Laparoscopic versus laparotomic surgery for adnexal masses: role in elderly.

BACKGROUND: The purpose of this study is to compare laparoscopy (LPS) and laparotomy (LPT), in terms of surgical outcomes, in elderly patients (>65 years) with adnexal masses. METHODS: We retrospectively reviewed a series of women older than 65 who had a diagnosis of adnexal masses. Then, all patients were divided into two different groups according to the type of surgery: 27 who underwent LPS (LPS group) and 24 who underwent LPT (LPT group). We took into consideration: age, comorbidity, histological diagnosis, surgery approach, and surgical outcome. Then, we calculated the percentages of all of these data and then χ (2) test and t-Student test were used to calculate the p value, to compare the two surgical techniques. A p value lower than 0.05 was considered to be statistically significant. RESULTS: At first, we evaluated the relation between the diagnosis and the surgery approach, and we obtained statistically significant results for serous cyst, adenocarcinoma serous/mucinous, and others, and the table highlights that some of the benign masses were mostly treated with LPS, while borderline and malignant masses were treated with LPT. Then, we evaluated the comorbidities of the patients, and we found that those cases had a significantly higher prevalence of cardiovascular disease and metabolic diseases. Finally, we compared the surgery outcome of LPS versus LPT surgeries for adnexal masses in elderly women, and there were statistically significant results for postoperative complications, number of patients who needed drainage, and number of days of hospitalization after surgery. CONCLUSIONS: Our results demonstrated that the patients who underwent LPS, compared to the patients who underwent LPT, have better outcomes in terms of postoperative complications (7.4 % with LPS and 37 % with LPT), number of patients who needed drainage (11.1 % with LPS and 62.5 % with LPT), and number of days of hospitalization after surgery, in term of mean (5 for LPS and 10.9 in term of LPT).

Quality of sex life in endometriosis patients with deep dyspareunia before and after laparoscopic treatment.

PURPOSE: The present work aims at showing how dyspareunia linked to endometriosis can affect the life of fertile age women and how surgical treatment of endometriosis can relieve painful symptoms and consequently improve sex and social life. METHODS: From a cohort of 320 women with a clinical and instrumental diagnosis of pelvic endometriosis, 67 patients were selected. These patients had deep dyspareunia that underwent laparoscopic surgical treatment. All the patients had filled out a pre- and post-surgery questionnaire. RESULTS: Six months after laparoscopic treatment, a significant reduction of dyspareunia was recorded, per VAS scores. A statistically significant improvement in sex life was observed between the pre- and post-surgical condition: in particular, an increased number of coituses and of non-difficult coituses, a higher number of patients who declared that pain did not negatively affect sexual pleasure and of patients achieving orgasm. CONCLUSIONS: The quality of the sex life in patients with endometriosis and dyspareunia showed significant improvement 6 months after laparoscopic treatment. In view of the diagnostic delay characterizing this disease and confirmed by our results, it is essential to involve a multidisciplinary team to assess all the signs and symptoms of endometriosis that may appear in a women of fertile age. This clinical approach is able to ensure a treatment that is as personalized as possible and an appropriate follow-up also with the objective of preserving reproductive performance.

A uterus soaked in blood with low haemoglobin in a case of unrecognized uterine sarcoma.

INTRODUCTION: Uterine sarcomas are rare and aggressive tumors. In some cases they can cause rupture of the uterus with or without clinical and radiological symptoms. Therefore, it is important to observe patients with clinical and/or radiological suspicion of sarcoma, even when there are no clinical manifestations. CASE REPORT: A 71-year old woman, who was under the authors' observation for pain in the right iliac fossa. The US and the CT scan showed an abdominal-pelvic mass.Laboratory tests showed a slight but progressive reduction of haemoglobin, which could not be explained by the clinical symptoms and by the results of the imaging tests. During the surgical intervention, a small amount of peritoneal fluid, an increased uterine volume, and a subverted anatomy were observed A haematoma was found in the uterus and this could explain the progressive reduction of haemoglobin and the very low presence of peritoneal effusion. CONCLUSION: The rupture of the uterus could not have been suspected as the patient did not have any type of symptoms, except for the slow and progressive reduction in the haemoglobin value. Therefore, it is important to observe patients with clinical and/or radiological suspicion of sarcoma, even when there are no clinical manifestations.

Attitudes towards abortion in Italian women: socio-economic trends and epidemiological features.

PURPOSE OF INVESTIGATION: The aim of this study was to analyze trends and attitudes towards abortion in Italian women in the last decades. MATERIALS AND METHODS: The authors analyzed number, socio-economic trends, and major clinical-epidemiological features of induced abortion in Italy (1980-2009). RESULTS: Up to 1996 abortion rates were higher among married women, but from 1996 to 2009 they were higher among single women. The reduction of abortions has been observed in all age-groups, except in women from 15 to 19 years of age. Abortions were higher among younger women, women without previous abortions, nulliparous women, women with junior and senior high school diplomas (2005-2006), women with an academic degree (2007-2009), and professional women. Conclu- sion: In Italy, despite the decrease of the abortion rates, voluntary termination of pregnancy is still present and the spread of contraception is scarce. More information about contraception is necessary to help lower the incidence of both unintended pregnancy and abortion.

Endometriosis allergic or autoimmune disease: pathogenetic aspects--a case control study.

PURPOSE OF INVESTIGATION: The aim of this study was to evaluate the correlation between endometriosis and pathologies on an immune basis for the possible involvement of the immune system in the pathogenesis of endometriosis. MATERIALS AND METHODS: In this retrospective study, data of 304 patients with endometriosis and 318 without endometriosis were collected in a uniform manner for both groups and inserted into two databases, respectively, for patients with and without endometriosis. The authors calculated the percentages of patients with allergies, autoimmune diseases, asthma in both groups, and later statistical analysis were performed with two different chi-square tests. RESULTS: The results obtained have shown that patients with endometriosis have a higher prevalence of allergies (p = 0.0003) and coexistence of both allergies and autoimmune diseases (p = 0.0274), compared to those without. CONCLUSIONS: The present study seems to support the possible association between endometriosis and allergic diseases.

Poor responders in IVF: an update in therapy.

INTRODUCTION: Assisted reproduction techniques are the frequent treatment of infertility. Despite the advances in science and technology, the management of poor responder patients is still considered as one of the most urgent problems. The lack of unified definition makes the management of the poor responder patients very difficult. The aim of this review is to examine and compare the different studies done about the problem of poor responder patients. METHODS: On an online research of MEDLINE/PUBMED, we found several studies on pharmacological treatment for poor responders' patients. RESULTS: Our review shows that in the years numerous therapies for the management of these patients who do not respond to ovarian stimulation have been evaluated and studied, but the main problem is the large and still not well-defined meaning of poor responder women. CONCLUSION: The management of the poor responder patients is very difficult. Currently, there is no any standard treatment for poor responder patients. Considering the importance of the problem, it is important to identify a diagnostic and therapeutic target. Our review shows that there are many studies with different therapeutic approaches which deserve further in-depth study to standardize diagnostic and therapeutic target.

Pulmonary embolism in pregnancy.

Venous thromboembolism (VTE) is a major cause of maternal morbidity and mortality during pregnancy or early after delivery, remaining a diagnostic and therapeutic challenge in both states. The absolute incidence of pregnancy-associated VTE has been reported as 1 in 1,000 to 1 in 2,000 deliveries. With 5-6 million new births computed in Europe in 2010, the potential clinical relevance of diagnosing and treating gravidic VTE is immediately evident. Fivefold higher in a pregnant as compared with a non-pregnant woman, VTE risk is also higher in postpartum than antepartum period. Ranked absolute and relative thrombotic risk may be described in the several thrombophilic conditions experienced by women at risk, according to which specific prophylactic and therapeutic recommendations have been formulated by recent guidelines. The main purpose of the present review article was to emphasize the most recent findings and recommendations in diagnostic strategies, discussing thrombophilic risk evaluation, as well as risks and benefits of various diagnostic techniques for both mother and fetus.

A 29-year-old woman with complex atypical hyperplasia and polycystic ovary syndrome: a challenging issue.

BACKGROUND: The standard treatment for complex atypical hyperplasia is hysterectomy and bilateral salpingo-oophorectomy. Although radical surgery offers high survival prospects, it also eliminates any chance of further fertility, thus in young nulliparous women who wish to preserve their childbearing potential, a conservative progestin therapy is preferable. CASE REPORT: The authors report a case of complex atypical hyperplasia in a 29-year-old nulliparous woman with polycystic ovary syndrome treated with norethisterone acetate in order to preserve her childbearing potential. The specimens sampled during the follow-up demonstrated inactive endometrium with pseudodecidual changes and no ultrasonographic images exhibited abnormal endometrial thickness. CONCLUSION: According to literature and to the authors' experience, they can affirm that progestin treatment is the most reasonable option for young nulliparous women affected by complex atypical hyperplasia who desire to maintain their fertility potential, showing its efficacy also in patients with an associated polycystic ovary syndrome.

Premature ovarian failure in a 17-year-old woman.

INTRODUCTION: Premature ovarian failure (POF) in a healthy adolescent is a rare event. It is diagnosed by the presence of amenorrhea, hypoestrogenism, and elevated follicle-stimulating hormone (FSH) levels before the age of 40. CASE: The patient presented with amenorrhoea at 17 years after identifying a change from her regular to irregular and metrorrhagic cycles. No positive medical history was noted regarding smoking, chemotherapy, radiation or autoimmune diseases and the physical examination was normal. Her family history revealed that both her maternal aunt and grandmother were affected by POF, but the karyotype test was normal and the FMR1 screening premutation test was negative. The patient underwent an ovarian biopsy which revealed the absence of functional follicles. She began a replacement therapy with estroprogestogens and she was informed about the most successful means to start a family, including adoption and oocyte donation. CONCLUSION: POF is a heterogeneous, multifactorial, and poorly understood condition that involves medical concerns, psychological sphere, and sexuality of the affected patients. Management should be directed at symptoms resolution, bone protection, and psychosocial support for women facing this unexpected and devastating diagnosis.

Celiac disease and endometriosis: an insidious and worrisome association hard to diagnose: a case report.

BACKGROUND: Primary infertility is an unusual presentation of celiac disease (CD). When non-classical symptoms are present, the diagnosis is not easy and it becomes even more difficult when CD is associated with endometriosis, representing a diagnostic challenge for medical practitioners and gynecologists. CASE REPORT: A 34-year-old patient presented to the authors' observation with primary infertility. Formerly she was treated for endometriosis and the diagnosis of CD was delayed. A favorable clinical and serological response following a gluten-free-diet (GFD) was achieved and a successful pregnancy was obtained. DISCUSSION: This case report emphasizes the role of the CD in women's infertility and the possible association between CD and endometriosis. Even if the relationship between these two diseases is still unclear and further studies to address this issue are required, more attention from gynecologists is needed, considering that the later this association is diagnosed, the greater the probability of adverse outcomes of health developing.

In vitro fertilization stimulation protocol for normal responder patients.

The aim of this prospective observational study is to determine the different outcomes of IVF/ICSI treatments after using antagonists or agonists of gonadotrophin-releasing hormone (GnRH) for controlled ovarian hyperstimulation (COH) in normal responder patients. Two hundred forty-seven patients undergoing IVF treatment at the Centre of Reproductive Medicine, Rome (CERMER), from January 2005 to December 2008, were included in the study. Patients were stimulated either with a standard long protocol with GnRH agonists (n = 156) or with GnRH antagonists (n = 91). The use of GnRH antagonists resulted in a significant reduction in the duration of the stimulation (Agonist Group 14.10 ± 2.25 vs Antagonist Group 11.34 ± 2.11; p < 0.001) and in the amount of gonadotrophin (IU of r-FSH) needed (Agonist Group 1878 ± 1109 vs Antagonist Group 1331 ± 1049; p = 0.0014). Moreover a lower number of cycles were cancelled with the antagonist protocol (4.39 vs 6.41%). The GnRH antagonist protocol, when compared to the GnRH agonist one, is associated with a similar clinical pregnancy rate, similar implantation rate, significantly lower gonadotrophin requirement and shorter duration of stimulation. For this reason, GnRH antagonists might be a good treatment even for normal responder patients undergoing IVF.

Heavy metals and placental fetal-maternal barrier: a mini-review on the major concerns.

BACKGROUND: Heavy metals (HMs) are environmental contaminants with toxic properties for wildlife and humans. The placenta is a privileged organ that, along with the fetal membranes and amniotic fluid, enables growth and development of the fetus during the physiological pregnancy. It also acts as a filter reducing the passage of harmful substances, protecting the embryo and then the fetus from exposure to pollutants. The placental barrier is not completely impermeable to the passage of harmful substances; indeed, HMs were detected not only in placental tissues, but also in amniotic fluid and umbilical cord blood. The amniotic fluid can be considered as a valuable marker of prenatal exposure to exogenous factors, and as an indicator of the integrity of placental barrier. The effect of an intrauterine exposure to heavy metals has been amply evaluated during the last decades. Several studies investigated the exposure to HMs in order to evaluate the mechanism of placental transfer and the impact on fetuses and later children's health. In particular,  the early exposure to Pb, Hg, and Cd was correlated to infant health effects, such as neurological, developmental, and endocrine disorders. The aim of this mini-review is to summarise the current state of knowledge about the interaction between HMs and placental barrier, considering possible implications on fetal health.

The addition of GnRH antagonists in intrauterine insemination cycles: a pilot study.

AIM: This prospective study was designed to assess whether the use of GnRH antagonists can improve the success rate of controlled ovarian stimulation (COS) in intrauterine insemination (IUI) treatments. PATIENTS AND METHODS: Eighty patients were divided into two groups: GnRH antagonist group (Group A, n=40) and control group (Group B, n=40). Patients in Group B underwent COS with recombinant Follicle Stimulating Hormone (r-FSH, 50-75 IU/d) only, while patients in Group A were administered r-FSH (50-75 IU/d) plus cetrorelix (0.25 mg/d, starting when ≥ 2 follicles ≥ 14 mm were detected on ultrasound scan). In both groups a single insemination was performed 36 hours after human Chorionic Gonadotropin (hCG, 250 mcg) administration. The primary outcome was clinical Pregnancy Rate (PR). Secondary outcomes were ongoing PR, incidence of Premature Luteinization (PL), number of follicles with mean diameter ≥ 16 mm and between 11 and 15 mm on the day of hCG administration, miscarriage rate, cycle cancellation rate, total amount of r-FSH used and duration of treatment. Student's t test and Chi-square test were used (p < .05 statistically significant). RESULTS: A total of 146 cycles were performed (Group A: n=72; Group B: n=74). A trend towards higher PR in Group A was detected, although it was not statistically significant (Clinical PR: 18.05% vs 10.81%). The number of follicles ≥ 16 mm was significantly increased in Group A. The incidence of both premature LH surge and premature luteinization (PL) was significantly higher in Group B. No significant differences were found in the duration of the stimulation protocol, and in the total amount of r-FSH administered. CONCLUSIONS: The addition of GnRH antagonist in COS/IUI protocol significantly increases the number of mature follicles. However, this multifollicular recruitment is not linked to a significantly higher PR.

GnRH antagonists in assisted reproductive techniques: a review on the Italian experience.

Current Controlled Ovarian Stimulation (COH) for Assisted Reproductive Techniques (ART) pursues three main objectives: hypophyseal activity suppression, multiple follicle growth stimulation, and ovulation induction. By suppressing hypophyseal activity, it is possible to prevent untimely LH surge and allow the appropriate development of the leading follicle. The classical GnRH agonist long protocol is the most widely used in COH for ART. However, an alternative regimen based on GnRH antagonist has been recently introduced in clinical practice. As competitive antagonists, these drugs display an immediate and quickly reversible effect and they avoid hormonal withdrawal side effects. Moreover, this protocol shows undeniable advantages, including the shorter duration of the treatment, the lower amount of gonadotropin required, the shorter hormonal and ultrasound monitoring of patients, milder physical and emotional stress, and a lower risk of Ovarian Hyperstimulation Syndrome (OHSS). The use of GnRH antagonists was traditionally restricted to selected patients, as "poor responders" and women at high-risk of developing OHSS such as Polycystic Ovary Syndrome (PCOS) and patients who had previously experienced OHSS. These findings could prompt a trend to change from the standard agonist protocol to the antagonist protocol in all categories of patients. This review provides a comprehensive overview of the use of GnRH antagonist protocols applied both to IVF techniques and to IUI procedures in the Italian experience.

Endometrial adenocarcinoma in a young woman.

BACKGROUND: Endometrial carcinoma usually occurs in post-menopausal women, but in three to five percent of cases, it affects patients under 40 years of age, who wish to preserve their fertility. Patients with polycystic ovarian syndrome (PCOS) and the features of this syndrome (including obesity, hyperinsulinemia, and hyperandrogenism) are at great risk of developing endometrial carcinoma. CASE REPORT: The authors report a case of endometrial adenocarcinoma at Stage I in a 37-year-old obese woman with PCOS who underwent surgical staging. DISCUSSION: In young women with obesity and PCOS, a periodic evaluation of the endometrium and implementation of risk-reducing measures for the development of endometrial cancer are needed.

An unusual clinical presentation of a pure yolk sac tumor of the ovary: case report.

INTRODUCTION: Yolk sac tumor (YST) of the ovary is a rare neoplasm, which belongs to the group of ovarian germ cell tumors. It most commonly occurs in children and young women and it is characterized by high malignancy given its premature metastasis. An early diagnosis is important but not easy. CASE: An 18-year-old girl came to the authors' observation for amenorrhea lasting approximately 16 weeks. Abdominal examination revealed a painless palpable mass in the right lower abdomen. At admission ultrasonography (US) and magnetic resonance imaging (MRI) showed a complex mass of the right adnexa with a diameter of about 15 cm. The alpha-fetoprotein (AFP) serum level was elevated to 960 UI/ml. Fertility-sparing surgery was undertaken and the histopathology revealed a Stage IA pure YST. Chemotherapy was avoided and an intensive 36 months follow-up was performed without clinical and radiological evidence of recurrence. CONCLUSION: This is the first case report of a pure YST of the ovary presented with amenorrhea. It is also a very interesting case for its Stage IA despite prolonged duration of symptoms and AFP high levels.

[Venous thromboembolism in pregnancy: current state of the art]. / Tromboembolismo venoso in gravidanza: attuale stato dell'arte.

Venous thromboembolism (VTE) is a major cause of maternal morbidity and mortality during pregnancy or early after delivery and it remains a diagnostic and therapeutic challenge. The latest Confidential Enquiry into Maternal Deaths (2006-2008) showed that VTE is now the third leading cause of direct maternal mortality, beside sepsis and hypertension. In particular the prevalence of VTE has been estimated to be 1 per 1000-2000 pregnancies. The risk of VTE is five times higher in a pregnant woman than in non-pregnant woman of similar age and postpartum VTE is more common than antepartum VTE. A literature search was carried out on Pubmed using the following key words: "venous thromboembolism", "pregnancy", "risk factors", "prophylaxis", "anticoagulants". Studies from 1999 onwards were analyzed. This review aimed to provide an update of whole current literature on VTE in pregnancy highlighting the most recent findings in diagnostic and therapeutic strategies, considering in detail risks and benefits of various techniques and drug classes, for both mother and fetus. Large trials of anticoagulants administration in pregnancy are lacking and recommendations are mainly based on case series and on expert opinions. Nonetheless, anticoagulants are believed to improve the outcome of pregnancy for women with current or previous VTE.

Recombinant luteinizing hormone priming in multiple follicular stimulation for in-vitro fertilization in downregulated patients.

Follicle development is controlled amongst other factors by pituitary gonadotropins follicle-stimulating hormone (FSH) and luteinizing hormone (LH) that act in synergy in completing follicle maturation. Exogenous gonadotropins, combined with gonadotropin-releasing hormone agonists, have been successfully used in patients with ovulatory disorders undergoing assisted reproduction. There is some evidence of a beneficial role of androgens or LH administration before FSH stimulation. This study was designed to verify whether the addition of LH in the early follicular phase, in downregulated patients undergoing follicular stimulation for assisted reproduction, would add benefits in terms of general outcomes and pregnancy rates. We compared two groups of patients one of which was treated with recombinant FSH (rFSH) alone and the other with rFSH plus recombinant LH (rLH), in the early follicular phase only. The number of eggs recovered was higher in the group treated with FSH only; however, the number of embryos available at transfer was similar in the two groups and, more importantly, the number of Grades I and II embryos was higher in the group pretreated with LH. Similarly, although biochemical pregnancy rate and clinical pregnancy rates were similar in both groups, a beneficial role of LH priming was demonstrated by the higher implantation rate achieved in these patients.

Fertility-sparing treatment of endometrial cancer precursors among young women: a reproductive point of view.

BACKGROUND: Early-stage endometrial cancer and complex atypical hyperplasia are treated with hysterectomy and bilateral salpingo-oophorectomy. An emerging issue among younger women affected is the possibility of a fertility-sparing treatment with progestative therapy and close follow-up. AIM: To assess the possibility of conceiving after a diagnosis of atypical endometrial hyperplasia among women younger than 40 years old, in term of delaying definitive treatment and achieving pregnancy. MATERIALS AND METHODS: 15 women younger than 40 years old with complex CAH or early carcinoma of the endometrium and a wish to preserve fertility. Progestins were administered orally for at least a 12 weeks period. Endometrial biopsies were used at follow-up. RESULTS: In 11 women, a complete pathological remission of the disease was observed. 4 pregnancies were attained in 4 women. 3 showed progression and underwent definitive surgery at 18 months. 1 showed no response at 24 months and 3 cycles and was counseled to receive a hysterectomy. CONCLUSIONS: A conservative approach in patients younger than 40 years appears a valid option, and a progestative therapy trial should be attempted whether a valid consensus is attained. Considering the risk to find AEH at biopsies and eventually a carcinoma at hysterectomy (25% of cases) a careful management is strictly required.

Heavy metals in human amniotic fluid: a pilot study.

OBJECTIVE: Many heavy metals are essential nutrients for a healthy life. However, significant evidence supports prolonged prenatal exposure as a risk factor for several adverse health effects. The aim of this study is to evaluate the presence of heavy metals in human amniotic fluid (AF) to demonstrate that there is an early fetal in utero exposure. METHODS: The concentrations of a variety of heavy metals, including Be, Ag, Ba, Pb, U, Hg, Sr, Cu, Mn, V, Pd, Sn, Sb, Te, Pt, Sc, Tl, Ni, As, Co, Zn and Se, were measured in 25 AF samples obtained from amniocentesis between 15 and 18 weeks of gestational, after informed consent. RESULTS: Be, Ag, Ba, Pb, U, Cu, Sr, Mn, V, Sn, Te, Pt, As, Tl, Sb, Co, Se and Zn concentrations were detected in measurable amounts in second trimester AF. Mg levels are elevated in all samples. Pd, Ni, Sc and Hg concentrations are below the detection limits in all samples. CONCLUSION: This study demonstrates that heavy metals pass into and accumulate in AF from a very early stage of gestation. Other studies are needed to evaluate the long-term health effects of this early exposure.