Does Endometriosis Impact the Composition of Follicular Fluid in IL6 and AMH? A Case-Control Study.

OBJECTIVE: The aim of this study was to compare follicular liquid levels of IL6 and AMH in women with and without endometriosis and to evaluate their potential impact on ICSI outcomes. MATERIALS AND METHODS: It is a prospective case-control study conducted on 25 women with proven endometriosis and 50 patients diagnosed with other causes of infertility. All these patients were candidates for ICSI cycles. Their follicular fluid was collected at the time of oocyte retrieval and used to evaluate IL-6 and AMH titers by electro-chemiluminescent immunoassay (Cobas e411-Roche). RESULTS: The IL-6 levels in follicular fluid were higher in the endometriosis group than in the control group (152.3 vs. 19.9 pg/mL; p = 0.02). The median level for AMH was 2.2 ± 1.88 ng/mL with no statistical difference between the two groups (2.2 vs. 2.7 ng/mL, p = 0.41). No significant correlation between the follicular IL6 and AMH levels was observed. CONCLUSIONS: The oocyte quality seems to be preserved in patients with endometriosis with the adequate response to ovarian stimulation. High levels of follicular IL6 are in accordance with the inflammatory phenomenon of the disease; however, this increase has no impact on ICSI outcomes.

Evaluation of ovarian reserve before and after chemotherapy.

BACKGROUND: Progress in oncology has improved patient survival. However, cancer chemotherapy can be gonadotoxic and affect their fertility. Recourse to fertility preservation before starting these treatments is therefore necessary in order to allow a better life quality after survival. The aim of this work was to study the impact of chemotherapy on ovarian reserve by AMH measurement. METHODS: This is a descriptive and longitudinal study from 2015 to 2018 carried out at Aziza Othmana hospital ART center in Tunis on patient aged less than 41 years who were candidates for fertility preservation. Patients included had AMH measurement prior to cancer treatment. We called them back to follow up the AMH level after chemotherapy. The AMH assay was performed by electrochemilumiescence technique. At the end, only 66 patients met the inclusion criteria. RESULTS: The most frequent pathologies were Hodgkin's lymphoma and breast cancer. The mean age of patients was 26.7 ± 6.8. The most used chemotherapy protocols were BEACOPP, ABVD or the combination of both in lymphoma and FEC + TXT for breast cancer treatment. A significant difference between AMH before and after chemotherapy was found for BEACOPP and FEC + TXT protocols (p < 10 3). The patient's age was correlated with the AMH decrease after chemotherapy (r = 0.577, p < 10 3). CONCLUSION: Our results showed that the high risk gonadotoxicity protocols were BEACOPP for lymphoma treatment and FEC + TXT for breast cancer treatment. However, studies with a larger sample and more time extended monitoring are necessary for a better gonadotoxicity understanding of the cancer treatments available today.

Robotic Surgery in Gynecology.

Minimally invasive surgery (MIS) can be considered as the greatest surgical innovation over the past 30 years. It revolutionized surgical practice with well-proven advantages over traditional open surgery: reduced surgical trauma and incision-related complications, such as surgical-site infections, postoperative pain and hernia, reduced hospital stay, and improved cosmetic outcome. Nonetheless, proficiency in MIS can be technically challenging as conventional laparoscopy is associated with several limitations as the two-dimensional (2D) monitor reduction in-depth perception, camera instability, limited range of motion, and steep learning curves. The surgeon has a low force feedback, which allows simple gestures, respect for tissues, and more effective treatment of complications. Since the 1980s, several computer sciences and robotics projects have been set up to overcome the difficulties encountered with conventional laparoscopy, to augment the surgeon's skills, achieve accuracy and high precision during complex surgery, and facilitate widespread of MIS. Surgical instruments are guided by haptic interfaces that replicate and filter hand movements. Robotically assisted technology offers advantages that include improved three-dimensional stereoscopic vision, wristed instruments that improve dexterity, and tremor canceling software that improves surgical precision.

Ovarian Drilling in PCOS: Is it Really Useful?

Polycystic ovary syndrome (PCOS) is a frequent disorder, affecting approximately 5-10% of infertile women. It can represent more than 80% of cases of infertility due to anovulation. The main goal of treatment is the induction of mono-ovulatory cycles. A pragmatic management of infertility in PCOS will allow most patients to conceive. Weight loss and clomiphene citrate (CC) are the first-line components of patients treatment before gonadotrophins are used. However, during gonadotrophin administration, there is a high risk of ovarian hyper-stimulation and multiple pregnancies. So, surgery with laparoscopic ovarian drilling is often used before gonadotrophins in order to obtain normal ovulatory cycles.

Endometriosis and Vesico-Sphincteral Disorders.

OBJECTIVES: The aim of this mini review is to determine the relationship between endometriosis and urinary tract symptoms and to investigate the consequences of surgical treatment of mild to severe endometriosis, especially deep lesions, on the vesico-sphincteral function (lower urinary tract function). MATERIALS AND METHODS: We performed a literature review by searching the MEDLINE database for articles published between 2000 and 2014, limiting the searches to the words: urinary tract, vesico-sphincteral, dysfunction, endometriosis, symptoms, and surgery. RESULTS: The incidence of vesico-sphincteral symptoms in endometriosis varies from 3.4 up to 15.4%. The frequency of such symptoms seems to be under estimated because of a lack of specific questionnaire including urinary symptoms. Urodynamic evaluation could help to detect unsuspected abnormalities. It seems that endometriosis surgery (particularly deep infiltrating lesions) is a purveyor of de novo urinary dysfunction, with an incidence varying from 6.8 up to 17.5%. Nerve sparing processes such as neuro-navigators or neuro-stimulators seem to be promising techniques to avoid postoperative urinary tract dysfunction. CONCLUSION: A precise anamnesis and the use of specific validated questionnaires (IPSS and BFLUTS) improve the screening of vesico-sphincteral symptoms in case of endometriosis. No recommendation can be found in the literature about the place of urodynamic evaluation. Most publications lack of proof and therefore do not allow making recommendations about optimal treatment of endometriotic lesions to avoid urinary tract disorders.

Chromosomal evaluation in a group of Tunisian patients with non-obstructive azoospermia and severe oligozoospermia attending a Tunisian cytogenetic department.

Male infertility is the cause in half of all childless partnerships. Numerous factors contribute to male infertility, including chromosomal aberrations and gene defects. Few data exist regarding the association of these chromosomal aberrations with male infertility in Arab and North African populations. We therefore aimed to evaluate the frequency of chromosomal aberrations in a sample of 476 infertile men with non-obstructive azoospermia (n=328) or severe oligozoospermia (n=148) referred for routine cytogenetic analysis to the department of cytogenetics of the Pasteur Institute of Tunis. The overall incidence of chromosomal abnormalities was about 10.9%. Out of the 52 patients with abnormal cytogenetic findings, sex chromosome abnormalities were observed in 42 (80.7%) including Klinefelter syndrome in 37 (71%). Structural chromosome abnormalities involving autosomes (19.2%) and sex chromosomes were detected in 11 infertile men. Abnormal findings were more prevalent in the azoospermia group (14.02%) than in the severe oligozoospermia group (4.05%). The high frequency of chromosomal alterations in our series highlights the need for efficient genetic testing in infertile men, as results may help to determine the prognosis, as well as the choice of an assisted reproduction technique. Moreover, a genetic investigation could minimize the risk of transmitting genetic abnormalities to future generations.

Endometriosis and infertility: how and when to treat?

Endometriosis is defined as the presence of endometrial-like tissue (glands or stroma) outside the uterus, which induces a chronic inflammatory reaction. Although endometriosis impairs fertility, it does not usually completely prevent conception. The question of evidence based-medicine guidelines in endometriosis-associated infertility is weak in many situations. Therefore, we will highlight in this issue where the challenges are.

Placental site trophoblastic tumor: a case report and review of the literature.

Placental site trophoblastic tumor is rare. They represent a rare form of gestational trophoblastic disease. They occur mainly in women who have a history of miscarriage, termination of pregnancy, or even a normal or pathological ongoing pregnancy. The clinical course is unpredictable. This malignancy has different characteristics from other gestational trophoblastic tumors. Following a clinical case that we encountered and treated, we conducted a literary research and review, focusing primarily on prognostic factors and treatment.

[Diagnostic hysteroscopy before the first in vitro fertilization. For whom?]. / Hystéroscopie diagnostique avant la 1ère Fécondation In Vitro. Pour Qui ?

BACKGROUND: For some teams, hysteroscopy, should be performed before each IVF attempt to maximize the chances of implantation because of the high cost, the investment in time and the psychological impact of each IVF cycle, but answer to the question of the systematic practice of hysteroscopy prior to IVF is far from settled. AIM: Assess the benefits of conducting a routine hysteroscopy before the first IVF / ICSI and to identify subgroups in whom this examination provides a real benefit. METHODS: This is a comparative retrospective study about 334 patients, included in an IVF program with micro-injection, in the center of ART of Aziza Othmana hospital of Tunis, for a period of one year. The results of ICSI in patients with a first attempt at IVF / ICSI were compared according to the realization (HSC +) or not (HSC-) of a diagnostic hysteroscopy prior to the first IVF attempt. results : The implantation rate in our series was 21.62%. We got a pregnancy in 128 cases, that is a pregnancy rate per transfer of 38.32%. The rate of live births was 29.34%, including 94.89% deliveries to terms with living fetus. We found no significant difference between groups "HSC +" and "HSC -" in terms of pregnancy rates of biological or clinical pregnancy rate or in terms of live births. But, in patients aged 40 and over, we found improved results of IVF in a meaningful way in the group "+ HSC". CONCLUSION: Our study finds no benefit in terms of outcomes of IVF/ ICSI to the completion of hysteroscopy in a systematic way, despite a high incidence of abnormalities detected by intra-cavity examination. The benefit of routine hysteroscopy is significant only in women 40 and older.

[Cost of medical treatment with methotrexate for ectopic pregnancy. Study comparing medical treatment versus laparoscopy. Experience of Aziza Othmana Hospital]. / Coût du traitement médical par méthotrexate de la grossesse extra utérine. Etude comparative traitement médical versus traitement coeliochirurgical. Expérience de l'Hôpital Aziza Othmana.

BACKGROUND: The ectopic pregnancy can be treated surgically (conservative or radical) or medically. Currently, the choice between medical and surgical treatment is a critical issue. One of the parameters of this choice is the total cost of management. AIM: To compare the cost of the management of ectopic pregnancy by medical treatment (methotrexate, MTX) and coeliochirurgicaux. METHODS: This is a prospective, comparative, nonrandomized,unicentric study, on 39 patients who have ectopic pregnancies treated with MTX versus 16 patients treated by laparoscopic surgery with conservative treatment. This study was collected at the service of Obstetrics and Gynecology Reproductive Medicine Aziza Othmana Hospital (Tunis) for a period of two years. RESULTS: The average cost of hospital stay per patient was 549.38 dt for the MTX group against 268.39 dt for laparoscopic surgery group (p <0.001). There was no statistically significant difference between the two groups. In terms of overall absenteeism, there is no statistically significant difference (16.43 vs 17.5 days). CONCLUSION: The initial treatment with MTX costs more cost than the conservative laparoscopic treatment and this is mainly due to the long period of hospitalization.

[Quality of life during menstruation in women with an inherited bleeding disorder: report of 31 cases]. / Qualité de vie pendant les menstruations chez les patientes portueses d'un troble héréditaire de l'hémostase: a propos de 31 patientes.

BACKGROUND: Menstruations, by their abundance and their duration, can be a source of impaired quality of life. Women with inherited bleeding disorders appear to be, specially at risk. AIM: Assess the impact of menstrual blood loss on the quality of life for women with inherited bleeding disorders. METHODS: 31 women with various inherited bleeding disorders were interviewed. They completed a quality of life questionnaire. RESULTS: Von Willebrand disease was the most frequent inherited bleeding disorder in our population (38.7%). 54.8% of patients had a menstrual period more than 6 days 61.3% of them consider their menstrual flow to be normal. The general condition apart of the menstrual period was considered medium to poor in 35.5% of patients. The average score assessing the impact of menstruation on daily life was of 5.00 ± 3.47. Only 19.35% of patients felt that dysmenorrhea significantly affect their quality of life. Impaired quality of life was seen in 64.5% of patients according to score Aand in 41.9% of them according to score B. During menstruation 22.6% of the patients didn't do to work or to school because of the menstrual flow. On the other hand, 48.4% of patients were hospitalized at least once for a heavy menstrual flow. CONCLUSION: The quality of life during menstruation, in women with an inherited bleeding disorder, according to the different scores appear altered. Although because of the small size of our study population, we could not prove correlation between the importance of menstrual blood loss and the impairment of quality of life.

[Basal fsh level is only predictive of the quantitative aspect of the ovarian response]. / Le taux basal de FSH à j3 du cycle est un facteur prédictif de l'aspect quantitatif de la réponse ovarienne à la stimulation.

BACKGROUND: Determination FSH and LH at day 3 of the menstrual cycle predicts the response to stimulation. AIM: To evaluate the value of FSH and LH measurements compared with women's age in predicting qualitative and quantitative ovarian response to gonadotrophin stimulation. METHODS: 305 patients underwent at least one intra cytoplasmic sperm injection (ICSI) cycle. The levels of FSH and LH at day 3 were determined in an earlier cycle. A good quantitative ovarian response was defined as ³3 oocytes retrieved and 3 embryos obtained. A good qualitative ovarian response was defined as a percentage of mature oocytes ³75% and immature ones²15% of the total number of oocytes retrieved with at least one top quality embryo obtained. RESULTS: Receiver operating characteristic (ROC) curves were generated for FSH, LH and female age. FSH is better than female age in predicting the number of oocytes retrieved (respectively ROCAUC=0.77, p=10-3 versus ROCAUC=0.73, p=10-3) and the number of embryos obtained (ROCAUC=0.69, p=10-3 versus ROCAUC=0.66, p=10-3). LH is non predictive. None of the three tested parameters was predictive of the fertilization and pregnancy rates. An FSH cutoff was calculated and a value of 7.8mUI/ml is associated with a sensitivity of 73% and a specificity of 70% for the prediction of ovarian response to controlled stimulation. CONCLUSION: Basal FSH level predicts good quantitative rather than qualitative response. LH is non predictive. FSH and LH do not predict pregnancy rate. Patients having high FSH levels should not be excluded from IVF/ICSI treatment.

Successful conservative treatment of a cesarean scar pregnancy with systemically administered methotrexate and subsequent dilatation and curettage: a case report.

Cesarean scar pregnancy is a rare type of ectopic pregnancy associated with severe complications such as uterine rupture, uncontrollable bleeding which may lead to hysterectomy, and definitive infertility. Many therapeutic options are available such as Dilatation & Curetage, excision of trophoblastic tissues using either laparotomy or laparoscopy, systemically administered Methotrexate, and more recently uterine artery embolization. The use of Methotrexate sometimes required laparotomy later because of severe hemorrhage. Through this paper, we demonstrated that viable cesarean scar pregnancy can be managed safely by systemically delivered Methotrexate at the cost of a prolonged followup.

[Delivery in twin pregnancies. The experience of the obstetrics department of Aziza Othmana's Hospital, about 117 cases]. / L'accouchement des grossesses gémellaires. Expérience de la maternité de l'Hôpital Aziza Othmana : A propos de 117 cas.

BACKGROUND: The conduct and delivery of twin pregnancies are interspersed with as well as maternal fetal and neonatal complications. The obstetrician is faced with the birth of 2 children often fragile and a uterus often exposed to dynamic dystocia. AIM: To study the maternal and newborn morbidity and mortality in twins, in order to clear the optimal route of delivery in such circumstances. METHODS: A retrospective study over a period of 3 years (1 January 2005 to December 31, 2007), about 117 twin pregnancies. Inclusion criteria were a term exceeding 28 weeks and fetuses alive. We analyzed maternal complications during and after delivery and neonatal complications. RESULTS: Maternal complications were significantly more frequent in case of caesarean section. The frequency of perinatal complications (Apgar score, respiratory distress, immediate neonatal resuscitation and neonatal intensive care unit transfer) in the first twin was not influenced by the route of delivery as opposed to the second twin which Apgar score's alters when vaginally. The newborns of low birth weight (<1,500 Kg) and those whose term was less than 32 weeks were more at risk of an Apgar score <7 (at 1 and 5 minutes), respiratory complications, need for immediate resuscitation and transfer to intensive care and that statistically significant both for the 1st and the 2nd twins. CONCLUSION: The twins pregnancies' morbidity appears to be more related to prematurity and intra uterine growth retardation) more than to the mode of delivery and hence the interest to detect and prevent its anomalies. It seems that vaginal delivery has a deleterious effect at least for the second twin but cesarean section doesn't seem to be the solution. Better learning techniques and obstetric maneuvers would reduce morbidity.

Ruptured intramural pregnancy with myometrial invasion treated conservatively.

Background. Intramural pregnancy is a rare form of ectopic pregnancy, difficult to diagnose and generally complicated by uterine rupture. Case. A 38-year-old woman, gravida 5 para 1, was diagnosed with intramural pregnancy by ultrasound and confirmed with MRI. A uterine rupture occurred, which lead to laparotomy and a conservative treatment. Conclusion. Early diagnosis is necessary for conservative treatment.

[Particularities of pregnancy and labor in 40-year-old women. Report of 300 cases]. / Particularités de la grossesse et de l'accouchement chez la femme de 40 ans et plus: à propos de 300 cas.

BACKGROUND: Pregnancy beyond age 40 is considered as a high risk pregnancy associated with high rates of maternal and fetal complications. AIM: To analyze particularities of pregnancy and labor and to examine obstetrical and neonatal outcomes among women age 40 years and older. METHODS: There was a retrospective study including two groups of 300 patients, the first including the 40-year- old and over women (case group), and the second including 20-to 39 -year-old mothers (control group). RESULTS: The mean age for the case group was 41 years. Ten (10.6%) of the women in the ca se group were primiparous as compared with twenty-seven (27.5%) in the control one (p=0.001).The antenatal surveillance was better in the control group. The morphologic sonograhy was performed in 73% of cases of 40-year -old-women versus 90% in the control group (p<0.001). Maternal age 40 and over was associated with an increased risk for gestational diabetes (6.4% versus 1.7%, p<0.001). The premature rupture of membranes was frequent in the case group (25.7% versus 11.7% p<0.001), and the amniotic fluid meconuim (16.3% versus 6.7%, p<0.001). The risk for cesarean section was higher in older women (25.7% versus 14% avec p <0.001). Neonatal outcomes (Apgar score, birth weight, perinatal mortality) were similar to those in the younger age group. CONCLUSION: The analysis of our results and the review of the literature have proven that advanced-maternal-age-pregnancy is associated with increased complications. So some recommendations' are necessary to ameliorate the management of this pregnancy.