Surgical Management of Ovarian Endometrioma: Impact on Ovarian Reserve Parameters and Reproductive Outcomes.

Ovarian endometriomas have a negative impact on a patient's reproductive potential and are likely to cause a reduction in ovarian reserve. The most commonly employed ovarian reserve parameters are anti-Müllerian hormone (AMH) and antral follicular count (AFC). Surgical management options of endometrioma include cystectomy, ablative methods, ethanol sclerotherapy and combined techniques. The optimal surgical approach remains a matter of debate. Our review aimed to summarize the literature on the impact of surgical management of endometrioma on AMH, AFC and fertility outcomes. Cystectomy may reduce recurrence rates and increase chances of spontaneous conception. However, a postoperative reduction in AMH is to be anticipated, despite there being evidence of recovery during follow-up. The reduction in ovarian reserve is likely multi-factorial. Cystectomy does not appear to significantly reduce, and may even increase, AFC. Ablative methods achieve an ovarian-tissue-sparing effect, and improved ovarian reserve, compared to cystectomy, has been demonstrated. A single study reported on AMH and AFC post sclerotherapy, and both were significantly reduced. AMH levels may be useful in predicting the chances of conception postoperatively. None of the aforementioned approaches has a clearly demonstrated superiority in terms of overall chances of conception. Surgical management of endometrioma may, overall, improve the probability of pregnancy. Evidence on its value before medically assisted reproduction (MAR) is conflicting; however, a combination of surgery followed by MAR may achieve the optimal fertility outcome. In view of the complexity of available evidence, individualization of care, combined with optimal surgical technique, is highly recommended.

The predictive value of maternal serum AFP to PAPP-A or b-hCG ratios in spontaneous preterm birth.

The use of the second trimester alpha-fetoprotein (AFP) along with the first trimester pregnancy-associated plasma protein-A (PAPP-A) has been found to be useful in the estimation of unfavourable pregnancy outcome. Our aim in this study was to determine the relationship between maternal PAPP-A and b-hCG and AFP concentrations in spontaneous preterm birth (sPTB). This prospective cohort study included 372 singleton pregnancies with PAPP-A, b-hCG and AFP levels in the first trimester, which were converted to multiples of the median (MoM). The predictive ability of AFP-to-PAPP-A and AFP-to-b-hCG ratios for sPTB was evaluated. The risk for sPTB ≤34 weeks increased in women with AFP-to-PAPP-A ratio >7 (OR 2.9, 95% CI 1.2-6.4). Women with AFP-to-b-hCG ratio >0.6 had a 3.5-fold higher risk for sPTB ≤32 weeks. Increased maternal AFP-to-PAPP-A or AFP-to-b-hCG ratios in the first trimester may help to predict pregnant women at high risk for sPTB, and this may be beneficial in developing management plans.Impact StatementWhat is already known on this subject? There is a synergistic association between the combination of low pregnancy-associated plasma protein-A (PAPP-A) in the first trimester with alpha-fetoprotein (AFP) in the second trimester with subsequent development of PTB. Maternal serum biochemical markers measured as a part of aneuploidy screening are reflective of pregnancy adverse outcomes related with placental insufficiency. PAPP-A and AFP have a low predictive ability to determine women at high risk for preterm birth.What do the results of this study add? Elevated AFP:PAPP-A or AFP:B-HCG ratio in the first trimester is associated with increased risk for sPTB. The ratios of these biochemical markers in the first trimester may be beneficial to identify women at high risk for sPTB.What are the implications of these findings for clinical practice and/or further research? The ratios may predict pregnant women at high risk for sPTB, and such risk may be helpful in the development of a management plan. Incorporation of AFP:PAPP-A or AFP:B-HCG ratios in the first trimester may help to improve the screening efficacies, and provide a simple alternative tool.

T-Cadherin, E-Cadherin, PR-A, and ER-α Levels in Deep Infiltrating Endometriosis.

The goal of this study was to compare the T-cadherin, E-cadherin, progesterone receptor (PR), and estrogen receptor (ER) staining levels of deep infiltrating endometriosis (DIE) tissue, ovarian endometriomas and normal endometrial tissues in the same individuals. The tissue sections of both DIE nodule(s) and endometrioma(s) of 15 cases were examined. As a control group, normal endometrial tissue sections of 23 cases were examined. T-cadherin, E-cadherin, ER-α, and PR-A staining levels of DIE, endometrioma tissues, and endometrial tissues were compared immunohistochemically. H -score was calculated to compare the expression of T-cadherin, E-cadherin, ER-α, and PR-A in immunohistochemical staining based on the percentage of cells stained at each intensity level. T-cadherin, E-cadherin, ER, and PR H -score were lowest in DIE tissue and highest in endometrial tissue ( P <0.0001, <0.0001, <0.0001, and <0.0001, respectively). In correlation analysis, a positive correlation was found between T-cadherin, E-cadherin, PR, and ER H -score ( P <0.0001 for each). T-cadherin, E-cadherin, ER, and PR H -score were lowest in DIE tissue and highest in endometrium tissue. We think that examination of DIE tissue and endometrioma tissue from the same individual excludes the possibility of an effect due to different genetic and environmental factors from different individuals. With the help of this exclusion we showed that DIE and endometrioma have different biological properties.

A multimodal concept for vaginal cuff closure by modification of the Bakay technique in total laparoscopic hysterectomy: a randomized clinical study.

BACKGROUND: The aim of this study was to compare the outcomes of modified Bakay technique (MT) to standard colpotomy (ST) and cuff closure in total laparoscopic hysterectomy (TLH). METHODS: This two-centre, randomized-controlled study included a total of 160 patients who were scheduled for TLH for benign diseases (ClinicalTrials.gov Identifier is NCT05080114 and the first posted date was 15/10/2021). The patients were allocated into two groups by a computer-based randomization programme as ST group and MT group. Total operative time, cuff closure time, length of hospital stay, intra- and postoperative complications according to the Clavien-Dindo classification, pre- and postoperative vaginal length, and patient satisfaction according to the Patient Global Impression of Improvement (PGI-I) questionnaire were assessed. RESULTS: Seventy-seven patients in the ST group and 80 patients in the MT group underwent TLH. The total operative time was significantly shorter in the MT compared to the ST (55.5 vs. 59 min, respectively; p = 0.001). The median total operative time for colpotomy, extraction of uterus, and vaginal cuff closure steps was 9 (range 6-12 in MT vs. 6 to 11 in ST) min in both groups. The median hospital stay was 2 (range 1-4) days in both groups. Intraoperative blood loss was not significantly different between the groups (90 mL in ST vs. 80 mL in MT; p = 0.456). The mean uterine weight for the ST group and MT group was comparable (258.6 ± 88.6 g vs. 232.9 ± 102.5 g, respectively; p = 0.107). The preoperative vaginal length was not significantly different between the groups (p = 0.502). The median postoperative vaginal length was significantly higher in the MT group compared to the ST group on Day 90 (8 cm vs. 7,5 cm, respectively; p = 0.001). The PGI-I questionnaire score on Day 90 postoperatively was 2 (range 1-5) in both groups (p = 0.636). The complication rates were similar between the groups (p = 0.230). CONCLUSION: The MT can be safely performed in most of the cases requiring TLH with the advantages of vaginal cuff closure before the alteration of pelvic anatomy, support to primary healing of the vaginal cuff, and routine concomitant apical support.

The deep infiltrating endometriosis tissue has lower T-cadherin, E-cadherin, progesterone receptor and oestrogen receptor than endometrioma tissue.

OBJECTIVE: To compare the T-cadherin, E-cadherin, PR and ER staining levels of deep infiltrating endometriosis (DIE) tissue, ovarian endometriomas and normal endometrial tissues. MATERIALS AND METHODS: DIE tissue of 24 cases, endometrioma of 30 cases and normal endometrial tissues of 30 cases were examined. T-cadherin, E-cadherin, ER-α and PR-α staining levels of DIE, endometrioma tissues and endometrial tissues were compared immunohistochemically. H-score was calculated to compare the expression of T-cadherin, E-cadherin, ER-α, PR-α in IHC staining based on the percentage of cells stained at each intensity level. RESULTS: T-cadherin, E-cadherin, ER and PR H-score were found lowest in DIE tissue and the highest in endometrial tissue (p < 0.0001, <0.0001, <0.0001 and < 0.0001, respectively). In correlation analysis, a positive correlation was found between T-cadherin, E-cadherin, PR and ER H-score (p < 0.0001 for each). No correlation was found between age, body mass index (BMI), visual analog scale (VAS) score, CA125, endometrioma size and the severity of dysmenorrhea, dyspareunia and dystonia (p > 0.05). CONCLUSION: T-cadherin, E-cadherin, ER and PR H-score were found lowest in DIE tissue, the highest in endometrium tissue. The finding of lower expression of PR-α in endometriotic nodule in our study may be related to decrease in progesterone effect which could not inhibit the decrease in the expression of T-cadherin and E-cadherin, thus the invasiveness of DIE tissue. These findings suggest that DIE tissue and ovarian endometrioma tissues have a different biology.

A Comparative Multicentric Study on Serosal and Endometrial Myomectomy During Cesarean Section: Surgical Outcomes.

OBJECTIVE: This multi-center study aims to determine the efficiency and safety of endometrial myomectomy (EM) for the removal of uterine fibroids during cesarean section (CS). METHODS: Retrospective review of 360 women diagnosed for fibroids during pregnancy. They all delivered by CS between 2014 and 2019. The study groups included 118 women who only underwent EM, 120 women who only had subserosal myomectomy by traditional technique and 122 women with fibroids who decided to avoid cesarean myomectomy, as control group. They were analyzed and compared the surgical outcomes. RESULTS: The EM, subserosal myomectomy and control groups were statistically (p > 0.05) similar for to age, body mass index (BMI), gravidity, parity, gestational age at delivery, indications for CS, number of excised fibroids, size of the largest myoma. Postoperative hemoglobin values and ? (?) hemoglobin concentrations were lower in SM group (10.39gr/dl vs 9.98 gr/dl vs 10.19 - 1.44 gr/dl vs 1.90 gr/dl vs 1.35; p = 0.047, p = 0.021; respectively) Hybrid fibroids were significantly more frequent in the EM group than subserosal myomectomy and control groups (respectively, 33.1% vs 23.3% vs 27.0%, p = 0.002). Surgery time was significantly longer in the subserosal myomectomy group than EM and control groups (respectively, 46.53 min vs 37.88 min vs 33.86 min, p = 0.001). Myomectomy took significantly longer time in the subserosal myomectomy than EM group (13.75 min vs 8.17 min, p = 0.001). CONCLUSIONS: Endometrial myomectomy is a feasible choice for treatment of fibroids during CS, and, basing on our results could be an alternative to traditional cesarean subserosal myomectomy.

Reproductive outcome after operative hysteroscopy for uterine septum: scissors or diathermy?

INTRODUCTION: Hysteroscopic septoplasty is a safe and routinely used procedure for the treatment of septate uterus. The aim of this paper is to determine which hysteroscopic technique (scissors, monopolar/bipolar diathermy) is superior for post-treatment reproductive outcome. EVIDENCE ACQUISITION: Two different hysteroscopic septoplasty instruments (scissors and monopolar/bipolar diathermy) were compared, focusing on the pregnancy outcome. In addition, all published studies and reviews regarding pregnancy outcomes that occurred after operative hysteroscopy using different techniques (bipolar, monopolar electrodes, resectoscope, VERSAPOINT™ [Ethicon LLC] and scissors) were reviewed. Dichotomous analysis, with use of the Mantel-Haenszel method, was performed for all five outcomes, with fixed effect analysis model and odds ratio (OR) as the effect measure. Analysis details included totals and subtotals with 95% confidence interval. The Multinomial CI package for the R statistical language was also used. EVIDENCE SYNTHESIS: Out of 26 full-text articles available in the literature, two studies were finally selected as eligible, with a total number of 125 patients. Pregnancy rate for scissors was 88.8% and for resectoscope was 75.6% (OR: 2.13, I2=29%; P=0.23). Delivery rate for scissors was 78.1% and for resectoscope was 75.0% (OR: 1.29, I2=0%; P=0.53). Miscarriage rate for scissors was 21.8% and for resectoscope was 27.1% (OR: 0.78, I2=0%; P=0.53). Preterm delivery rate for scissors was 6.2% and for resectoscope was 6.7% (OR: 0.85, I2=0%; P=0.94). Term delivery rate for scissors was 71.8% and for resectoscope was 66.1% (OR: 1.32, I2=0%; P=0.47). The lack of evidence in literature regarding the potential influence in the reproductive outcome of the instrument used when performing a hysteroscopy to treat a septate uterus became radically clear. CONCLUSIONS: No statistically significant differences were observed in reproductive outcomes between women treated for septate uterus using resectoscope or scissors.

Laparoscopic Diagnosis and Treatment of Obturator Nerve Entrapment Because of a Deep Infiltrating Endometriotic Nodule: A Case Report.

Deep infiltrating endometriosis (DIE) is a particular form of endometriosis causing a variety of severe pelvic pain in women. The involvement of peripheral nerves by DIE implants is very rare. The most common involved site is the sacral plexus. There are few reported cases of involvement of the obturator nerve by DIE. To our knowledge, only 6 cases of symptomatic obturator nerve involvement by DIE have been described (according to PubMed database search in July 2018), and 3 of them were treated laparoscopically. We report a rare case of a deep infiltrating endometriotic nodule entrapping the right obturator nerve. Unlike the previously reported cases, patient history, clinical and laboratory data, and missed findings in previous imaging studies made our case difficult to diagnose. We successfully diagnosed the case and treated the patient with laparoscopic surgery. A video showing the surgery is also included. The recent follow-up in July 2018 (18 months after the operation was performed in January 2017) showed no signs or symptoms of recurrence or any other new complaints. The 18-month follow-up for this case is the longest follow-up data reported in the literature.

Evaluation of smoking as a risk factor for activated protein C resistance during pregnancy.

OBJECTIVE: The effect of smoking on the activated protein C (APC) ratio in normal gestation was systematically investigated. The frequency of acquired APC resistance (APCR) in the smoking and non-smoking subjects with normal follow-up of pregnancy and the outcome observed in these two groups were documented. STUDY DESIGN: A total of 180 normal pregnant women (non-smokers 138, smokers 42) in different trimesters of gestation admitted to the hospital were enrolled into a cross-sectional study. APC ratio, factor V, factor VIII, protein S and protein C were quantitated. Factor V Leiden mutation analyses were performed by real-time PCR. RESULTS: This cross-sectional study tries to detail the effect of smoking on APCR together with the changes in some components of the protein C/protein S system which may contribute to alterations in the APC ratio in normal gestation. A decreased APC ratio observed in pregnancy was statistically significant in the smokers (p = 0.03). When the trimesters were taken into consideration, APC ratios were significantly lower in the third trimester in the smokers compared with the non-smokers in the same trimesters (p = 0.001). The difference in the APC ratio between the groups in early pregnancy was not significant. CONCLUSION: These studies have demonstrated that the modified test abolishes the pregnancy-related effect on the APCRs in normal pregnant non-smoking women presumably by normalization of coagulation factors (except factor V). Our result for the non-smoking group is consistent with data provided in previous studies. However, we noted a very significant decrease in the APC ratio in smoking pregnant women in the third trimester, most likely secondary to decreased factor V levels.