Vaginal oxygen plus hyaluronic acid on genito-urinary symptoms of breast cancer survivors.

OBJECTIVES: This study aimed to evaluate the efficacy of vaginal oxygen and hyaluronic acid on genito-urinary symptoms of breast cancer survivors. METHODS: Patients were enrolled at the Menopause Outpatient Clinic of a university hospital. Breast cancer patients in a stable relationship, suffering from vaginal atrophy (VA) consequent to hypoestrogenism, were included. Natural oxygen was introduced into the vagina for 15 min, coupled in the last 5 min with a 2% solution of hyaluronic acid. Treatment was repeated five times, every 15 days. RESULTS: Out of the 40 breast cancer patients enrolled, 65% had no sexual intercourse due to pain. During treatment, the Vaginal Health Index Score gradually improved from 9.5 ± 2.2 to 16.8 ± 2.8 (p < 0.001), the visual analog scale score for dyspareunia decreased from 8.9 ± 1.3 to 3.4 ± 2.1 (p < 0.001) and the Female Sexual Function Index increased from 8.6 ± 6.3 to 15.2 ± 8.1 (p < 0.001). At the end of treatment, only 15% women (p = 0.001 vs. pretreatment) had no intercourse due to pain. Benefits remained 30 days after last treatment. CONCLUSION: Vaginal oxygenation coupled with hyaluronic acid every 15 days improves VA, sexuality and urinary symptoms of breast cancer patients. Beside data confirmation, additional studies are needed to determine the best interval between treatments, the optimal length of treatment and the long-term duration of the benefits.

Diginyc partial hydatidiform mole with increased fetal nuchal translucency and ovarian hyperstimulation syndrome.

PURPOSE OF INVESTIGATION: Hydatidiform mole (HM) is an abnormal pregnancy characterized by proliferation of cytotrophoblast and syncytiotrophoblast and vesicular swelling of placental villi. The fetus or embryo can be absent or abnormal. HMs can be complete or partial. CASE REPORT: A case of diginyc partial HM at 12 weeks of gestational age was referred to the present center of prenatal diagnosis. The patient showed ovarian hyperstimulation syndrome. At ultrasonography, increased fetal nuchal translucency (NT) with fetal anomaly was evident, without sonographic signs of placental mole. Pregnancy was terminated with legal abortion. RESULTS: Partial HM (PHM) was suspected by ultrasonographic fetal markers with ovarian hyperstimulation syndrome, but the diagnosis was performed only with fluorescent in situ hybridization. In particular fetal NT appeared increased also in diginyc mole. CONCLUSION: In order to improve the detection rate of PHM, routine histological examinations may be associated to fluorescent in situ hybridization in all cases of fetal anomalies.

Mitochondrial DNA in Day 3 embryo culture medium is a novel, non-invasive biomarker of blastocyst potential and implantation outcome.

In assisted reproduction technology, embryo competence is routinely evaluated on morphological criteria. Over the last decade, efforts in improving non-invasive embryo assessment have looked into the secretome of embryos. Human embryos release genomic DNA (gDNA) and mitochondrial DNA (mtDNA) into the culture medium, and the mtDNA/gDNA ratio is significantly correlated with embryo fragmentation. Here, we investigate whether mtDNA/gDNA ratio in embryo spent medium is correlated with blastulation potential and implantation. The mtDNA/gDNA ratio was assessed in 699 Day 3 culture media by quantitative polymerase chain reaction (qPCR) to investigate its correlation with embryo morphology, blastocyst development and implantation. A logistic regression model evaluated whether mtDNA/gDNA ratio in the secretome may improve the prediction of blastulation. We found that embryos that successfully developed into blastocysts exhibited a significantly higher mtDNA/gDNA ratio in the culture medium compared with those that arrest (P = 0.0251), and mtDNA/gDNA, combined with morphological grading, has the potential to predict blastulation better than morphology alone (P = 0.02). Moreover, mtDNA/gDNA ratio was higher in the media from good-quality embryos that reached the full blastocyst stage on Day 5 compared with those that developed more slowly (P < 0.0001). With respect to blastocyst morphology, higher trophectoderm quality was associated with a higher mtDNA/gDNA ratio in the culture medium. Finally, a high mtDNA/gDNA ratio in spent medium was associated with successful implantation outcome (P = 0.0452) of good-quality embryos. In summary, the mtDNA/gDNA ratio in the Day 3 embryo secretome, in combination with morphological grading, may be a novel, non-invasive, early biomarker to improve identification of viable embryos with high developmental potential.

Mitochondrial DNA content in embryo culture medium is significantly associated with human embryo fragmentation.

STUDY QUESTION: Is the amount of cell-free DNA released by human embryos into culture medium correlated with embryo morphological features? SUMMARY ANSWER: The mitochondrial DNA (mtDNA) content of culture medium is significantly associated with the fragmentation rate on Days 2 and 3 of embryo development, whether the oocyte came from women ≤ 35 or >35 years old. WHAT IS KNOWN ALREADY: Cellular fragmentation is often utilized as one of the morphological parameters for embryo quality assessment. The amount of cellular fragments is considered to be an important morphological parameter for embryo implantation potential. It has been hypothesized that fragments are apoptotic bodies or anuclear cytoplasmatic pieces of blastomeres, although no definitive conclusion has been drawn about their pathogenesis. STUDY DESIGN, SIZE, DURATION: Human fertilized oocytes were individually cultured from Day 1 to Days 2 and 3. A total of 800 samples (166 spent media from Day 2 and 634 from Day 3) were enrolled into the present study. PARTICIPANTS/MATERIALS, SETTING, METHODS: Double-stranded DNA (dsDNA) was quantified in 800 spent embryo culture media by Pico Green dye fluorescence assay. After DNA purification, genomic DNA (gDNA) and mtDNA were profiled by specific quantitative PCR. Statistical analyses defined correlations among DNA contents, embryo morphology and maternal age. MAIN RESULTS AND THE ROLE OF CHANCE: Different independent tests confirmed the presence of DNA into embryo culture medium and, for the first time, we demonstrate that both gDNA and mtDNA are detectable in the secretome. The amount of DNA is larger in embryos with bad quality cleavage compared with high-grade embryos, suggesting that the DNA profile of culture medium is an objective marker for embryo quality assessment. In particular, DNA profiles are significantly associated with fragmentation feature (total dsDNA: P = 0.0010; mtDNA; P = 0.0247) and advanced maternal age. LIMITATIONS, REASONS FOR CAUTION: It is necessary to establish whether DNA profiling of spent embryo culture medium is a robust onsite test that can improve the prediction of blastulation, implantation and/or pregnancy rate. WIDER IMPLICATIONS OF THE FINDINGS: The approach we are proposing may provide a novel, non-invasive, objective tool for embryo quality grading. The correlation between a high mtDNA concentration and the fragmentation rate of embryos is suggestive that fragments are mainly anuclear cytoplasmatic debris arising during cleavage. Therefore, blastomere shaping as an early event during in vitro development may play a homeostatic role and be related to embryo competence. STUDY FUNDING/COMPETING INTEREST: This project was funded by Merck Serono (Grant for Fertility Innovation 2011). The sponsor had no role in study design, data collection, data analysis, data interpretation and writing of the paper. Authors declare no conflicts of interest. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Identifier: NCT01397136.

Is letrozole needed for controlled ovarian stimulation in patients with estrogen receptor-positive breast cancer?

OBJECTIVE: To assess the advantages and disadvantages of using letrozole for controlled ovarian stimulation (COH) in young patients with estrogen receptor-positive (ER+) breast cancer, wishing to cryopreserve oocytes. DESIGN: Retrospective cohort analysis. SETTING: Sixteen Italian units for reproductive medicine and in vitro fertilization. METHODS: Data of 50 ER+ breast cancer patients undergoing COH to cryopreserve oocytes before gonadotoxic chemotherapy with a letrozole plus gonadotropins (Le+Gn) protocol were compared with those of 25 young women with ER- breast cancer, submitted to COH using a protocol with gonadotropins alone (Gn-only). RESULTS: The Le+Gn protocol implied a significantly lower total Gn consumption and allowed to maintain significantly lower circulating E2 levels at all checkpoints throughout stimulation (peak E2 value 446 ± 357 versus 1553 ± 908 pg/ml, respectively; p = 0.001). On the other side, the Le+Gn protocol allowed a significantly lower yield of oocytes available for cryostorage (6.6 ± 3.5 versus 8 ± 5, respectively; p = 0.038). CONCLUSIONS: In breast cancer patients, the association of letrozole to Gn significantly reduces the number of oocytes available for cryostorage in comparison with the use of Gn alone. On the other side, it is associated with significantly lower E2 levels during the whole stimulation cycle, a safety issue that has been traditionally considered advantageous in case of ER+ cancers.

Long-acting gonadotropin-releasing hormone agonist trigger in fertility preservation cycles before chemotherapy.

BACKGROUND: Oocytes/embryo cryopreservation and ovarian function suppression with gonadotropin-releasing hormone (GnRH) agonists (GnRHas) are two established strategies for preserving fertility in patients with cancer, frequently both being offered to the same woman. As the first injection of GnRHa should be administered before chemotherapy, it is usually performed in the luteal phase of the urgent controlled ovarian stimulation (COS) cycle. The GnRHa flare-up effect on recently stimulated ovaries may cause ovarian hyperstimulation syndrome (OHSS) and this risk may discourage some oncologists to offer an ovarian function preservation method with proven efficacy. We suggest the long-acting GnRHa as an option to trigger ovulation for egg retrieval in oncological patients, whenever ovarian suppression during chemotherapy is planned. PATIENTS AND METHODS: We retrospectively analyzed prospectively collected data from all consecutive ovarian stimulation cases in oncological patients for oocyte cryopreservation from 2016 to 2021 in a single academic referral center. The COS was performed according to good clinical practice standards. Since 2020 long-acting GnRHa trigger was offered to all patients for whom ovarian suppression after cryopreservation was planned. All other patients served as controls, stratified for the triggering method used: highly purified chorionic gonadotrophin 10 000 UI or short-acting GnRHa 0.2 mg. RESULTS: Mature oocytes were collected, with the expected maturation rate, in all the 22 cycles triggered with GnRHa. The mean number of cryopreserved oocytes was 11.1 ± 4, with a maturation rate of 80% (57%-100%), versus 8.8 ± 5.8, 74% (33%-100%) with highly purified chorionic gonadotrophin and 14 ± 8.4, 80% (44%-100%) with short-acting GnRHa. No case of OHSS was observed after long-acting GnRHa triggering and by 5 days after egg retrieval most patients had reached luteinizing hormone levels showing suppression. CONCLUSIONS: Our preliminary data show that long-acting GnRHa is efficacious in inducing the final oocytes' maturation, reducing OHSS risk and suppressing ovarian function by the start of chemotherapy.

Combined treatment with myo-inositol, alpha-lipoic acid, folic acid and vitamins significantly improves sperm parameters of sub-fertile men: a multi-centric study.

OBJECTIVE: Reduction in motility and number of spermatozoa and change in their morphology are some of the most relevant causes of male infertility. Production of reactive oxygen species may affect motility, morphology and DNA stability of spermatozoa. This study aimed at evaluating the effect of combined treatment with myo-inositol, alpha-lipoic acid, folic acid, betaine and vitamins (namely, Sinopol®) on semen parameters of sub-fertile men. PATIENTS AND METHODS: We recruited 143 sub-fertile men, 26-53 years aged, no-smokers, without any testicular pathologies, with a normal endocrinological/metabolic profile, and no concomitant consumption of drugs. Out of them, 25 patients did not meet study inclusion criteria mainly due to the history of genital diseases that came to light after Sinopol® prescription. Among the 118 men that fulfilled inclusion criteria, 10 (8.4%) patients were lost at follow-up and in 8 (6.8%) cases the partner got pregnant spontaneously. Thus, 100 patients completed the study and semen analysis was performed before and after 90 days of treatment. RESULTS: Semen quality improved after 90 days of treatments, with a statistically significant increase of sperm concentration (p=0.0009), of number of spermatozoa (p=0.0017), of progressive motility (p=0.0047), of total motile sperm count (p=0.0010), and of normal sperm morphology (p<0.0001). CONCLUSIONS: For the first time we reported that a combination of nutraceuticals composed of myo-inositol, alpha-lipoic acid, folic acid, betaine and vitamins improves sperm parameters in sub-fertile men. We are aware that to clarify the clinical relevance of the data studies with larger sample sizes and longer durations are needed, as well as evaluation of myo-inositol and alpha-lipoic acid co-treatment effectiveness in improving the chances to obtain a pregnancy spontaneously or following assisted reproduction.

Hydrothorax following ovarian hyperstimulation for assisted reproduction. Case report and review of the literature.

In case of ovarian hyperstimulation syndrome, the high incidence of dyspnea in relation with ascites and enlarged ovaries should not justify omission of thoracic evaluation. This manuscript reviews the pathogenesis and clinical presentation of hydrothorax following controlled ovarian hyperstimulation. In addition, we describe the case of a 33-year-old woman with a right massive hydrothorax resulting from controlled ovarian hyperstimulation for intracytoplasmic sperm injection.

Semen analysis following allogeneic bone marrow transplantation. Additional data for evidence-based counselling.

Knowledge of the impact of different conditioning regimens used in bone marrow transplantation on spermatogenesis is important in pre-BMT counselling for three reasons: (1) Most young patients who have not had children are concerned with their subsequent fertility; (2) For a number of diseases there are competing therapeutic options that may affect spermatogenesis more or less seriously; (3) Since spontaneous recovery of spermatogenesis is rare, it would be necessary to offer cryopreservation as soon as possible after diagnosis and prior to any treatment. This retrospective study evaluates 99 semen samples obtained in 64 patients who underwent BMT between 1982 and 1996. Recovery of spermatogenesis was observed in 90% of patients conditioned with cyclophosphamide (CY), in 50% of patients with CY plus busulphan (BU) or thiotepa and in 17% of patients with CY plus total body irradiation (TBI) or thoracoabdominal irradiation (TAI). Sperm quality following CY was within the normal range (WHO) in the majority of patients, whereas it was consistently severely impaired in patients who received irradiation or two alkylating agents. Following CY, spermatogenesis recovery was observed in 60% of patients tested 1 year post transplant and it was accomplished within the third year in 80% of cases. Following CY + TBI/TAI recovery of spermatogenesis never occurred before the 4th year post transplant and was demonstrated as late as 9 years in one patient who was azoospermic 1 year earlier. No statistical correlation between age and recovery of spermatogenesis could be demonstrated. The overall high incidence of azoospermia (70.3%) supports the indication for semen cryopreservation in young patients undergoing BMT. These results have implications for semen sample timing before and after BMT and underline a need to collect further data through prospective multi-center studies.

Naltrexone in functional hypothalamic amenorrhea and in the normal luteal phase.

Fifteen young women with a diagnosis of secondary hypothalamic amenorrhea of at least 2 years' duration were given either 50 mg naltrexone daily or placebo, following a randomized double-blind crossover scheme. Seven patients did not menstruate with either therapy. In the other eight, the following results were recorded (mean +/- SD and range): a cycle length of 28.7 +/- 7.6 (12-45) days for naltrexone compared with 30.8 +/- 5.9 (16-43) days for placebo, a follicular phase length of 20.8 +/- 5.4 (14-34) days for naltrexone and 23.2 +/- 4.3 (19-32) days for naltrexone and 8.3 +/- 1.6 (5-10) days for placebo. The number of ovulatory cycles was 18 of 24 (75%) with naltrexone and eight of 24 (33%) with placebo (P less than .05). Most luteal phases were short. In five normally menstruating women, we gave either naltrexone or placebo in the luteal phase using a crossover blinded scheme. Steroidogenesis in the normal luteal phase was not impaired by naltrexone therapy. In functional hypothalamic amenorrheic patients with normal weight, menstruation might be restored by either placebo or naltrexone, but naltrexone provides a clinical and therapeutic advantage by increasing the ovulation rate.

Treatment of endometriosis with goserelin depot, a long-acting gonadotropin-releasing hormone agonist analog: endocrine and clinical results.

Thirty-two patients with laparoscopic diagnosis of endometriosis were treated for 6 months with the gonadotropin-releasing hormone agonist goserelin depot. Hormonal and clinical evaluations were conducted during treatment and for a 6-month follow-up period. Serum 17 beta-estradiol levels were sharply suppressed. Luteinizing hormone was also decreased, whereas follicle-stimulating hormone, after an initial fall, gradually rose to pretreatment levels. Ovarian androgenic production was less inhibited, total testosterone being the only significantly suppressed hormone. There was a marked improvement of signs and symptoms of endometriosis and a 47.3% reduction of laparoscopic score. The results of this study suggest that goserelin depot provides a very good suppression of ovarian estrogen production and is highly effective in decreasing the symptoms of endometriosis with an acceptable compliance by the patient.

Comparison of different ovarian stimulation protocols for gamete intrafallopian transfer in patients with minimal and mild endometriosis.

Three different stimulation protocols were tested in patients affected by stage I and II endometriosis with no other causes of infertility, and scheduled for the gamete intrafallopian transfer technique. In two protocols a gonadotropin hormone-releasing hormone analog was used. The analog was started 6 months before stimulation in the former and along with the exogenous gonadotropin in the latter. Patients receiving only gonadotropin served as controls. Sixty patients were selected for this study; 55 reached laparoscopy. Whereas patients receiving either gonadotropin alone or simultaneous analog and gonadotropin had similar pregnancy rates, this was much higher in the patients undergoing a prolonged, medically induced hypoestrogenism. Prolonged analog pretreatment before ovarian stimulation may give better chances of success in endometriosis patients undergoing assisted reproduction techniques.

Use of combined exogenous gonadotropins and pulsatile gonadotropin-releasing hormone in patients with polycystic ovarian disease.

We previously tested a combined regimen based on the administration of gonadotropin in the early follicular phase followed by pulsatile gonadotropin-releasing hormone (GnRH) until complete follicular maturation in patients suffering from polycystic ovarian disease. Despite good clinical results, a high rate of premature luteinization was observed with this approach. We therefore evaluated in this study whether starting pulsatile GnRH therapy before gonadotropin administration might reduce premature luteinization. Eight women underwent induction of ovulation with both combined therapy and pure exogenous follicle-stimulating hormone alone using a crossover scheme. No premature luteinization and a single follicular growth were recorded with the modified combined regimen. Clinical results (8/8 versus 3/7 ovulatory cycles; 3/8 versus 1/7 pregnancies) favor the combined approach over gonadotropin alone.

Transcervical selective salpingography: a diagnostic and therapeutic approach to cases of proximal tubal injection failure.

OBJECTIVE: Evaluation of selective salpingography for diagnosis and treatment of tubal injection failure during hysterosalpingography (HSG). DESIGN: Prospective study. SETTING: Obstetrics and Gynecology Department, University of Genoa (Italy)--tertiary care. PATIENTS: One hundred eighty infertile women with unilateral or bilateral proximal tubal injection failure during HSG were submitted to the procedure. INTERVENTION: Under fluoroscopy, a 4.5-F nylon catheter (3-F tip) was inserted into the ostium with or without the aid of a J-shaped, coaxial, angiographic guide wire, and 2 to 3 mL of contrast medium were injected. The procedure lasts 20 to 30 sec/tube. MAIN OUTCOME MEASURES: Of 155 tubal ostia, 145 (94.2%) were catheterized. RESULTS: Of the 146 catheterized tubes, 110 (75%) were rendered patent. Of the others, 21 (14.3%) presented hydrosalpinx or distal obstructions, and isthmic obstruction was present in 5 (3.4%). Patency of at least one tube was achieved in 82 (81.2%) of the 101 catheterized women; 8 conceived spontaneously and 11 after gamete intrafallopian transfer to the recanalized tube. CONCLUSIONS: During HSG, selective salpinography can be performed when proximal injection failure is observed to determine its cause or to restore patency.

Four year experience in laparoscopic dissection of intact ovarian dermoid cysts.

BACKGROUND: Intraperitoneal spillage of dermoid cyst content, if not followed immediately by abundant peritoneal lavage, can cause a chemical peritonitis with subsequent adhesion formation. STUDY DESIGN: We performed an open clinical study in a university hospital. Forty-four consecutive ovarian dermoid cysts were removed intact from 40 premenopausal women operated on between October 1993 and December 1997. The laparoscopic technique included: 1) creation of a cleavage plane between the cyst and the ovary; 2) dissection of the cyst by a combination of water, scissors, and gravity without direct traction on the cyst; and 3) extraction of the cyst after its placement inside a laparoscopic bag. RESULTS: The mean cyst diameter was 6.5 cm (range 3 to 12 cm). Mean operating time was 125 minutes (range 50 to 180 minutes). All patients were discharged within 48 hours. The cysts were dissected completely intact and were extracted without spillage in the abdominal cavity in all cases. Operative followup was available in 15 of the 40 patients; mild adhesions were found on the treated ovary in 3 (20%). CONCLUSIONS: It is always possible to prevent rupture and spillage of dermoid cysts during laparoscopic operations, but this approach is time consuming and needs expert surgical technique.

Effects of gonadotrophin-releasing hormone agonist on uterine fibroids and bone density.

Bone density (BD) was evaluated by single photon absorptiometry (SPA) in 18 women treated with Buserelin a gonadotrophin-releasing hormone (LHRH) analogue, for uterine fibroids. Buserelin was administered for a period of 6 mth. Amenorrhoea and oestradiol levels in the follicular-phase range were recorded in all patients during treatment. Fibroid volume was evaluated by means of ultrasound. SPA was performed at the 1/3 proximal radius and at the 1/10 distal radius sites before starting therapy and every 2 mth subsequently for 12 mth. BD was also measured in a control group of 18 normally-menstruating premenopausal women, matched for age and body mass index. No significant changes in BD at the proximal or distal radius sites were observed in either the cases or the controls during the study. Moreover, comparison of the data on the cases and the controls revealed no differences in BD at 0, 6 or 12 mth. Thus, although LHRH analogue treatment proved effective in reducing fibroids, it did not cause any significant changes in BD.

Luteinizing hormone-releasing hormone analog therapy of uterine fibroid: analysis of results obtained with buserelin administered intranasally and goserelin administered subcutaneously as a monthly depot.

From January 1987 to February 1988 patients affected by uterine fibroid were offered medical treatment with luteinizing hormone-releasing hormone analogs as an alternative to surgery. The aim was to compare results obtained with two different analog formulations. 42 patients were randomly assigned to receive either intranasal buserelin, preceded by a short period of subcutaneous injections (500 micrograms thrice daily for 10 days) or subcutaneous goserelin. Treatment was always started in the luteal phase. Response to therapy was evaluated through periodic clinic, endocrine and echotomographic controls. There were no significative differences in fibroid reduction between the two treatment groups. After 6 months of treatment, a fibroid reduction of more than 30% of the initial volume was observed in 16 patients in the buserelin group and in 18 patients in the goserelin group. The fibroid regrowth observed in all patients during the follow-up period severely limits the usefulness of this medical approach to selected clinical cases.

[Luteal phase support in assisted reproductive cycles using either vaginal (Crinone 8) or intramuscular (Prontogest) progesterone: results of a prospective randomized study]. / La supplementazione della fase luteale in cicli di Riproduzione Assistita con progesterone per via vaginale (Crinone 8) o per via intramuscolare (Prontogest): risultati di uno studio prospettico e randomizzato.

BACKGROUND: To compare local tolerance and patients compliance to intravaginal and intramuscular progesterone administration. METHODS: Ninety-nine patients have been randomised to receive either intravaginal Crinone, 90 mg/day (n=51) or intramuscular Prontogest 50 mg/day (n=48) for luteal supplementation in IVF/ICSI cycles. Local and systemic side effects as well as pattern of menstrual bleeding were reported on a self administered questionnaire. Progesterone levels were evaluated pre-treatment, in the mid-luteal phase and the day of pregnancy test. RESULTS: Patients age, BMI, duration and causes of infertility were comparable in the two treatment groups. All parameters of ovarian response as well as pregnancy rates did not show significative difference in the two groups. A significative larger number of patients assigned to intravaginal support were free from side effects. Furthermore side effects, when reported, resulted significantly more severe in the intramuscular group. In the non pregnant patients menstrual flow appeared significantly earlier in those treated with vaginal progesterone (p<0.001). CONCLUSIONS: Crinone 8 is a good alternative to parental progesterone for luteal support in ART cycles. It is well tolerated but it is linked to an earlier appearance of menstrual flow in non conceptional cycles.

How complete is full thickness disc resection of bowel endometriotic lesions? A prospective surgical and histological study.

BACKGROUND: This study aims to evaluate the completeness of full thickness disc resection in the treatment of deep endometriotic bowel lesions. METHODS: This study comprised 16 women with bowel endometriotic lesions requiring segmental resection. For the purpose of the study, before intestinal resection, nodulectomy was performed. The presence of endometriotic infiltration in direct continuity with the removed nodule and the presence of fibrosis in the area surrounding the nodule were histologically evaluated. RESULTS: In seven out of 16 cases (43.8%; 95% CI, 19.8-70.1), endometriosis was found in the bowel wall adjacent to the site of nodulectomy; the infiltration was visible in the muscular layer in all cases. In cases of incomplete nodulectomy, the muscular layer of the bowel segment surrounding the endometriotic nodule contained limited or no fibrosis. CONCLUSIONS: Full thickness disc resection is not complete in > or =40% of women with bowel endometriosis. Our finding that fibrosis in the muscular layer, the main landmark during surgical resection, does not always surround bowel endometriotic lesions might explain why incomplete resection may occur.