neovagina in a patient with Morris' syndrome.

BACKGROUND: Vaginal agenesis is a rare condition, therefore the incidence of a malignant transformation in the neovagina is extremely low. CASE REPORT: We report on a 42-year-old patient with Morris' syndrome and urinary bladder neovagina with a history of prolonged infections of the urinary bladder and intertrigo of the perineal region. The biopsy revealed a squamous cell carcinoma arising from the neovagina. The patient underwent combined radio- and chemotherapy and was disqualified from surgical treatment because of the advanced stage of the disease. CONCLUSIONS: Because of the high risk of malignant transformations regular follow-ups are necessary in patients with neovagina creation, including gynecological examination, cytological screening, and biopsy if necessary. In addition, urinary bladder does not seem to be a good material for a functional vagina.

Gynecological issues after organ transplantation.

Organ transplantation has become universally accepted treatment of end-stage organ failure. The main problem focuses on preventing the graft from rejection with the use of immunosuppressive agents. High incidence of infection is the most frequent adverse effect of immunosuppressive therapy. Symptoms of inflammation are often reduced in immunosuppressed patients. All invasive diagnostic and therapeutic procedures should be associated with the increase in dose of steroids and prophylactic antibiotics. Ovarian and menstrual function is usually restored in transplanted women. Function of the hypothalamus-pituitary-ovary axis in transplanted women is believed to be normal. Most common abnormal uterine bleeding in graft recipient are: prolonged and profuse menstruation and inter-menstrual bleeding or spotting. Among the underlying diseases are lesions of the uterus (fibroids, endometrial or cervical polyps), infections of sex organs or hormonal disturbances. Higher rate of endometrial hyperplasia (without atypia) is reported in renal graft recipients. Organ transplantation results in the restored fertility thus effective family planning method is necessary in women of reproductive age who do not want to conceive. Vaginal diaphragms are not advised and intrauterine device are contradicted. Observational studies indicate for safety and high rate of acceptance of oral and transdermal hormonal contraception in transplanted women. Over ten-year experiences of HRT administration in graft recipient have proved the benefits of the therapy. Patients after organ transplantation have three to four-fold increased incidence of malignancy compared with general population. All transplant women must undergo regular gynecological screening for premalignant and malignant lesions of sex organs and breast.

Molecular analysis of defects in the CFTR gene and AZF locus of the Y chromosome in male infertility.

OBJECTIVE: To investigate the frequency and potential impact of mutations and polymorphisms in the CFTR gene and deletions in AZF locus of the Y chromosome in patients with azoospermia (AZOO), cryptozoospermia (CRYPTO) or oligoasthenoteratozoospermia (OAT) who were to be included in an assisted reproductive technologies (ART) program. STUDY DESIGN: A total of 188 infertile men were enrolled in the study: 100 patients with AZOO, 38 with CRYPTO and 50 with OAT. RESULTS: The CFTR gene mutations or IVS8-5T variant in at least 1 allele was identified with similar frequencies among the AZOO (33%) and CRYPTO (21%) patients; 55% of the AZOO patients with normal spermatogenesis (NS) had mutations in 1 or 2 alleles. The novel R810G mutation in exon 13 was identified in 1 NS patient. The OAT or AZOO patients with Sertoli cell only syndrome (SCO) had mutations in the CFTR gene with similar frequencies to that in the general Polish population. The deletions in the AZF locus were detected in 20% of SCO patients, 11.5% of AZOO patients with maturation arrest and in 5% of CRYPTO patients. The other groups (NS, OAT) did not carry deletions in the region studied. CONCLUSION: Molecular diagnosis of the CFTR gene, Y chromosome deletion analysis and genetic counseling are necessary diagnostic elements for patients with male infertility, especially if the are included in an ART program.

Effects of free fatty acids on the course of gestational diabetes mellitus.

AIM OF THE STUDY: The investigation of the influence of maternal serum free fatty acids (FFA) levels on the course of gestational diabetes mellitus (GDM). MATERIAL AND METHODS: On the basis of GDM diagnosis 52 diabetic and 39 non-diabetic pregnant women were recruited to the study. Treatment modalities for diabetic group included diet alone (GDM1; n-36) or a combination of insulin and diet (GDM2; n-16). Maternal serum free fatty acids were measured before treatment, after 4 weeks therapy, during delivery and in umbilical cord blood. RESULTS: Plasma levels of FFA were higher in GDM pregnant women treated later only by diet compare with GDM patients required later insulin and non-diabetic gravidas. In GDM diet treated group plasma FFA levels progressively decreased with treatment duration. The plasma FFA levels in umbilical cord blood did not differ between the study groups. We found a positive correlation between maternal venous and umbilical cord blood concentration of free fatty acids. Maternal FFA levels positively correlated with neonatal births weight. CONCLUSION: Elevated plasma FFA levels are associated with GDM and can influence fetal growth. Early and intensified GDM treatment may decrease the level of circulating fatty acids.

Clinical, hormonal and sonographic features of the identical twins with Klinefelter syndrome--a case report.

A rare case of Klinefelter syndrome in identical twins is reported. Hormonal levels before and after hCG administration and testicular artery Doppler flow measurements are presented.

[The preliminary evaluation of surgical treatment of pelvic organ prolapse with polypropylene mesh by double transobturator approch technique (double TOT)]. / Wstepna ocena wyników operacyjnego leczenia zaburzen statyki narzadu plciowego z uzyciem siatki polipropylenowej z podwójnym dostepem przez otwory zaslonione (Double Transobturator Approach).

OBJECTIVES: The aim of this study was to evaluate preliminary results of a new, simple surgical technique with the use of polypropylene mesh (double TOT) used for the treatment of cystocele associated / not associated with urinary incontinence in females. MATERIAL AND METHODS: 19 women, aged 49-76, BMI 24-40, with cystocele associated or not with urinary incontinence, were operated on at the 1st Department of Obstetrics and Gynaecology in Warsaw, using double TOT technique. In this technique, described by Theobald, the trapezoidal polypropylene four-arm vaginal mesh is inserted through the obturator foramens from the outside to the inside and is positioned without tension under the urethra. RESULTS: 9 patients qualified for the operation were grade III in POPQA, 5--grade IV, 4--grade II and one patient grade I. 16 women had additional operations performed beside double TOT. The duration of operations varied from 30 to 135 minutes. No intra-operative complications were observed. There were no complications in short 6 weeks follow-up. CONCLUSIONS: Double Transobturator technique is simple, easy to learn, safe and, at the same time, efficient surgical procedure for the treatment of pelvic organ prolapse and female urinary stress incontinence. The results of longer follow-up on a larger group of operated patients will be more accurate.

[Heterotopic pregnancy]. / Ciaza heterotopowa.

We report a case of combined intrauterine and extrauterine (tubal) pregnancy in 24-year-old woman. The patient was admitted to the Clinic at 9 weeks gestational age with abdominal pain lasting 2 hours. Pelvic ultrasonography revealed alive 9-week intrauterine pregnancy, free fluid in the peritoneal cavity and left adnexal mass. A left salpingectomy was performed, with removal of ruptured ampulla with ectopic pregnancy, without complications. The intrauterine pregnancy proceeded uneventfully to 39 weeks, was terminated by cesarean section, resulting in birth of a healthy female infant of 3630 grams.

[HELLP syndrome in the postpartum period]. / Zespól HELLP w pologu.

The HELLP syndrome was described by Weinstein as a complication of pregnancy induced hypertension (PIH). There are few clinical reports about HELLP during postpartum period. We present the history of 31 years old pregnant patient, who developed in 36 week of her first pregnancy PIH, pregnancy was terminated in 39 week by cesarean section and postpartum period was complicated with HELLP syndrome (class I). The patient was treated surgically (hysterectomy), than continue at ICU. The treatment was successful without any late organ complications.

Immunoexpression of androgen receptors and aromatase in testes of patient with Klinefelter's syndrome.

Klinefelter's syndrome (47, XXY) is the most common chromosome aneuploidy in men and is usually characterized by underdeveloped testes and sterility. The aim of the present study was to detect cellular distribution of androgen receptors (AR) and aromatase in testes of patient with KS. The tissue sections were processed for morphological and immunohistochemical staining. Additionally, levels of FSH, LH, PRL, estradiol, and testosterone were measured in the plasma. Morphological analysis revealed a complete absence of spermatogenesis. No germ cells were present in seminiferous tubules. In some tubules, nests of apparently degenerating Sertoli cells were found. In the interstitium, Leydig cell hyperplasia was observed. Using immunohistochemistry, nuclear AR staining was detected in Sertoli cells and peritubular cells, whereas in Leydig cells the staining was exclusively cytoplasmic. The immunostaining of aromatase was detected in the cytoplasm of Sertoli cells and Leydig cells. Increased levels of gonadotropins and decreased level of testosterone concomitantly with the cytoplasmic localization of AR in Leydig cells might contribute to the impaired testicular function in patient with KS.

The naloxone test in Klinefelter syndrome.

UNLABELLED: AIM TO THE STUDY: The investigation of the influence of anti-opioid drug on hypophyseal and gonadal hormones secretion in case of Klinefelter syndrome. MATERIAL AND METHODS: The naloxone test (0,4 mg iv) was performed in 14 patients with Klinefelter syndrome aged from 19 to 32 and in 12 age matched control subjects with azoospermia and normal spermatogenesis in testicular histology. The plasma levels of FSH, LH, prolactin, testosterone and estradiol were established before and after 30, 60, 60 and 120 minutes respectively, following the drug administration. RESULTS: Basal FSH, prolactin and estradiol levels were significantly higher whereas basal testosterone was significantly lower in patients with Klinefelter syndrome than in the control group. After the naloxone administration the mean plasma prolactin level decreased significantly (p=0.01) in Klinefelter subjects. The respective diminution in control group was not significant. The levels of FSH and LH as well as testosterone and estradiol did not change during the naloxone test in both Klinefelter and control subjects. CONCLUSIONS: The naloxone administration in Klinefelter syndrome caused the decrease in plasma prolactin levels but did not affect the plasma level of another hypophyseal and gonadal hormones. The opioid controlled gonadotropin secretion is altered in case of Klinefelter syndrome.

[Protocol of GNRH antagonist in poor responders in IVF-ET cycles]. / Zastosowanie protokólu z antagonista GnRH w grupie pacjentek zle odpowiadajacych na stymulacje w cyklach zaplodnienia in vitro.

INTRODUCTION: Response to stimulation is one of the factors that affect the results of infertility treatment in IVF-ET cycles. Poor responders as well as the occurrence of ovulation prior to the oocyte retrieval is a main reason of nearly 30% of cancellations of the treatment cycles. In poor responders high doses of gonadotrophins are sometimes required. However administration of gonadotrophins alone does not prevent premature LH surge. The aim of the study was to assess controlled ovarian stimulation protocols with GnRH antagonists (Cetrotide) in poor responders. MATERIAL AND METHODS: The study group consisted of 27 infertile women, mean age 35.8 (range 28-45) undergoing the second IVF cycle. In those women the first cycle was either cancelled due to the lack of follicles' development or the small number of growing follicles (1-2). Ovarian stimulation was started on the 2 day of cycle with administration of 225 IU or rFSH or hMG. Cetrotide was administered subcutaneously in a daily dose of 0.25 mg starting when estradiol serum concentration reached 150 pg/ml with a lead follicle 14 mm diameter and continued throughout the gonadotrophin treatment until HCG administration. RESULTS: In 31 cycles the mean number of MII oocytes retrieved was 4.71 (range 1-10). In one woman there was no mature oocytes obtained during pick-up. In one case the cycle was cancelled due to the bad response. The mean duration of cetrotide administration was 5.16 days. The mean number of rFSH and HMG ampoules was 23 and 30 respectively. The fertilisation rate was 64%. Embryo transfer was performed on the 3rd day after pick-up. The pregnancy rate in this group was 22%. There weren't any adverse effects of Cetrotide in treated women. No case of ovarian hyperstimulation syndrome occurred. CONCLUSION: Ovarian stimulation protocol with GnRH antagonist is effective in poor responders in IVF-ET cycles.

[Congenital adrenal hyperplasia due to 21-hydroxylase deficiency--management in adults]. / Wrodzony przerost nadnerczy z niedoboru 21-hydroksylazy--problemy i postepowanie u doroslych.

Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is one of the most common autosomal recessive hereditary diseases. The impairment of cortisol synthesis leads to excessive stimulation of the adrenal glands by adrenocorticotropic hormone (ACTH), adrenal hyperplasia, and excessive androgen synthesis. The syndrome is characterised by a considerable correlation between the genotype and the phenotype with the type of CYP21A2 gene mutation affecting the severity of 21-hydroxylase deficiency. The clinical manifestations of CAH in adults result from adrenocortical and adrenomedullary insufficiency, hyperandrogenism, and the adverse effects of glucocorticosteroids used for the treatment of the condition. Non-classic CAH may sometimes be asymptomatic. In patients with classic CAH obesity, hyperinsulinaemia, insulin resistance, and hyperleptinaemia are more often seen than in the general population. These abnormalities promote the development of metabolic syndrome and its sequelae, including endothelial dysfunction, and cardiovascular disease. Long-term glucocorticosteroid treatment is also a known risk factor for osteoporosis. Patients with CAH require constant monitoring of biochemical parameters (17a-hydroxyprogesterone and androstenedione), clinical parameters (body mass, waist circumference, blood pressure, glucose, and lipids), and bone mineral density by densitometry. The principal goal of treatment in adults with CAH is to improve quality of life, ensure that they remain fertile, reduce the manifestations of hyperandrogenisation in females, and minimise the adverse effects of glucocorticosteroid treatment. Patients with classic CAH require treatment with glucocorticosteroids and, in cases of salt wasting, also with a mineralocorticosteroid. Radical measures, such as bilateral adrenalectomy, are very rarely needed. Asymptomatic patients with non-classic CAH require monitoring: treatment is not always necessary. Medical care for patients with CAH should be provided by reference centres, as the management of such patients requires collaboration between an endocrinologist, diabetologist, gynaecologist, andrologist, urologist, and psychologist.

[Peripartum cardiomyopathy and preeclampsia complicated with HELLP syndrome--a case report]. / Kardiomiopatia okoloporodowa i stan przedrzucawkowy powiklany zespolem HELLP--opis przypadku.

Peripartum cardiomyopathy (PC) and preeclampsia with HELLP syndrome are serious complications of pregnancy, but the coincidence of both in one pregnancy is extremely rare. Here, we report a case of 32-year-old primipara who in 35th Hbd presented for the first time in her life symptoms of severe heart failure (HF) in NYHA class III/IV. In 37th Hbd the diagnosis of PC was established based on clinical status and echocardiographic examination, which demonstrated a dilatation of heart chambers and impaired left ventricular systolic function with decreased ejection fraction (EF) 17%. In 37th Hbd she developed symptoms of preeclampsia complicated with HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) and further a DIC syndrome as well. Because the patient was in critical condition and the foetus' life was threatened the pregnancy was terminated with urgent cesarean section. Then the patient developed shock, respiratory insufficiency and increasing renal failure. Successful treatment, included administration of pressor amines, respirator, hemodialyses, multiple fresh frozen plasma and blood transfusions. The symptoms of HELLP syndrome resolved by 9th day of treatment. Although optimal treatment of HF was administered with significant clinical improvement, the normalization of left ventricle systolic function was not observed. At 2 and 13 months follow-up, EF remained low and was 34 and 36% respectively. This allows to diagnose persistent PC. Based on the case, the issues of etiopathogenesis, treatment, prognosis and the risk of recurrence of PC and HELLP syndromes in a possible pregnancy are discussed.

[Use of misoprostol in the termination of missed abortion]. / Zastosowanie misoprostolu w indukcji poronienia u kobiet z ciaza obumarla.

The efficiency of misoprostol in the termination of missed abortion was estimated. The group of 66 patients aged 19 - 37, who received 400 microg of vaginal misoprostol for termination of missed abortion was subjected. The overall success rate for a complete abortion was 30.3%, for incomplete abortion 25.8% and in a group of 27.2% women there was no need for cervix canal dilatating during the excochleation of uterus cavity. 16.7% cases failed. The results obtained in this study led us to the conclusion that 400 microg of vaginal misoprostol can induce the termination of missed abortion or dilatation of the uterus' canal.