Adenomyosis and Infertility: A Literature Review.

Background and Objectives: Adenomyosis (the presence of ectopic endometrial glands and stroma below the endometrial-myometrial junction) is a benign condition which is increasingly diagnosed in younger women suffering from infertility. The aim of this narrative review was to study the pathophysiology and prevalence of adenomyosis, the mechanisms causing infertility, treatment options, and reproductive outcomes in infertile women suffering from adenomyosis. Materials and Methods: A literature search for suitable articles published in the English language was performed using PubMed from January 1970 to July 2022. Results: The literature search retrieved 50 articles that met the purpose of this review and summarized the most recent findings regarding the accuracy of diagnostic methods, pathophysiology, and the prevalence of adenomyosis and optimal strategies for the treatment of infertile women with adenomyosis. Conclusions: Adenomyosis is a common gynecological disorder, affecting women of reproductive age. It negatively affects in vitro fertilization, pregnancy and the live birth rate, as well as increases the risk of miscarriage. With the advent of non-invasive diagnoses with MRI and TVUS, the role of adenomyosis in infertility has been better recognized. Overall, more randomized controlled trials (RCTs) are needed to provide strong data on the accuracy of diagnostic methods, the pathophysiology and the prevalence of adenomyosis, the fertility outcomes of patients and the optimal strategy for the treatment.

Role of laparoscopic hysterectomy in cervical and endometrial cancer: a narrative review.

Endometrial cancer is the most common carcinoma of the female genital organs and cervical cancer is the leading cause of cancer death in women worldwide. The aim of this review is to evaluate the role of laparoscopic hysterectomy in patients with endometrial and cervical cancer in this period, and analyze the outcome of hysterectomy in terms of survival. Moreover, we present the historical background, new techniques, the anatomical features, and surgical steps of radical hysterectomy. According to new evidence, minimally invasive surgery in patients with cervical cancer is associated with higher rates of recurrence and mortality compared to the open approach. Despite the numerous explanations offered for this phenomenon, the reasons for these results are unclear. Additional large trials have been launched to reevaluate the above-mentioned data. On contrary, the laparoscopic approach provides surgical outcomes and similar survival rates as open surgery in patients with early endometrial carcinoma. Furthermore, the radicality of hysterectomy does not influence local recurrence rates or overall survival in cases with complete surgical removal of the tumor. A laparoscopic radical hysterectomy is no longer an option in patients with cervical cancer. When minimally invasive surgery is offered, the patients must be counseled in detail about the current debate.

Identification of cancer biomarkers of prognostic value using specific gene regulatory networks (GRN): a novel role of RAD51AP1 for ovarian and lung cancers.

To date, microarray analyses have led to the discovery of numerous individual 'molecular signatures' associated with specific cancers. However, there are serious limitations for the adoption of these multi-gene signatures in the clinical environment for diagnostic or prognostic testing as studies with more power need to be carried out. This may involve larger richer cohorts and more advanced analyses. In this study, we conduct analyses-based on gene regulatory network-to reveal distinct and common biomarkers across cancer types. Using microarray data of triple-negative and medullary breast, ovarian and lung cancers applied to a combination of glasso and Bayesian networks (BNs), we derived a unique network-containing genes that are uniquely involved: small proline-rich protein 1A (SPRR1A), follistatin like 1 (FSTL1), collagen type XII alpha 1 (COL12A1) and RAD51 associated protein 1 (RAD51AP1). RAD51AP1 and FSTL1 are significantly overexpressed in ovarian cancer patients but only RAD51AP1 is upregulated in lung cancer patients compared with healthy controls. The upregulation of RAD51AP1 was mirrored in the bloods of both ovarian and lung cancer patients, and Kaplan-Meier (KM) plots predicted poorer overall survival (OS) in patients with high expression of RAD51AP1. Suppression of RAD51AP1 by RNA interference reduced cell proliferation in vitro in ovarian (SKOV3) and lung (A549) cancer cells. This effect appears to be modulated by a decrease in the expression of mTOR-related genes and pro-metastatic candidate genes. Our data describe how an initial in silico approach can generate novel biomarkers that could potentially support current clinical practice and improve long-term outcomes.

Comments on the ESHRE recommendations for the treatment of minimal endometriosis in infertile women.

According to ESHRE recommendations for women with stage I/II endometriosis, if a decision is made to proceed to laparoscopy then operative laparoscopy (excision or ablation of the endometriotic lesions) should be performed rather than only diagnostic laparoscopy, to increase ongoing pregnancy rates. Also, for infertile women with stage I/II endometriosis doctors may consider complete surgical removal of endometriosis to improve live birth rate prior to assisted reproductive treatment. This last recommendation is not well established. Does laparoscopic treatment of minimal endometriosis increase the fertility of women with minimal endometriosis? Should we perform surgery in all cases of minimal endometriosis to improve reproductive outcomes prior to assisted reproductive treatment? The aim of this article is to present evidence on these two questions and comment on the ESHRE recommendations. Evidence is quite robust that laparoscopic destruction of minimal to mild endometriosis and associated adhesions enhances fecundity. On the other hand, to date no clear benefit has been demonstrated of performing laparoscopy for minimal endometriosis in women undergoing IVF/intracytoplasmic sperm injection, therefore it is not recommended in these cases. Further studies are needed to assess the mechanisms of endometriosis-associated infertility and how it may be overcome in cases of minimal and mild endometriosis.

Recent management of endometrial cancer: a narrative review of the literature.

Endometrial cancer is a common female gynecological neoplasia and its incidence rate has increased in the past years. Due to its predominant symptoms, most women will present uterine bleeding. It is usually diagnosed at an early stage and surgery has an important role in the treatment plan. The prognosis and quality of life of these patients can be quite favorable, if proper treatment is offered by surgeons. Traditionally, more invasive approaches and procedures were offered to these patients, but recent data suggest that more conservative and minimal invasive choices can be adopted in the treatment algorithm. Minimal invasive surgery, such as laparoscopy and robotic surgery, should be considered as an acceptable alternative, compared to laparotomy with less comorbidities and similar oncological and survival outcomes. Furthermore, sentinel lymph node biopsy has emerged in the surgical staging of endometrial cancer, in order to replace comprehensive lymphadenectomy. It is associated with less intra- and postoperative complications, while preliminary data show no difference in survival rates. However, sentinel lymph node biopsy should be offered within a strict algorithm, to avoid residual metastatic disease. The aim of this review is to analyze all the available data for the application of minimal invasive surgery in early endometrial cancer and especially the role of sentinel lymph node biopsy.

Diagnosis of Endometriosis by Transvaginal Ultrasound: An Online Survey of Gynecologists Practising in Greece.

Accurate diagnosis and assessment of endometriosis by transvaginal ultrasound scan (TVS) can be challenging. We performed an online survey of specialist gynecologists who perform TVS on a regular basis regarding their views as well as clinical experience on the use of TVS in the diagnosis of endometrioma and deep endometriosis (DE). We collected 64 responses. Sixty-one participants (95.31%) answered that they can confidently diagnose endometrioma by TVS "always" or "most of the time". With the exception of DE of the recto-vaginal septum/posterior vaginal vault, for all other DE locations, more than 50% of participants felt that they can "rarely" or "never" diagnose it by TVS in their own clinical practice. Forty-two participants (65.6%) stated that additional, specialized training is required for the diagnosis of endometrioma. When asked about a diagnosis of DE, 58 participants (90.6%) felt that the same is required. The only statistically significant association was between the number of TVSs performed per year and the clinician's ability to diagnose bowel DE in their practice. The answers to all other questions did not differ significantly based on professional status, years of experience post-residency, or number of TVSs per year. Our results demonstrate the delayed adoption of novel diagnostic approaches in endometriosis and confirm the urgent need for specialized ultrasound training.

Rate of Leiomyosarcomas during Surgery for Uterine Fibroids: 8-Year Experience of a Single Center.

The aim of this study is to investigate the prevalence of occult malignant mesenchymal tumors in patients operated on for uterine fibroids in relation to the surgical approach and type of operation. A retrospective review of all patients that underwent surgery for uterine fibroids (January 2011-December 2018) at the 1st Department of Obstetrics & Gynecology at "Papageorgiou" Hospital. The surgical approach and clinicopathological characteristics were analyzed. A total of 803 patients were operated on: 603 (75.1%) with laparotomy, 187 (23.3%) laparoscopically, and 13 (1.6%) vaginally. Furthermore, 423 (52.7%) patients underwent hysterectomy and 380 (47.3%) myomectomies. Laparoscopy and myomectomy were offered to younger patients with fewer smaller uterine fibroids and were associated with statistically significant shorter hospitalization. The pathological reports revealed: 690 (86%) benign leiomyomas, 32 (4%) cellular leiomyomas, 29 (3.6%) degenerated leiomyomas, 22 (2.7%) adenomyomas, 18 (2.2%) atypical-bizarre leiomyomas, 1 (0.1%) STUMP, 5 (0.65%) endometrial stromal sarcomas, and 6 (0.75%) cases of leiomyosarcomas (LMS). All LMS were preoperatively characterized as suspicious and underwent abdominal hysterectomy. Morcellation was offered in two cases of atypical leiomyomas, with no morcellation-associated complication. Laparoscopy as a valuable surgical approach for young patients with fewer in number and smaller in size fibroids is associated with shorter hospitalization. The risk of unintended morcellation of LMS seems to be very low and can be reduced with careful preoperative work-up but not eliminated.

Effect of tumor morcellation in patients with early uterine sarcoma: a multicenter study in Germany

Objective: The use of power morcellation at laparoscopy may worsen survival rates for patients with malignancy. The aim of the present study was to report the outcome of patients with early-stage uterine sarcoma after morcellation or total en-bloc resection, and evaluate potential signs of sarcoma preoperatively. Material and Methods: This multicenter retrospective study consisted of patients, who underwent surgery for FIGO-stage-1 uterine sarcoma. Twenty-four patients were divided into a non-morcellation group and a morcellation group. Clinical records and the outcomes of patients, including one-, three- and five-year survival rates were reviewed. Preoperative characteristics of patients with sarcoma were compared to those of a control group with uterine myoma (1:4 ratio), matched by age and type of operation. Results: Obesity was an independent risk factor for uterine myoma. Tumor growth, solitary growth, largest-diameter lesion >8.0 cm, and anechoic areas suggesting necrosis and increased vascularization were significantly more common in the sarcoma group. A large tumor diameter was significantly associated with mortality. Patients in the non-morcellation group had a slightly lower disease-free survival, but poorer overall survival (OS) rates compared to patients in the morcellation group, but neither difference was statistically significant. Patients in the non-morcellation group, who had undergone a re-exploration experienced late recurrence, but no upstaging was evident after the operation. Conclusion: Preoperative ultrasound characteristics could be useful to distinguish sarcoma from leiomyoma of uterus. Morcellation of a sarcoma may increase abdominal and pelvic recurrence rates, but may not be associated with OS in patients with FIGO-stage-1 disease.

Aromatase inhibitors in stimulated IVF cycles.

Aromatase inhibitors have been introduced as a new treatment modality that could challenge clomiphene citrate as an ovulation induction regiment in patients with PCOS. Although several randomized trials have been conducted regarding their use as ovulation induction agents, only few trials are available regarding their efficacy in IVF stimulated cycles. Current available evidence support that letrozole may have a promising role in stimulated IVF cycles, either when administered during the follicular phase for ovarian stimulation. Especially for women with poor ovarian response, letrozole appears to have the potential to increase clinical pregnancy rates when combined with gonadotropins, whereas at the same time reduces the total gonadotropin dose required for ovarian stimulation. However, given that in all of the trials letrozole has been administered in GnRH antagonist cycles, it is intriguing to test in the future how it may perform when used in GnRH agonist cycles. Finally administration of letrozole during luteal phase in IVF cycles offers another treatment modality for patients at high risk for OHSS taking into account that it drastically reduces estradiol levels.

Pregnancy-Related Hysterectomy for Peripartum Hemorrhage: A Literature Narrative Review of the Diagnosis, Management, and Techniques.

Postpartum hemorrhage is a life-threatening situation, in which hysterectomy can be performed to prevent maternal death. However, it is associated with high rates of maternal morbidity and mortality and permanent infertility. The incidence of pregnancy-related hysterectomy varies across countries, but its main indications are the following: uterine atony and placenta spectrum (PAS) disorders. PAS disorder prevalence is rising during the last years, mainly due to the increased number of cesarean sections. As a result, obstetricians should be aware of the difficulties of this emergent condition and improve its accurate antenatal diagnosis rates, as well as its modern management strategies. Of course, special skills are required during a pregnancy-related hysterectomy, so these patients should be referred to centers of excellence in antenatal care, where a multidisciplinary team approach is followed. This study is a narrative review of the literature of the last 5 years (PubMed, Cochrane) regarding postpartum hemorrhage to offer obstetricians up-to-date knowledge on this pregnancy-related life-threatening issue. However, there is a lack of available high-quality data, because most published papers are retrospective case series or observational cohorts.

Surgical outcomes of conventional laparoscopic and robotic-assisted hysterectomy.

INTRODUCTION: The aim of the present study was to compare surgical outcomes of total laparoscopic hysterectomy with those of the robotic approach using the da Vinci Xi system. METHODS: Patients who underwent hysterectomy with da Vinci Xi for early endometrial cancer or benign indications from 2018 to 2019 were selected. The control group consisted of patients who underwent conventional laparoscopy. RESULTS: A total of 300 patients were included in the study. The mean duration of surgery differed significantly (p = 0.025) between those who underwent laparoscopy (125.01 ± 76.168) and robotic-assisted surgery (142.96 ± 82.657 min). Blood loss, median hospital stay, intraoperative and postoperative complications were similar in both groups. No statistical difference was observed in the subgroups with a body mass index of more than 30 kg/m2 or more than 40 kg/m2 concerning the duration of surgery or the surgical outcome. CONCLUSION: The da Vinci Xi did not improve surgical outcomes in patients who underwent hysterectomy by trained laparoscopists and takes more time than conventional laparoscopy when performed in patients of normal weight.

A pancancer overview of FBN1, asprosin and its cognate receptor OR4M1 with detailed expression profiling in ovarian cancer.

Ovarian cancer affects >295,000 women worldwide and is the most lethal of gynaecological malignancies. Often diagnosed at a late stage, current research efforts seek to further the molecular understanding of its aetiopathogenesis and the development of novel biomarkers. The present study investigated the expression levels of the glucogenic hormone asprosin [encoded by fibrillin-1 (FBN1)], and its cognate receptor, olfactory receptor 4M1 (OR4M1), in ovarian cancer. A blend of in silico open access The Cancer Genome Atlas data, as well as in vitro reverse transcription-quantitative PCR (RT-qPCR), immunohistochemistry and immunofluorescence data were used. RT-qPCR revealed expression levels of OR4M1 and FBN1 in clinical samples and in ovarian cancer cell lines (SKOV-3, PEO1, PEO4 and MDAH-2774), as well as the normal human ovarian surface epithelial cell line (HOSEpiC). Immunohistochemical staining of a tissue microarray was used to identify the expression levels of OR4M1 and asprosin in ovarian cancer samples of varying histological subtype and grade, including clear cell carcinoma, serous ovarian cancer and mucinous adenocarcinoma. Immunofluorescence analysis revealed asprosin expression in SKOV-3 and HOSEpiC cells. These results demonstrated the expression of both asprosin and OR4M1 in normal and malignant human ovarian tissues. This research invokes further investigation to advance the understanding of the role of asprosin and OR4M1 within the ovarian tumour microenvironment.

Sonographic changes after laparoscopic cystectomy compared with three-stage management in patients with ovarian endometriomas: a prospective randomized study.

BACKGROUND: Laparoscopic surgery is the gold standard treatment for ovarian endometriomas. The aim of this study was to evaluate the impact of two different laparoscopic methods on sonographic indicators of ovarian reserve in the treated ovary. METHODS: In this prospective randomized clinical trial, 20 patients with endometriomas were randomly assigned to undergo either laparoscopic cystectomy (Group 1) or the 'three-stage procedure' (Group 2). All patients underwent ultrasound examination preoperatively and 6 months after laparoscopy. Another ultrasound examination was performed 12 months after intervention in order to detect any recurrence. We investigated the alterations in the residual ovarian volume, ovarian vascular supply and antral follicle count (AFC) on the ovary with the endometriotic cyst by transvaginal color Doppler ultrasonography. RESULTS: The residual ovarian volume and the lowest pulsatility and resistance indexes were found to be similar between the two groups before and 6 months after laparoscopic intervention. The AFC of the operated ovary was increased significantly (P = 0.002) in Group 2 compared with Group 1 after 6 months. One year after laparoscopy, two recurrences of endometriomas were detected in Group 2, although none were detected in Group 1 (P = 0.47). CONCLUSIONS: Ovarian volumes and vascularization were comparable among the two laparoscopic methods. On the contrary, functional ovarian tissue as determined by AFC was higher after the 'three-stage' procedure.

Endometrial changes in estrogen and progesterone receptor expression during implantation in an oocyte donation program.

Implantation is the final and most important stage of embryogenesis and is of paramount importance in achieving a successful pregnancy. Progesterone and estrogen are steroid hormones responsible for the regulation of the implantation window and the current study hypothesised that their receptors may be implicated in women undergoing oocyte donation. A total of 15 women aged 25-32 years old (mean ± SD, 28.9±2.89) undergoing oocyte donation were recruited into the present study. Participants underwent ovarian stimulation with gonadotrophin-releasing hormone antagonist and recombinant follicle-stimulating hormone. Endometrial aspiration biopsy was performed on the day of oocyte retrieval and after 5 days (on days 0 and 5, respectively). Endometrial histology and evaluation of estrogen receptor (ER)α and progesterone receptor (PR)-B were performed on days 0 and 5. The ER nodal staining percentage on day 0 was age-associated, with patients aged <30 years demonstrating 100% staining and those aged >30 years exhibiting 90% staining. Pathological staining revealed statistically significant differences between days 0 and 5 following all staining procedures. Wilcoxon signed-rank test resulted in the following P-values, for ER (nodes % and stromal %) day 0/5, P=0.0001; for PR (nodes % and stromal %) day 0/5, P=0.0001 and P=0.035, respectively; for ER (grade nodes and stromal %) day 0/5, P=0.0001; and PR (grade nodes and stromal %) day 0/5 P=0.0001 and P=0.016, respectively. Synchronization between blastocyst development and the acquisition of endometrial receptivity is a prerequisite for the success of in vitro fertilisation (IVF). Aside from the recent discovery of molecules that are considered crucial for successful embryo implantation, assessing the functional characteristics of the endometrium may offer unique insights into this process, thus improving IVF results.

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.

H2A Histone Family Member X (H2AX) Is Upregulated in Ovarian Cancer and Demonstrates Utility as a Prognostic Biomarker in Terms of Overall Survival.

Background: H2AX can be of prognostic value in breast cancer, since in advanced stage patients with high levels, there was an association with worse overall survival (OS). However, the clinical relevance of H2AX in ovarian cancer (OC) remains to be elucidated. Methods: OC H2AX expression studied using the TCGA/GTEX datasets. Subsequently, patients were classified as either high or low in terms of H2AX expression to compare OS and perform gene set enrichment. qRT-PCR validated in-silico H2AX findings followed by immunohistochemistry on a tissue microarray. The association between single nucleotide polymorphisms in the area of H2AX; prevalence and five-year OC survival was tested in samples from the UK Biobank. Results: H2AX was significantly overexpressed in OCs compared to normal tissues, with higher expression associated with better OS (p = 0.010). Gene Set Enrichment Analysis demonstrated gene sets involved in G2/M checkpoint, DNA repair mTORC1 signalling were enriched in the H2AX highly expressing OCs. Polymorphisms in the area around the gene were associated with both OC prevalence (rs72997349-C, p = 0.005) and worse OS (rs10790282-G, p = 0.011). Finally, we demonstrated that H2AX gene expression correlated with γ-H2AX staining in vitro. Conclusions: Our findings suggest that H2AX can be a novel prognostic biomarker for OC.

Differential expression of mTOR components in endometriosis and ovarian cancer: Effects of rapalogues and dual kinase inhibitors on mTORC1 and mTORC2 stoichiometry.

Endometriosis is a well­known risk factor for ovarian cancer. The genetic changes that characterise endometriosis are poorly understood; however, the mechanistic target of rapamycin (mTOR) pathway is involved. In this study, we investigated the expression of key mTOR components in endometriosis and the effects of rapalogues using an endometrioid ovarian carcinoma cell line (MDAH 2774) as an in vitro model. Gene expression of mTOR, DEPTOR, Rictor and Raptor was assessed by qPCR in 24 endometriosis patients and in silico in ovarian cancer patients. Furthermore, the effects of Rapamycin, Everolimus, Deforolimus, Temsirolimus, Resveratrol, and BEZ235 (Dactolisib, a dual kinase inhibitor) on mTOR signalling components was assessed. mTOR showed a significant increase in the expression in endometriosis and ovarian endometrioid adenocarcinoma patients compared to non­affected controls. DEPTOR, an inhibitor of mTOR, was downregulated in the advanced stages of ovarian cancer (III and IV) compared to earlier stages (I and II). Treatment of MDAH­2774 cells with the mTOR inhibitors resulted in the significant upregulation of DEPTOR mRNA, whereas treatment with rapamycin and BEZ­235 (100 nM) resulted in downregulation of the mTOR protein expression after 48 h of treatment. None of the treatments resulted in translocation of mTOR from cytoplasm to nucleus. Upregulation of DEPTOR is a positive prognostic marker in ovarian cancer and is increased in response to mTOR pathway inhibition suggesting that it functions as a tumour suppressor gene in endometrioid ovarian carcinoma. Collectively, our data suggest the mTOR pathway as a potential connection between endometriosis and ovarian cancer and may be a potential target in the treatment of both conditions.

Fertility potential in a man with ankylosing spondylitis as revealed by semen analysis by light, electron and fluorescence microscopy.

Ankylosing spondylitis affects 0.1%-0.5% of the adult population. The aim was to investigate the possible effects of both the disease and its treatment on semen quality by performing a highly detailed analysis in a man with ankylosing spondylitis, presenting for infertility. Sperm characteristics were evaluated by light microscopy, morphology by electron microscopy (transmission electron microscopy), DNA fragmentation by terminal deoxynucleotidyl transferase dUTP nick end labeling using fluorescence microscopy and chromosomal abnormalities by fluorescence in situ hybridisation using probes for chromosomes 13,15,16,18,21,22,X and Y. There was no evidence for an effect of either ankylosing spondylitis or its treatment with celecoxib and sulphasalazine on sperm quality as all parameters including concentration, motility, DNA fragmentation and aneuploidy incidence were within normal limits. Transmission electron microscopy, however, revealed a high incidence of head, neck and tail abnormalities, as well as the presence of immature sperm and phagocytes. Hysteroscopic removal of an endometrial polyp enabled the achievement of a spontaneous pregnancy and the delivery of a healthy boy.

Laparoscopic management of the adnexal mass.

In the past few years the contribution of operative laparoscopy in all fields of gynecological surgery has been revolutionary. Nowadays laparoscopic management of adnexal masses is the most frequently performed laparoscopic intervention. Laparoscopy in comparison to laparotomy has the advantages of lower morbidity, shorter length of hospital stay, decreased postoperative pain, lesser de novo adhesion formation, better cosmetic results, faster recovery, and reduced overall cost of care. However, careful preoperative evaluation is important for the appropriate and successful use of laparoscopy for removal of adnexal masses and the advantages of the laparoscopic approach should, in no way, compromise the clinical outcome in women with malignancy. Patient's age, history, findings of physical examination, and the results of serum markers in combination with the imaging assessment, such as Doppler sonography, CT, or MRI, should be considered to reach the diagnosis preoperatively. However, only pathology of the adnexal mass can provide the definitive diagnosis. The specific characteristics of the adnexal masses in childhood, adolescent, reproductive, and postmenopausal age represent the essential parameters that will determine the therapeutic strategy to be followed. Furthermore, the clinician has to determine whether an adnexal mass requires surgery or expectant management as well as to estimate the possibility of malignancy.