The use of near-infrared imaging with indocyanine green in the ovarian tissue transplantation: a case report.

The request for fertility preservation has consistently increased in recent years. To our knowledge this case report is the first to describe the application of near-infrared intraoperative imaging using indocyanine green (NIR-ICG) during ovarian tissue transplantation (OTT), to assist surgeon choosing the site of implantation of ovarian fragments. OTT was performed in a 42-year-old woman using NIR-ICG to evaluate the vascularisation of peritoneal area as the site of implantation for the ovarian graft. we believe this new approach could be useful in identifying the best reimplantation site.

Mechanical hysteroscopic tissue removal or hysteroscopic morcellator: understanding the past to predict the future. A narrative review.

BACKGROUND: In recent years, the available evidence revealed that mechanical hysteroscopic tissue removal (mHTR) systems represent a safe and effective alternative to conventional operative resectoscopic hysteroscopy to treat a diverse spectrum of intrauterine pathology including endometrial polyps, uterine myomas, removal of placental remnants and to perform targeted endometrial biopsy under direct visualisation. This innovative technology simultaneously cuts and removes the tissue, allowing one to perform the procedure in a safer, faster and more effective way compared to conventional resectoscopic surgery. OBJECTIVE: To review currently available scientific evidence concerning the use of mechanical hysteroscopic morcellators and highlight relevant aspects of the technology. MATERIAL AND METHODS: A narrative review was conducted analysing the available literature regarding hysteroscopic tissue removal systems. MAIN OUTCOME MEASURES: Characteristics of available mHTR systems, procedures they are used for, their performance including safety aspects and their comparison. RESULTS: A total of 7 hysteroscopic morcellators were identified. The diameter of the external sheet ranged from 5.25 to 9.0 mm, optics ranged from 0.8 to 6.3 mm with 0o angle. The cutter device diameter ranged from 2.9 to 4.5 mm most of them with rotation and reciprocation. CONCLUSION: We conclude that the adoption of mHTR has shown to reduce operating time, simultaneously cutting and suctioning tissue fragments avoiding the need for multiple removal and reinsertions of the device into the uterine cavity as well as reducing the volume of distension media required to complete the procedure compared to using the hysteroscopic resectoscope.

Methotrexate injection for interstitial pregnancy: Hysteroscopic conservative mini-invasive approach.

BACKGROUND: Interstitial localisation of ectopic pregnancy is associated with high rates of maternal morbidity and mortality. Considering the rarity of interstitial pregnancy, the optimal treatment regimen remains unclear. We propose the management of interstitial pregnancy with local methotrexate injection using a combined hysteroscopic and ultrasonographic approach. TECHNIQUE: Hysteroscopy was performed under local anaesthesia in the operating room, using a 2.9-mm Hopkins II Forward-Oblique Telescope 30° endoscope with a 4.3-mm inner sheath and 5 FR instruments. A needle was pushed into the cornual region injecting methotrexate solution directly into the gestational sac and into the myometrial tissue tangentially at the four cardinal points. A contemporary transabdominal ultrasound (US) was performed in order to reduce risks of complications. EXPERIENCE: Five patients with an US diagnosis of interstitial ectopic pregnancy admitted to our department between January 2016 and September 2019 were managed with a local hysteroscopic injection of methotrexate. The technique was effective in all patients and no surgical complications occurred during or after the procedure. Three patients were evaluated for tubal patency with contrast ultrasonography confirming bilateral tubal patency 9 months from treatment, while one patient had a spontaneous birth 22 months from their initial surgery. CONCLUSION: The hysteroscopic ultrasound-guided approach combined with the local injection of methotrexate is a minimally invasive conservative approach that seems to be promising in the management of interstitial ectopic pregnancy.

Assessment of levator hiatal area using 3D/4D transperineal ultrasound in women with deep infiltrating endometriosis and superficial dyspareunia treated with pelvic floor muscle physiotherapy: randomized controlled trial.

OBJECTIVES: Deep infiltrating endometriosis (DIE) is associated with chronic pelvic pain, dyspareunia and pelvic floor muscle hypertonia. The primary aim of this study was to evaluate the effect of pelvic floor physiotherapy (PFP) on the area of levator ani hiatus during Valsalva maneuver, assessed using transperineal ultrasound, in women with DIE suffering from superficial dyspareunia. METHODS: This was a randomized controlled trial of 34 nulliparous women diagnosed with DIE and associated superficial dyspareunia. After an initial clinical examination, all patients underwent three-dimensional/four-dimensional (3D/4D) transperineal ultrasound to measure the levator hiatal area (LHA) at rest, on maximum pelvic floor muscle contraction and on maximum Valsalva maneuver, and were asked to rate their pain symptoms using a numerical rating scale (NRS). Eligible women were assigned randomly (1:1 ratio) to no intervention (control group, 17 women) or treatment with five individual sessions of PFP (study group, 17 women). Four months after the first examination, all women underwent a second evaluation of pain symptoms and LHA on transperineal ultrasound. The primary outcome measure was the percentage change in LHA on maximum Valsalva maneuver between the baseline and follow-up examinations. The percentage changes in pain symptoms between the two examinations, including superficial and deep dyspareunia, dysmenorrhea, chronic pelvic pain, dysuria and dyschezia, were also evaluated. RESULTS: Thirty women, comprising 17 in the study group and 13 in the control group, completed the study and were included in the analysis. The percentage change in LHA on maximum Valsalva maneuver between the two examinations was higher in the study group than in the control group (20.0 ± 24.8% vs -0.5 ± 3.3%; P = 0.02), indicating better pelvic floor muscle relaxation. After PFP treatment, the NRS score for superficial dyspareunia remained almost unchanged in the control group (median change in NRS (Δ-NRS), 0 (interquartile range (IQR), 0-0)) while a marked reduction was observed in the study group (median Δ-NRS, -3 (IQR, -4 to -2); P < 0.01). Moreover, there was a significant difference between the PFP and control groups with regards to the change in chronic pelvic pain (median Δ-NRS, 0 (IQR, -2 to 0) vs 0 (IQR, 0-1); P = 0.01). CONCLUSIONS: In women with DIE, PFP seems to result in increased LHA on Valsalva maneuver, as observed by 3D/4D transperineal ultrasound, leading to improved superficial dyspareunia, chronic pelvic pain and pelvic floor muscle relaxation. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Fetal head progression and regression on maternal pushing at term and labor outcome.

OBJECTIVES: The aim of our study was two-fold. First, to evaluate the association between the change in the angle of progression (AoP) on maternal pushing and labor outcome. Second, to assess the incidence and clinical significance of the reduction of AoP on maternal pushing. METHODS: This was a prospective cohort study of nulliparous women with singleton pregnancy at term. AoP was measured at rest and on maximum Valsalva maneuver before the onset of labor, and the difference between AoP on maximum Valsalva and that at rest (ΔAoP) was calculated for each woman. Following delivery and data collection, we assessed the association between ΔAoP and various labor outcomes, including Cesarean section (CS), duration of the first, second and active second stages of labor, Apgar score and admission to the neonatal intensive care unit (NICU). The prevalence of women with reduction of AoP on maximum Valsalva maneuver (AoP-regression group) was calculated and its association with the mode of delivery and duration of different stages of labor was assessed. RESULTS: Overall, 469 women were included in the analysis. Among these, 273 (58.2%) had spontaneous vaginal birth, 65 (13.9%) had instrumental delivery and 131 (27.9%) underwent CS. Women in the CS group were older, had narrower AoP at rest and on maximum Valsalva, higher rate of epidural administration and lower 1-min and 5-min Apgar scores in comparison with the vaginal-delivery group. ΔAoP was comparable between the two groups. On Pearson's correlation analysis, AoP at rest and on maximum Valsalva maneuver had a significant negative correlation with the duration of the first stage of labor. ΔAoP showed a significant negative correlation with the duration of the active second stage of labor (Pearson's r, -0.125; P = 0.02). Cox regression model analysis showed that ΔAoP was associated independently with the duration of the active second stage (hazard ratio, 1.014 (95% CI, 1.003-1.025); P = 0.012) after adjusting for maternal age and body mass index. AoP reduction on maximum Valsalva was found in 73 (15.6%) women. In comparison with women who showed no change or an increase in AoP on maximum Valsalva, the AoP-regression group did not demonstrate significant difference in maternal characteristics, mode of delivery, rate of epidural analgesia, duration of the different stages of labor or rate of NICU admission. CONCLUSIONS: In nulliparous women at term before the onset of labor, narrower AoP at rest and on maximum Valsalva, reflecting fetal head engagement, is associated with a higher risk of Cesarean delivery. The increase in AoP from rest to Valsalva, reflecting more efficient maternal pushing, is associated with a shorter active second stage of labor. Fetal head regression on maternal pushing is present in about 16% of women and does not appear to have clinical significance. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Laparoscopic management of early stage ovarian cancer: is it feasible, safe, and adequate? A retrospective study.

INTRODUCTION: Minimally invasive surgery to stage early ovarian cancer is still regarded as pioneering among gynecologic oncologists. Previous retrospective experiences demonstrated the safety and feasibility of laparoscopy in this field. AIMS: To review the laparoscopic staging procedure in a series of patients with early ovarian cancer and compare results with the literature. MATERIALS AND METHODS: From January 2004 to September 2011, 19 patients with apparent early stage ovarian/fallopian tube cancer Stage IA to IC underwent either primary treatment or completion staging by laparoscopy. Surgical, pathologic, and oncologic outcomes were analyzed. RESULTS: The mean operative time was 212 +/- 69 minutes. Three patients (16%) underwent fertility sparing surgery. The mean estimated blood loss was two +/- two g/dl. The mean number of pelvic and para-aortic lymph nodes collected was 17 (range 7-27) and 14 (range 8-21), respectively. The mean volume of ovarian/tubal tumor was 119 cm3 (range 1.5-500). The disease was reclassified to a higher stage in ten women (52%). One major intraoperative complication (five percent) occurred which required the conversion to laparotomy. The mean follow up period was 30 +/- 16 months (range 10-74). Overall survival and disease-free survival were 100% and 84%, respectively. CONCLUSIONS: Laparoscopic staging of early ovarian cancer appears to be feasible and comprehensive when performed by gynecologic oncologists experienced with advanced laparoscopy.

Three-dimensional transvaginal sonography in local staging of cervical carcinoma: description of a novel technique and preliminary results.

OBJECTIVE: To evaluate the feasibility of three-dimensional multiplanar sonography in the local staging of cervical carcinoma. METHODS: Between January 2005 and May 2006, 14 patients with invasive cervical carcinoma underwent transvaginal volume ultrasound examination prior to primary surgery. Parametrial invasion was evaluated in the coronal plane, while both bladder and rectal invasion were evaluated in the sagittal plane. Ultrasound findings were compared with surgical and histological results. RESULTS: In 12 of the 14 cases, three-dimensional ultrasound findings were compatible with pathology results. In the remaining two cases, either infiltration of right parametrium or rectal invasion were suspected at ultrasound but not confirmed at pathology. CONCLUSIONS: Despite the small number of patients evaluated, three-dimensional multiplanar sonography appears to be a promising technique in the local staging of cervical carcinoma.

A comparison of the transition from first words to grammar in English and Italian.

Cross-linguistic similarities and differences in early lexical and grammatical development are reported for 1001 English-speaking children and 386 Italian-speaking children between 1;6 and 2;6. Parents completed the English or Italian versions of the MacArthur Communicative Development Inventory: Words and Sentences, a parent report instrument that provides information about vocabulary size, vocabulary composition and grammatical complexity across this age range. The onset and subsequent growth of nouns, predicates, function words and social terms proved to be quite similar in both languages. No support was found for the prediction that verbs would emerge earlier in Italian, although Italians did produce a higher proportion of social terms, and there were small but intriguing differences in the shape of the growth curve for grammatical function words. A strikingly similar nonlinear relationship between grammatical complexity and vocabulary size was observed in both languages, and examination of the order in which function words are acquired also yielded more similarities than differences. However, a comparison of the longest sentences reported for a subset of children demonstrates large cross-linguistic differences in the amount of morphology that has been acquired in children matched for vocabulary size. Discussion revolves around the interplay between language-specific variations in the input to young children, and universal cognitive and social constraints on language development.

Associative visual agnosia resulting from a disconnection between intact visual memory and semantic systems.

We report the case of a patient (RC) who developed a severe visual agnosia, associated to alexia without agraphia, color anomia and amnesia, following an ischemic stroke in the territory supplied by the left posterior cerebral artery. Based on his proficient performance on tests evaluating analysis of elementary visual features, formation of viewer-centered and object-centered representations of visual stimuli and discrimination between drawings representing real and unreal objects, we concluded that the critical locus of deficit was a disconnection between the normally functioning visual memory store and the semantic system. RC's disturbance in visual processing of human faces paralleled his recognition disorder of other classes of objects. The possible contribution of neurobiological factors in determining RC's agnosic deficit is discussed.

Interaction between menstrual cyclicity and gonadotropin pulsatility.

Pulsatile gonadotropin secretion is a critical endocrine component of the regulation of the normal menstrual cycle. Pulsatile luteinizing hormone (LH) secretion changes dynamically across the menstrual cycle. Derangements of pulsatile LH secretion are found in virtually every menstrual disorder. This article summarizes the key features of pulsatile LH secretion in the normal menstrual cycle and in ovulatory disorders.

Subcutaneous administration of a depot gonadotropin-releasing hormone agonist induces profound reproductive axis suppression in women.

OBJECTIVE: To compare the i.m. and s.c. routes of depot GnRH agonist administration. DESIGN: Prospective, controlled pharmacokinetics study. SETTING: Volunteers in an academic research environment. PATIENT(S): Forty women with benign gynecologic disorders. INTERVENTION(S): Triptorelin administration (3.75 mg) at 28-day intervals for 6 consecutive months. Twenty patients were treated with IM triptorelin, and 20 patients were treated with SC triptorelin. MAIN OUTCOME MEASURE(S): Assessment of side effects, GnRH test results, and triptorelin, LH, FSH, estradiol, and progesterone levels. RESULT(S): The occurrence of injection site redness and itching and of some hypoestrogenic side effects was increased significantly in the SC group. Plasma triptorelin levels were significantly higher in the IM group in the first month of treatment; thereafter, the pattern reversed, with a nonsignificant trend toward higher plasma triptorelin levels in the SC group. Serum LH, FSH, estradiol, and progesterone levels were low after the first month of treatment and did not differ between the two treatment groups. On day 196 (2 months after the last depot triptorelin injection), triptorelin was still measurable and gonadotropins and gonadal steroids were still suppressed. Spontaneous menses returned significantly later in the SC group than in the IM group. CONCLUSION(S): Subcutaneous triptorelin can be administered by the patient. Both IM and SC triptorelin administration are cliniclly effective, but they result in different triptorelin pharmacokinetics. Subcutaneous triptorelin is associated with more prolonged amenorrhea than is IM triptorelin, suggesting enhanced pituitary-ovarian suppression. These results suggest that SC triptorelin may allow lower drug dosage administration and/or longer administration intervals.

Role of different GnRH agonist regimens in pituitary suppression and the outcome of controlled ovarian hyperstimulation.

Gonadotrophin-releasing hormone (GnRH) agonists have become irreplaceable addition to gonadotrophins in ovulation induction for assisted reproduction. Of the several schemes currently employed, long regimens appear to be maximally effective to optimize patient scheduling and to improve clinical results.

Is multiple pregnancy an unavoidable complication of ovulation induction? The case for pulsatile GnRH.

Ovarian hyperstimulation (OHS) and multiple pregnancy are dreaded complications of ovulation induction. The use of pulsatile GnRH permits to prevent the occurrence of OHS and results in few multiple pregnancies. Low-dose GnRH administration, avoidance of preovulatory hCG, patient selection, and the use of GnRH agonist pituitary desensitization in selected patients permits to limit multiple conceptions to a level comparable with the occurrence of this complication in normal unstimulated women.