Diagnosis and Management of Pelvic Congestion Syndrome: Comprehensive Review.

BACKGROUND: Pelvic congestion syndrome (PCS) is a poorly understood condition that can be associated with chronic pelvic pain and could impact quality of life. The diagnosis is often made by exclusion of other causes of pelvic pain. OBJECTIVE: The purpose of our review was to provide an update on the etiology, anatomy, physiology, identification, and the therapeutic management of PCS. METHOD: We conducted a literature review involving publications from 2003 to 2024 in PubMed, Elsevier, MEDLINE, as well as manual searches of primary and review articles using keywords such as "pelvic veins", "embolization", "venography", "pelvic congestion syndrome", and "chronic pelvic pain". CONCLUSION: PCS remains poorly understood. Symptoms can be non-specific and difficult to distinguish from other diseases; yet it is an important cause of chronic pelvic pain in women. To date, there have been only a small number of randomized trials and high-level evidence is still lacking. OUTLOOK: We call for an increased awareness of PCS and additional clinical studies in a large number of patients.

Effects of Low Luteinizing Hormone Serum Levels on Oocyte Retrieval, Fertilization Rate, and Embryo Quality during Controlled Ovarian Stimulation: Results from a Prospective Cohort Analysis.

OBJECTIVES: Luteinizing hormone (LH) plays a key role in normal follicular development and oocyte maturation in controlled ovarian stimulation. LH stimulates the proliferation and differentiation of theca cells for the secretion of androgens, synergistically increasing estrogen production. This study aimed to investigate the effects of low LH concentrations on oocyte retrieval, fertilization, and embryo development in patients undergoing in vitro fertilization/intracytoplasmic sperm injection. DESIGN: We prospectively (ClinicalTrials ID: NCT05755529) analyzed patients undergoing in vitro fertilization/intracytoplasmic sperm injection, subdividing them into three groups according to their age. Serum LH levels were evaluated on day 3, during stimulation (day 10) and before ovulation induction (day 12). PARTICIPANTS/MATERIALS, SETTING, METHODS: Forty-three consecutive women were scheduled for IVF and received ovarian stimulation with follitropin alfa (Gonal F, Merck Serono, Germany) and ganirelix (Fyremaldel, Sun Pharma, Italy). Statistical analysis was performed with InStat 3.10, GraphPad software, San Diego, CA, USA. Normal distribution was tested by the Shapiro-Wilk test. Continuous variables were expressed as the mean and standard deviation. Categorical variables are expressed as frequencies and percentages. RESULTS: Our data analysis suggests that serum LH levels progressively decrease during controlled ovarian stimulation, and this effect is more evident in the early phase of this procedure. From this perspective, circulating LH levels may significantly decrease during the late follicular phase due to the negative feedback of ovarian hormones from multiple follicular developments or after the suppressive effects of gonadotropin-releasing hormone antagonists. LIMITATIONS: Although our study confirms that exogenous LH can be considered a strategy in women with reduced LH levels during ovarian stimulation to improve oocyte quality and reproductive outcome, the generalizability of the results is limited by the low number of participants enrolled. CONCLUSIONS: Exogenous LH may be considered a strategy in women with a decrease in LH levels during ovarian stimulation to improve oocyte quality and reproductive outcome.

Effect of Maternal Age and Body Mass Index on Induction of Labor Using Oral Misoprostol in Late-Term Pregnancies: A Retrospective Cross-Sectional Study.

INTRODUCTION: Several studies have shown that late- and post-term pregnancies are associated with an increased risk of perinatal morbidity and mortality. In this case, induction of labor is the recommended approach. For full-term pregnancies, various methods exist to prepare the cervix and/or commence labor. Prostaglandins serve the dual purpose of cervical ripening and labor induction, blurring the distinction between the two processes. The aim of this research was to evaluate the effect of maternal age and body mass index (BMI) on oral misoprostol induction of labor for late-term pregnancies. METHODS: This was a retrospective cross-sectional study (ClinicalTrial ID: NCT06184139), including only late-term pregnancies in healthy nulliparous women carrying a single cephalic fetus with normal birthweight who underwent induction of labor with oral misoprostol. We used the oral misoprostol regimen proposed by the World Health Organization (WHO) for induction of labor in term singleton pregnancies in women who have not had a previous cesarean delivery and a Bishop score <7. The regimen was oral misoprostol in aqueous solution at the low dose of 25 µg every 2 h until a Bishop score ≥7, labor, or for a maximum of 8 doses. RESULTS: One hundred and four pregnant women underwent induction of labor with oral misoprostol for late-term pregnancy on the 290th day of gestation. Study population was divided in two groups based on age (<35 and ≥35 years) and obesity (BMI <30 and ≥30). No statistically significant differences were recorded between younger and older women. Obese women reported a longer time between the last dose of misoprostol and cervical dilation of 6 cm (p = 0.01), a longer time between the last dose of misoprostol and delivery (p = 0.04), and a higher rate of grade II vaginal lacerations (p = 0.02). CONCLUSIONS: Maternal BMI is a factor negatively influencing the efficacy of oral misoprostol for induction of labor in late-term pregnancy.

Reproductive Outcomes in Young Women with Early-Stage Cervical Cancer Greater than 2 cm Undergoing Fertility-Sparing Treatment: A Systematic Review.

Background and Objectives: Despite advancements in detection and treatment, cervical cancer remains a significant health concern, particularly among young women of reproductive age. Limited data exists in the literature regarding fertility-sparing treatment (FST) of cervical cancers with tumor sizes greater than 2 cm. The objective of this systematic review was to evaluate the reproductive outcomes of women diagnosed with cervical cancer greater than 2 cm who underwent FST. Materials and Methods: A comprehensive search of the literature was carried out on the following databases: MEDLINE, EMBASE, Global Health, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register), the Health Technology Assessment Database, and Web of Science. Only original studies (retrospective or prospective) that reported reproductive outcomes of patients with cervical cancer >2 cm were considered eligible for inclusion in this systematic review (CRD42024521964). Studies describing only the oncologic outcomes, involving FST for cervical cancers less than 2 cm in size, and case reports were excluded. Results: Seventeen papers that met the abovementioned inclusion criteria were included in the present systematic review. In total, 443 patients with a cervical cancer larger than 2 cm were included in this systematic review. Eighty pregnancies occurred, with 24 miscarriages and 54 live births. Conclusions: FST appears to be a viable option for women of childbearing age diagnosed with cervical cancer larger than 2 cm. However, careful consideration is advised in interpreting these encouraging results, as they are subject to limitations, such as variability in study designs and potential biases. In addition, reproductive outcomes should be further cross-referenced with oncologic outcomes to clarify the potential risk-benefit ratio. It is critical to conduct further research using standardized approaches and larger participant groups to strengthen the validity of the conclusions drawn.

Cornual Pregnancy: Results of a Single-Center Retrospective Experience and Systematic Review on Reproductive Outcomes.

Background and Objectives: Cornual pregnancies (CPs) are rare forms of ectopic pregnancy. When abortion does not occur, it can be a life-threatening condition for the mother and can also impair future fertility. We present our experience in the diagnosis and management of CPs. A systematic review was also conducted to investigate the reproductive outcomes after treatment. Materials and Methods: Between January 2010 and December 2022, we performed a retrospective, cross-sectional, single-center, and descriptive data collection and analysis (ClinicalTrial ID: NCT06165770). The search for suitable articles published in English was carried out using the following databases (PROSPERO ID: CRD42023484909): MEDLINE, EMBASE, Global Health, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Cochrane Methodology Register), Health Technology Assessment Database, Web of Science, and search register such as ClinicalTrial. Only studies describing the impact of CP treatment on fertility were selected. Results: Two studies were included in the systematic review. Seventeen patients suffering from CPs were selected. In our series, a pelvic ultrasound allowed for the diagnosis of a cornual localization in 35.30% of cases. Thirteen women (76.47%) underwent immediate surgical management. The laparoscopic approach was the most used (76.92%), with a laparotomic conversion rate of 30%. Four patients (23.52%) received medical treatment with methotrexate. After treatment, two patients managed to achieve pregnancy. Conclusions: CP is a rare form of ectopic pregnancy that can quickly become life-threatening for the mother. Ultrasound does not lead to a precise diagnosis in all cases. In the absence of complications and emergencies, laparoscopy is an approach that could be considered valid. For selected asymptomatic patients, medical treatment may be a valid alternative. The data from the studies included in the systematic review, although demonstrating a superiority of medical treatment in terms of future pregnancies, are heterogeneous and do not allow us to reach a definitive conclusion.

Evaluation of the benefit of indocyanine green as an educational and practical tool for ureteral identification in laparoscopic pelvic surgery: a cross-sectional study.

BACKGROUND: Indocyanine green (ICG) is a visible near-infrared fluorescent dye. Several studies have reported its benefit in identifying important anatomical structures, tissue vascularization, and sentinel lymph nodes in the case of tumors. Studies have shown that ICG is critical and safe in gynecologic surgeries. However, research on how ICG dye can help surgeons in laparoscopic surgeries correctly identify the course of the ureter has yet to be further investigated. METHOD: This cross-sectional study enrolled 62 gynecology attending and resident surgeons who were asked to identify the course of the ureter on images of laparoscopic surgeries. The results were then compared with images in which ICG dye highlighted the course of the ureter. The purpose of this study was to detect the ability of surgical assistants and residents to adequately identify the course of the ureter in laparoscopic pelvic surgeries. RESULTS: No statistically significant differences were found in terms of year of residency, years of experience, number of laparoscopic procedures attended, and correct identification of ureter course. ICG proved useful in identifying the correct ureteral trajectory. CONCLUSIONS: ICG can be a valuable tool to improve the correct identification of ureters and improve surgical outcomes.

Outcomes of conventional and advanced energy devices in laparoscopic surgery: a systematic review.

INTRODUCTION: Hemostasis is an important step in all surgical procedures. Mechanical methods of hemostasis have been gradually abandoned in favor of electrosurgery. The aim of this systematic review was to evaluate the effectiveness of electrosurgical instruments utilized in minimally invasive gynecological procedures. MATERIAL AND METHODS: We performed a systematic review, including randomized controlled trials, prospective and retrospective studies, comparing the outcomes of different energy devices (EDs) used in laparoscopic gynecologic surgeries. We extracted data about blood loss (BL), mean operative time, post-operative pain, hospital stay and complications associated with each electrosurgical device. RESULTS: We included 30 studies reporting comparative outcomes concerning conventional (bipolar and monopolar) and innovative EDs (Harmonic scalpel, LigaSure, Plasma kinetic gyrus, Thunderbeat, EnSeal, Marseal, Caiman and ALAN). New EDs were found to be more efficient in complex surgeries due to less intraoperative BL and shorter operative time. No significant decrease in hospital stay, post-operative pain or complications was found with the use of new energy instruments. CONCLUSIONS: Although new electrosurgical devices seem an appealing and safer option, there is still insufficient evidence for one vessel-sealing technology to be considered superior to another. Therefore, monopolar and conventional bipolar (CB) are still widely used in laparoscopic gynecology.

Surgical Neuropelveology: Laparoscopic Nerve-sparing Excision of a Pelvic Schwannoma.

STUDY OBJECTIVE: To show how advanced pelvic Schwannoma can be safely managed with a laparoscopic approach. DESIGN: Demonstration of the laparoscopic technique with narrated video footage. SETTING: Schwannomas are benign tumors that arise from well-differentiated Schwann cells (glial cells) of peripheral nerve sheaths. Schwannomas are nonaggressive, slow-growing, solitary masses with a low rate of malignant transformation and a low risk of recurrence after resection. They rarely occur in the pelvis, with a reported incidence of 1% to 3%. Tumors involving spinal nerve roots commonly present with radicular pain and nerve compression syndromes (Supplemental Video 1-3). This video shows the management of pelvic Schwannoma originating from the left sacral root S1 by a minimally invasive approach. INTERVENTIONS: Laparoscopic nerve-sparing excision of a pelvic Schwannoma. CONCLUSION: Historically, pelvic schwannomas have been managed mainly by laparotomy. Here, we demonstrate the feasibility and safety of a large pelvic Schwannoma excision by a minimally invasive approach.

Clinical Outcomes after the Use of Antiadhesive Agents in Laparoscopic Reproductive Surgery.

INTRODUCTION: Intra-abdominal adhesions are abnormal fibrous attachments between tissues and organs that can be congenital or acquired. Adhesion formation is a critical postoperative complication that may lead to bowel obstruction, chronic abdominal pain, and infertility. Physical barrier agents separate opposing peritoneal surfaces in the critical 5-day period of remesotheliazation. These agents are subdivided into solid or liquid/gel. Liquid agents seem easier to use in laparoscopic procedures than solid agents. METHODS: The search for suitable articles published in English was carried out using the following databases: MEDLINE, Embase, Global Health, the Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register), Health Technology Assessment Database, Web of Science, and search register (ClinicalTrial.gov). Only studies reporting data about the impact of the use of an antiadhesive agent on adhesion formation after a primary gynecologic laparoscopic surgery were considered eligible. RESULTS: Twenty-two papers that met the inclusion criteria were included in this systematic review. CONCLUSIONS: Surgeons should consider applying antiadhesive agents after gynecologic surgery to help reduce adhesion formation and its adverse effects. However, further studies are still needed to confirm their impact on reproductive outcome and to implement clear guidelines on their per-operative application.

Training in Diagnostic Hysteroscopy: The "Arbor Vitae" Method.

Background and Objectives: Diagnostic hysteroscopy is the gold standard in the diagnosis of intrauterine pathology and is becoming an essential tool in the daily practice of gynecology. Training programs for physicians are necessary to ensure adequate preparation and learning curve before approaching patients. The aim of this study was to describe the "Arbor Vitae" method for training in diagnostic hysteroscopy and to test its impact on the knowledge and skills of trainees using a customized questionnaire. Materials and Methods: A three-day hysteroscopy workshop combining theory and practical "hands on "sessions with dry and wet labs has been described. The aim of the course is to teach indications, instruments, the basic principles of the technique by which the procedure should be performed, and how to recognize and manage the pathologies that can be identified by diagnostic hysteroscopy. To test this training method and its impact on the knowledge and skills of the trainees, a customized 10-question questionnaire was administered before and after the course. Results: The questionnaire was administered to 34 participants. All trainees completed the questionnaire, and no missing responses were recorded. Regarding the characteristics of the participants, 76.5% had less than 1 year of experience in performing diagnostic hysteroscopy and 55.9% reported performing fewer than 15 procedures in their career. For 9 of the 10 questions embedded in the questionnaire, there was a significant improvement in the scores between pre- and post-course, demonstrating a perceived significant improvement in theoretical/practical skills by the trainees. Conclusions: The Arbor Vitae training model is a realistic and effective way to improve the theoretical and practical skills required to perform correct diagnostic hysteroscopy. This training model has great potential for novice practitioners to achieve an adequate level of proficiency before performing diagnostic hysteroscopy on live patients.

Use of botulinum toxin in aesthetic medicine and gynaecology: current approaches, controversies, and future directions.

This review looks at the use of botulinum toxin in the gynaecological field with the aim of determining what needs to be further investigated to achieve a standardized application. Numerous studies have been conducted to explore how botulinum toxins (BoNT) can be applied, and it is becoming popular for treating various disorders such as chronic pelvic pain, vestibulodynia, and vaginism. However, the exact dosage and ideal location for injections still need to be clarified. The objective of this study is to point out which aspects need to be more carefully studied to ensure a consistent use of BoNT in gynaecology.

Luteinised unruptured follicle syndrome: pathophysiological background and new target therapy in assisted reproductive treatments.

Luteinised unruptured follicle syndrome (LUFS) is a cause of infertility consisting in the unruptured of the dominant follicle after the LH-surge. In fact, during assisted reproductive treatments (ART) clomiphene citrate and letrozole are frequently administered in order to achieve ovulation. However, considering the pathophysiology of LUFS, new possible therapy can be proposed. On this scenario, we performed a review of the literature searching for LUFS recurrency and its impact in infertility and ART. An inflammation theory has been proposed that can be fuel for further therapeutic possibilities. In particular, considering the increase in granulocytes accumulation, the granulocyte colony-stimulating factor (G-CSF) administration has been proposed as target therapy in IUI cycles hampered by LUFS. Although data are encouraging, randomised controlled trials are needed in order to confirm the efficacy of G-CSF administration for LUFS patients.

Utero-cutaneous fistula after caesarean section delivery: diagnosis and management of a rare complication.

Utero-cutaneous fistula is an extremely rare condition characterized by an abnormal communication between the anterior wall of the uterus and the abdominal wall. The causes include multiple caesarean sections, incomplete hysterorrhaphy, miscarriages, uterine cavity revision, retention of placental material after delivery, use of drains, post-operative infections, or injuries. Herein, we report a case of a 38-year-old female, who underwent caesarean section 42 days earlier and presented to the emergency room complaining of fever, abdominal pain, and purulent discharge from the abdominal wall from 6 days. Her medical history included 2 previous term caesarean section deliveries and an hysteroscopic polypectomy 2 years earlier. A pelvic computed tomography scan with contrast medium showed fluid/super-fluid phlogistic collection reported at the anterior wall of the uterus with a continuous solution of the uterine wall itself. Magnetic resonance imaging demonstrated the presence of a probable hyperintense fistula, extended for 30 mm and 16 mm of thickness, which ended in the subcutaneous area with an abscess joint without continuous solution with the skin. A laparotomic surgical procedure was successfully performed. Histopathology confirmed the surgical suspect of utero-cutaneous fistula. Although utero-cutaneous fistula is an extremely rare complication, it should be considered if after caesarean section delivery signs and symptoms of skin inflammation and/or infection persist.

Fertility-Sparing Approach in Women Affected by Stage I and Low-Grade Endometrial Carcinoma: An Updated Overview.

Endometrial cancer (EC) is a deleterious condition which strongly affects a woman's quality of life. Although aggressive interventions should be considered to treat high-grade EC, a conservative approach should be taken into consideration for women wishing to conceive. In this scenario, we present an overview about the EC fertility-sparing approach state of art. Type I EC at low stage is the only histological type which can be addressed with a fertility-sparing approach. Moreover, no myometrium and/or adnexal invasion should be seen, and lymph-vascular space should not be involved. Regarding the pharmaceutical target, progestins, in particular medroxyprogesterone acetate (MPA) or megestrol acetate (MA), are the most employed agent in conservative treatment of early-stage EC. The metformin usage and hysteroscopic assessment is still under debate, despite promising results. Particularly strict and imperious attention should be given to the follow-up and psychological wellbeing of women, especially because of the double detrimental impairment: both EC and EC-related infertility consequences.

Early diagnosis and surgical management of heterotopic pregnancy allows us to save the intrauterine pregnancy.

Heterotopic pregnancy is a rare but intriguing disease, which poses a high risk for pregnant women and for intrauterine pregnancy. Clinically, it is mainly characterized by pain and vaginal bleeding. b-hCG serum dosage is used to detect the pregnancy, but transvaginal ultrasound is needed to diagnose heterotopic pregnancy. From all the risk factors, the assisted reproductive treatments represent the most important, especially when multiple embryos are transferred. Patients with a heterotopic pregnancy are at risk of having a spontaneous or medically induced abortion, and for this reason appropriate and tailored treatment should be considered, pursuing the optimal risk/benefit ratio. Although conservative treatments are available in the case of only extrauterine pregnancy, such as methotrexate, often the laparoscopic approach seems unavoidable in heterotopic pregnancy. To preserve the intrauterine pregnancy, a conservative treatment is remarkable, both salpingotomy or salpingostomy. In this case report, we present a successful laparoscopic treatment of an extrauterine pregnancy with the prosecution of the intrauterine pregnancy up to the third trimester. In particular, a 25-year-old girl referred to the Villa Sofia Cervello Hospital complaining of abdominopelvic pain and vaginal bleeding for 2 days. The salpingectomy approach was performed, and every anatomical piece was sent for histopathology.

Myo-inositol in assisted reproductive technology from bench to bedside.

Inositols are insulin-sensitizing compounds of promising efficacy in the management of polycystic ovary syndrome (PCOS). On the one hand, myo-inositol (myo-ins) plays a regulatory role in male and female reproductive function, influencing the development of oocytes, spermatozoa, and embryos. On the other hand, high concentrations of D-chiro-inositol (D-chiro-ins) in the ovary may adversely affect oocyte quality. This review analyses the available literature, which encourages the clinical use of myo-ins in assisted reproductive technologies (ARTs) due to its beneficial effects on female and male reproduction.

Hormonal Therapies before in vitro fertilization in women with endometriosis: The Minotaur's Labyrinth and the Ariadne's Thread.

Endometriosis-related infertility is one of the most debated topics in reproductive medicine. In recent years, prolonged pre-cycle hormonal regimens gained attention as a mean of improving the assisted reproduction technologies (ART) success rates in endometriosis patients. GnRH agonists, dienogest, medroxyprogesterone acetate, and aromatase inhibitors are the most studied medications. Conflicting results and a high risk of bias exist in almost all of the conducted studies in the field. However, current evidence suggests that pre-cycle treatment with GnRH agonists may be beneficial for patients with stage III/IV endometriosis. Dienogest and medroxyprogesterone acetate-based progestin-primed ovarian stimulation protocol was shown to be comparable to the prolonged GnRH agonists protocol. Finally, aromatase inhibitors seem to be of limited benefit to the assisted reproductive outcomes of endometriosis patients. Although it is challenging to draw any clinical conclusions, pre-cycle hormonal treatments seem to be best indicated in endometriosis patients who had previously failed ART treatment.