The effect of unilateral tubal block diagnosed by hysterosalpingogram on clinical pregnancy rate in intrauterine insemination cycles: systematic review and meta-analysis.

BACKGROUND: Fallopian tube occlusion is a common cause of infertility, but the effect of unilateral tubal block (UTB) on pregnancy rates (PR) after controlled ovarian hyperstimulation and intrauterine insemination (COH-IUI) remains controversial. OBJECTIVE: To evaluate PR after COH-IUI among infertile women with proximal and distal UTB diagnosed by hysterosalpingogram (HSG), compared against women with bilateral patent tubes experiencing unexplained infertility. SEARCH STRATEGY: We searched EMBASE, MEDLINE, Google Scholar, Cochrane Library, and PUBMED from inception to 14 January 2018. SELECTION CRITERIA: Studies that report PR/cycle or cumulative PR among women with UTB and controls were included. DATA COLLECTION AND ANALYSIS: Two authors independently selected and extracted study characteristics and data. Methodological quality was assessed using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. MAIN RESULTS: Among 2965 patients and 5749 IUI cycles across ten studies, no significant difference in PR/cycle (odds ratio, OR = 0.88; 95% confidence interval, 95% CI = 0.69-1.12) and cumulative PR (OR = 0.80, 95% CI = 0.62-1.04) was observed. Patients with proximal UTB demonstrated similar PR/cycle (OR = 1.06, 95% CI = 0.68-1.66) and cumulative PR (OR = 1.10, 95% CI = 0.75-1.62), compared with controls, whereas patients with distal UTB had significantly lower cumulative PR (OR = 0.49, 95% CI = 0.25-0.97, P = 0.04). Patients with proximal block also demonstrated significantly improved cumulative PR, compared with patients with distal block (OR=2.41, 95% CI = 1.37-4.25, P = 0.002). CONCLUSION: Infertile patients with proximal UTB diagnosed by HSG can expect similar pregnancy rates after COH-IUI, compared with those with bilateral tubal patency and unexplained infertility, whereas patients with distal UTB have lower odds of pregnancy. These differences may reflect inherent diagnostic limitations of HSG or differences in underlying pathologies. TWEETABLE ABSTRACT: Meta-analysis evaluates pregnancy outcomes after COH-IUI in women with unilateral tubal block diagnosed by HSG.

Apoptosis and expression of Bcl-2, Bax, p53, caspase-3, and Fas, Fas ligand in placentas complicated by preeclampsia.

AIM: To determine whether preeclampsia is associated with an increase in placental apoptosis and altered expression of mediators of apoptosis such as Fas, Fas ligand, caspase-3, p53, Bcl-2 and Bax. METHODS: Placental samples obtained from 20 women with preeclampsia and 14 normal women were analyzed using the Klenow, Frag-EL DNA fragmentation detection kit for apoptosis. Expression of Fas, Fas ligand, caspase-3, p53 Bcl-2, and Bax was assessed using immunohistochemistry. RESULTS: The median percentage of apoptotic nuclei in trophoblasts was significantly higher for the preeclampsia group than for the controls (6.9 vs 0.25; p =.001). Fas ligand expression was significantly higher in the decidua among the subjects with preeclampsia compared with controls (1.2 vs 0; p = .023). Otherwise no difference was observed in the expression of Bax , Bcl-2, p53, caspase-3, and Fas between groups. CONCLUSION: Increased apoptosis in preeclampsia may not be associated with significant alterations in Fas, Fas ligand, caspase-3, p53, Bcl-2 and Bax expression.

The distribution of angiopoietin-1, angiopoietin-2 and their receptors tie-1 and tie-2 in the very early human placenta.

Angiopoietins are integral to vasculogenesis and angiogenesis, which play crucial roles in the growth and development of the placenta. The current study assessed expression of angiopoietins (Ang-1 and Ang-2) and their receptors (Tie-1 and Tie-2) during development of the early human placenta. First-trimester placental tissues were obtained from women undergoing curettage during normal pregnancies. The use of immunohistochemistry (IHC) showed that Ang-1 was primarily localized to syncytiotrophoblasts where it displayed moderate immunoreactivity, whereas weak immunoreactivity for Ang-1 was observed in endothelial cells and angiogenic cell cords (ACC). Strong immunoreactivity for Ang-2 was also found predominantly in syncytiotrophoblasts with lower immunostaining levels evident in cytotrophoblasts. Moderate immunoreactivity for Ang-2 was observed in endothelial cells, ACC and Hofbauer cells. By contrast, the trophoblastic shell, as well as endothelial cells and ACC exhibited strong staining intensity for Tie-1 with the strongest immunoreactivity for Tie-2 observed in cytotrophoblasts, ACC and endothelial cells. Western blotting of tissue extracts confirmed the IHC results. Previous studies focused on VEGF and its receptors in controlling vasculogenesis and angiogenesis in human placenta. However, the specific localization patterns of angiopoietins and their receptors revealed by the current study emphasize the importance of these molecules in placental vascular development. Functional studies aimed at identifying the molecular mechanisms of actions of these factors and receptors may prove essential in elucidating the pathophysiology of placental disorders such as intrauterine growth restriction and pre-eclampsia.

Effects of micronized purified flavonoid fraction (Daflon) on pelvic pain in women with laparoscopically diagnosed pelvic congestion syndrome: a randomized crossover trial.

BACKGROUND: We evaluated the effects of daflon, a venomimetic agent that regulates the circulatory tonus of the venous system, on pelvic pain and investigated the role of enlarged veins in the pathophysiology of pelvic congestion syndrome. METHODS: Twenty women (age 28-35 yrs) with chronic pelvic pain were diagnosed with the syndrome at laparoscopy. They all had prominent broad ligaments and ovarian veins without other pathologies such as endometriosis to explain the etiology of pelvic pain. Ten women were randomized in a fashion to receive 500 mg of Daflon twice/daily for six months, and ten a vitamin pill for placebo effect; they were crossed over for another six months. RESULTS: At the end of the third month, the frequency and severity of pelvic symptoms began to decrease with daflon compared with the pretreatment and vitamin arm. The mean scores were significantly less at the end of six months, respectively, p < 0.05. CONCLUSIONS: Pharmacologic enhancement of venous tonus may restore pelvic circulation and relieve pelvic symptomatology.

In vitro comparison of four tocolytic agents, alone and in combination.

OBJECTIVE: To compare the tocolytic effects of magnesium sulfate, ritodrine, terbutaline, and nifedipine on human myometrial strips. METHODS: Myometrial strips were suspended in organ chambers for isotonic measurements and contracted with KCI. STrips from nonpregnant patients were used to obtain concentration-response curves. Myometrial strips from pregnant uteri were then exposed to the molar concentrations causing 50% relaxation in the nonpregnant tissues. RESULTS: In strips from nonpregnant patients, nifedipine was found to be the most potent tocolytic. Using strips from nonlaboring patients, nifedipine caused relaxation similar to ritodrine, and both were more effective than magnesium sulfate or terbutaline. Combinations were more effective than single agents. These agents were found to be equally less effective in myometrial strips from laboring patients. CONCLUSIONS: Nifedipine, alone or in combination, relaxes myometrial strips more effectively than the other agents studied. Myometrial strips from laboring patients are more resistant to inhibition, with none of the agents being superior.

An incidental diagnosis of well-differentiated papillary mesothelioma in a woman operated on for recurrent endometriosis.

The case presented involves a report of severe endometriosis with recurrent disabling dysmenorrhea associated with well-differentiated mesothelioma. Although the course of mesotheliomas is predominantly benign, the diversity of lesions, variable behavior, and resemblance, and association with endometriosis warrant thorough diagnostic investigation. Multiple biopsies and differential diagnoses are recommended in cases of peritoneal endometriosis.

Term pregnancy after fallopian tube transposition.

A 28-year-old woman suffered from pelvic pain and secondary infertility. She previously had right salpingo-oophorectomy because of ruptured right cornual EP. She was found to have a normal appearing left fallopian tube that entered into a noncommunicating residual horn of the uterus. Microsurgical transposition of the left tube and tubouterine implantation was performed successfully. For cases in which tubocornual anastomosis of the transposed tube is impossible because of previous cornual resection, our technique remains an option.

Comparison of the effects of ovarian cauterization and gonadotropin-releasing hormone agonist and oral contraceptive therapy combination on endocrine changes in women with polycystic ovary disease.

OBJECTIVE: To study the effects of laparoscopic ovarian cauterization and combination of long-acting GnRH agonist (GnRH-a) and oral contraceptive (OC) therapy on endocrine changes in women with clomiphene citrate (CC)- resistant polycystic ovary disease (PCOD). DESIGN: Prospective, randomized. SETTING: University-based infertility clinic. PATIENTS: Seventeen women with CC-resistant PCOD were included randomly in the study to either laparoscopic ovarian cautery or GnRH-a and OC therapy for 3 months. MAIN OUTCOME MEASURES: Serum concentrations of LH, FSH, androstenedione (A), T, and sex hormone-binding globulin (SHBG) were determined before each therapeutic approach and during the follicular phase of first menstrual cycle after the cessation of each treatment. RESULTS: The mean serum concentrations and the clinical profiles were similar in both groups. Both groups showed significant changes in LH, FSH, A, T, and SHBG compared with pretreatment levels. There were no significant differences in the final concentrations of LH, FSH, and A between the two study groups after each treatment, whereas T and SHBG levels were significantly different in the goserelin and OC group. The decrease in LH and increase in SHBG serum concentrations were greater in the goserelin and OC-treated women [-59% and + 5.9% versus - 70% and + 13.5%, respectively]. Although the SHBG concentration increased in both groups, the serum SHBG concentration of the goserelin and OC group was significantly higher than the other group. CONCLUSION: Both therapeutic modalities revealed similar effects on the endocrine profiles in women with CC-resistant PCOD. Considering the invasiveness, cost, and potential complications of laparoscopic ovarian cauterization, noninvasive medical treatment with GnRH-a and OC combination may be more effective in restoring the optimal follicular environment in women with PCOD.

PIP: This paper reports findings from the study of the comparative effects of laparoscopic ovarian cauterization and combined long-acting GnRH agonist (GnRH-a) and oral contraceptive (OC) therapy upon endocrine changes in women with clomiphene citrate (CC)-resistant polycystic ovary disease (PCOD). 17 women with CC-resistant PCOD were included randomly into the prospective study of either laparoscopic ovarian cautery or GnRH-a and OC therapy for three months. Both therapeutic approaches produced similar effects upon the endocrine profiles of women with CC-resistant PCOD, with both groups showing significant changes in LH, FSH, androstenedione, T, and sex hormone binding globulin compared with pretreatment levels. However, given the invasiveness, cost, and potential complications of laparoscopic ovarian cauterization, noninvasive medical treatment with GnRH-a and OC may be the most practical and appropriate approach to restoring the optimal follicular environment in women with PCOD.

Effectiveness of tibolone on hypoestrogenic symptoms induced by goserelin treatment in patients with endometriosis.

OBJECTIVE: To investigate the efficacy and safety of tibolone on hypoestrogenic vasomotor symptoms and bone parameters in patients treated with goserelin acetate. DESIGN: Prospective, randomized placebo controlled double-blind study. SETTING: Human volunteers in a university-based fertility clinic. PATIENT(S): Twenty-nine women of mean age 29.2 +/- 4.8 years with mild to severe endometriosis undergoing 6 months of treatment with 3.6 mg goserelin acetate in an SC depot formulation were studied. INTERVENTION(S): The patients were allocated randomly to either 2.5 mg/d tibolone (n = 15) or an iron pill (n = 14) in a double-blinded fashion beginning in the third cycle. MAIN OUTCOME MEASURE(S): Frequency and severity of hot flushes, sweating, irritability, loss of libido, nervousness, and sleeplessness were assessed by the patients using 0 to 6 point scoring system and compared. Samples of urine were obtained for calcium and creatinine (Ca:Cr) ratios at the start of treatment and monthly there after. The vasomotor scoring for each symptom and Ca:Cr ratios before the treatment and at the end of 6th month were analyzed by parametric and nonparametric tests. RESULT(S): The mean age, weight, vasomotor scores, pelvic scores, and urine Ca:Cr ratios were similar in both placebo and tibolone group (28.7 +/- 4.8 versus 27.6 +/- 6.3 years, 50.9 +/- 5.3 versus 53.1 +/- 7.1 kg, 4.7 +/- 1.1 versus 4.2 +/- 0.8, and 0.056 +/- 0.008 versus 0.059 +/- 0.006, respectively). The decreases in vasomotor scoring as regards to hot flushing, sweating, and other associated symptoms were statistically significant in tibolone group compared with placebo (10.4 +/- 1.6 versus 24.6 +/- 4.9). During the study significant reductions in urine Ca:Cr ratio was obtained in the tibolone patients compared with placebo (0.031 +/- 0.006 versus 0.0055 +/- 0.007). The incidence of side effects (weight change, vaginal bleeding) was low and did not differ from the placebo group. CONCLUSION(S): Considering the beneficial effects of tibolone on vasomotor symptoms and bone loss, our data suggest that this synthetic steroid is an effective and safe option in relieving symptoms induced by GnRH-analogue.

High doses of oral contraceptives do not alter endometrial alpha 1 and alpha v beta 3 integrins in the late implantation window.

OBJECTIVE: To assess the effects of an emergency contraceptive agent on the distribution of integrin heterodimers during that part of the implantation window. DESIGN: Prospective, case-controlled study in a university-based Population Program. In the first ovulatory control cycle after the detection of LH surge, patients had endometrial sampling 11 days after the surge. In the next cycle the procedure was repeated 2 days after the administration of a postcoital contraceptive agent on day 9 after LH surge (100 g ethinyl E2 and 2 mg norgestrel). MAIN OUTCOME MEASURES: The effects of postcoital contraceptives on the expression of integrin heterodimers (alpha 1 and alpha v beta 3 subunits) reported to be unique to secretory phase was determined. RESULTS: All six specimens were consistent histologically with days 24 and 25 of the menstrual cycle by light microscopy. Using immunohistochemistry, strong membrane staining of endometrial glandular cells and superficial epithelium for both alpha 1 subunit and vitronectin (alpha v beta 3) receptor was observed in treatment and controls. No diminution of intensity or distribution was observed relative to pretreatment controls. CONCLUSIONS: There is no apparent change in the level of these two integrins in the human endometrium when high-dose oral contraceptives are given in the later stages of the implantation window. This suggests that the high doses of steroids used in emergency contraceptives may exert their effect through more complex mechanisms than endometrial cell surface changes.

PIP: In the human female, high doses of estrogen have been used to prevent implantation of the fertilized egg. Integrins function as receptors and play an important role in blastocyst attachment to the uterine wall. This article reports the findings of a study which tested what effects an emergency contraceptive agent has on integrin spread during the effective implantation window. Three women with regular menstrual cycles volunteered for this study. Endometrial biopsies were performed before any hormonal treatment; these samples were considered controls. These same patients were then orally given 100 g ethinyl E2 and 2 mg norgestrel. 11 days later a second endometrial biopsy was taken. All samples were divided into two groups. One group was fixed in glutaraldehyde and prepared for light microscopy examination. The second group was frozen in liquid nitrogen and subsequently used for cryosection examination. Immunohistochemistry techniques were performed on the tissues. No morphological differences were observed between the two groups. Immunohistochemistry results were unremarkable. Expected luteal phase endometrial changes were not observed. These results show that there is no apparent change in the level of different integrins in the human endometrium when high doses of oral contraceptives are administered. This further suggests that high doses of steroids used for preventing blastocyst implantation may not work through changes in the endometrial cell surface receptivity as previously believed.

Chronic ectopic pregnancy after clinically successful methotrexate treatment of ectopic pregnancy.

Persistent ectopic pregnancy, often a sequelae of conservative surgical procedures, is characterized by a residual trophoblastic activity site with rising or plateauing beta-human chorionic gonadotropin (hCG) titers after the initial treatment. Chronic ectopic pregnancy is a different entity which may be seen after expectant management of ectopic pregnancy and contains no active trophoblast with low or absent beta-hCG titers. A rare case with features of a chronic ectopic pregnancy, which followed successful methotrexate medical treatment of a persistent ectopic pregnancy, is presented.

Laparoscopic vaporization of diaphragmatic endometriosis in a woman with epigastric pain: a case report.

BACKGROUND: Endometriosis has been observed in 8-15% of reproductive age women and is commonly found in pelvic and nonpelvic organs. Despite its widespread prevalence, the etiology remains obscure. CASE: A 22-year-old woman with intractable epigastric and pelvic pain who was treated previously by laser ablation for pelvic and diaphragmatic endometriosis was referred to our clinic. The patient received leuprolide acetate for six months, but the symptoms did not improve. Second-look laparoscopy revealed deep endometriotic spots involving both the diaphragms, exactly in the line of the left ventricle. With visualization, endometriosis was excised in total with the help of hydrodissection and CO2 vaporization. CONCLUSION: As in pelvic endometriosis, therapy for extrapelvic endometriosis consists of surgical and hormonal manipulation following the diagnosis. The importance of extreme caution, meticulous surgery and cardiothoracic consultation when treating the diaphragmatic surface cannot be overemphasized.

Organochlorine residue and toxic metal (Pb, Cd and Cr) levels in the surface sediments of the Marmara Sea and the coast of Istanbul, Turkey.

In this study, organochlorine and toxic metal (Pb, Cd and Cr) analyses have been done in the surface sediments. Sediment samples have been collected from 7 parts of the Marmara Sea and the coast of Istanbul during 2009. Total Pb, Cd and Cr contents vary between 32 µg g(-1) and 122 µg g(-1); 0.19 µg g(-1) and 1.16 µg g(-1); 62 µg g(-1) and 372 µg g(-1), respectively. EF values of Pb and Cr are higher than 1.5 in all the stations. EF value of Cd is considerably high at Station MY1 (Tuzla Port). Total organochlorine residue contents range between 4.33 ng g(-1) and 22.2 ng g(-1) in the surface sediments.

Metal (Al, Fe, Mn and Cu) distributions and origins of polycyclic aromatic hydrocarbons (PAHs) in the surface sediments of the Marmara Sea and the coast of Istanbul, Turkey.

In this study, total metal (Al, Fe, Mn and Cu) and PAHs analyses have been done in the surface sediments. Sediment samples have been collected from seven parts of the Marmara Sea and the coast of Istanbul during 2009. Total Al, Fe, Mn and Cu contents vary between 1.8% and 5.4%; 1.1% and 2.8%; 122 and 259 µg g(-1); 27 and 416 µg g(-1), respectively. EF and CF values of Fe and Mn are lower than 1.5 and 1, respectively, in all the stations. Total PAH contents range between 135 and 6009 ng g(-1) in the surface sediments. The origin of PAHs has been found pyrolitic according to the Phe/Ant ratio in the all stations. Contrastingly, at K0, MKC and MY1 Stations, PAH origins have been observed petrogenic according to the Flu/Pyr ratio.

Laparoscopic repair of bladder injury and laceration.

The management of bladder injuries at laparoscopy is controversial. Some endoscopists believe in mandatory open repair, whereas others recommend laparoscopic cystotomy repair. We performed laparoscopy to treat two women with bladder injury, one with excision of a transmural nodule of bladder endometriosis, and the other with incidental cystotomy during adenexectomy in the presence of obliterative adhesions. After localizing the injury to the dome of the bladder remote from ureters, the edges of the injury were cleaned of damaged tissue and apposed in two layers using interrupted 4-0 polydioxanone endocorporeal sutures. The patients had an uneventful postoperative course, and neither experienced bladder function problems. We conclude that applying the already established tenets of bladder injury repair by laparotomy to laparoscopic procedures is acceptable in most endoscopic settings.

Normal pregnancy outcome after inadvertent exposure to long-acting gonadotrophin-releasing hormone agonist in early pregnancy.

Five infertile women exposed to long-acting gonadotrophin-releasing hormone agonist (GnRHa) during early pregnancy were studied to assess the risks of embryotoxicity on the outcome of their pregnancies. All the patients were diagnosed as stage 3-4 endometriosis following laparoscopy. Long-acting GnRHa (3.75 mg) was given in the first 3 days of their preceding menstrual period. Four of the five patients had two GnRHa injections and the last patient had three GnRHa injections. All patients were advised to use a barrier contraception (condoms) throughout the treatment period. Since all complained of no bleeding following the initial injections, human chorionic gonadotrophin (beta-HCG) concentrations were tested in order to rule out any pregnancy. Ultrasonographic examinations were commenced routinely and all patients had amniocentesis at 16-18 weeks gestational age. Genetic analysis revealed a normal karyotype in all fetuses. All five pregnancies progressed to term without complication, and normal healthy infants were delivered. Although there are still no clear answers concerning teratogenic and hormonal effects of GnRHa exposure in pregnancy, our data may suggest that luteal function, genetic structure and pregnancy outcome are not adversely affected by GnRHa. Since possible subtle effects on fetal endocrine organs cannot be disregarded, close monitoring is still needed in GnRHa-exposed pregnancies.