Should the Treatment of Patients with Repeated Embryo Implantation Failure Be Adapted as a Function of the Endometrial Cytokine Profile? A Single-Center Experience.

Repeated embryo implantation failures (RIF) is a source of distress and frustration for patients and clinicians alike. Today's approaches for treating RIF are largely empirical and have limited effectiveness. The main causes of RIF are poor endometrial receptivity and poor-quality embryos. Recent studies have suggested the involvement of immune dysregulation due to an imbalance between T-helper (Th) 1 and Th2 cytokines; this opens up perspectives for treating women with RIF and increasing the implantation rate. We conducted an interventional, longitudinal, prospective cohort study of the impact of correcting the cytokine imbalance on the clinical pregnancy rate in women with RIF. Seventy-seven women with RIF underwent an endometrial biopsy during the implantation window. The cytokine profile was evaluated by studying the activation and maturation of uterine natural killer (uNK) cells, the IL-15/Fn-14 mRNA ratio (a biomarker of uNK activation/maturation), and the IL-18/TWEAK mRNA ratio (a marker of angiogenesis and the Th1/Th2 balance). Personalized treatment was initiated for women with an abnormal endometrial cytokine profile (hyper-activation or hypo-activation). We documented the clinical pregnancy rate after subsequent embryo transfers. In total, 72.7% (56/77) of patients had an abnormal endometrial cytokine profile (hyper-activation in 68.8% (n = 53) and hypo-activation in 3.9% (n = 3). After treatment (or not) as a function of the endometrial profile, the overall clinical pregnancy rate was 30.2%. Our results indicated a potential positive effect of appropriate treatment on the ongoing pregnancy rate in women with RIF, despite the small number of cases analyzed. The results must now be validated in randomized studies with larger numbers of well-characterized patients. By applying a previously published decision tree, this treatment approach could be implemented in clinics worldwide.

Performance of MRI for the detection of anterior pelvic endometriotic lesions.

OBJECTIVE: To study the performance of MRI for the detection of anterior pelvic endometriotic lesions. MATERIALS AND METHODS: We carried out a retrospective, single site, case-controlled study of patients who underwent surgery for endometriosis between March 2005 and December 2013. Laparoscopy was used to obtain the reference diagnosis of the endometriotic lesions. We age-matched patients with anterior endometriosis with those with isolated posterior endometriosis for reference. All of the pre-therapeutic MRI data were anonymized and blindly reread by two radiologists (junior and senior) twice. They assessed the overall presence of anterior lesions, those of the inter-vesicouterine space, the detrusor, the uterus, and posterior lesions. For each site, we calculated the sensitivity (Se) and specificity (Sp) for each reading compared to the reference, as well as the inter- and intra-operator variability using the Kappa coefficient (K) with its 95% confidence interval (95% CI). RESULTS: During the study period, 256 patients underwent surgery for endometriosis: 22 presented with anterior endometriosis at surgery, and had had pre-preoperative imagery. We included 22 controls who had an isolated posterior lesion. For the overall detection of anterior lesions, the two radiologists had an identical Se of 77.3% (95% CI; 54.6-92.2). The Sp was 100% (95% CI; 82.4-100) for the junior, and 89.5% (95% CI; 66.9-98.7) for the senior radiologist. The area under the ROC curve was 0.89 (95% CI; 0.80-0.98) for the junior and 0.81 (95% CI; 0.68-0.93) for the senior radiologist. The intra-operator variability was low with almost perfect reproducibility for the overall detection of anterior lesions; k=0.90 (95% CI; 0.77-1) for the junior and k=0.85 (95% CI; 0.70-1) for the senior radiologist. For the various anterior sites, the junior radiologist had k values between 0.60 and 1, whereas those of the senior radiologist were between 0.87 and 1. For inter-operator reproducibility, there was modest agreement between the two radiologists, k=0.46 (95% CI; 0.19-0.73), for the overall detection of anterior lesions; k varied between 0.43 and 0.61, depending on the site. CONCLUSION: Our results show that the characterization of anterior lesions by MRI is specific, but not very sensitive, with only moderate inter-operator reproducibility depending on the site. MRI can be used to diagnose anterior lesions, but cannot replace laparoscopy.

External validation of the MR imaging scoring system for the management of adnexal masses.

OBJECTIVE: To investigate the prognostic value of ADNEX Magnetic Resonance Imaging Scoring in the preoperative management of adnexal masses. STUDY DESIGN: We performed a retrospective study on patients who underwent surgery for an adnexal mass, with prior exploration by Magnetic Resonance Imaging (MRI), at the Gynecology Department of the Poissy Teaching Hospital between May 2012 and August 2014. MRI data were retrospectively read by radiologists, without knowledge of the histology, and classified according to the criteria of the ADNEX MR score. The radiological presumption of benign or malignant mass was compared with the final histological diagnosis. We calculated the sensitivity, specificity, positive and negative likelihood ratios and ROC curve of the ADNEX MR score with their 95% confidence intervals (95%CI). RESULTS: One-hundred-and-forty-eight patients were included in the study of which 24 had malignant or borderline ovarian tumors. The proportion of malignant or borderline ovarian tumors in each class of the ADNEX MR score in our study was: ADNEX I: 0% (95%CI, 0-8); ADNEX II: 1.7% (95%CI, 0.04-8.9); ADNEX III: 7.7% (95%CI, 0.2-36); ADNEX IV: 57.1% (95%CI, 34.2-78.8) and ADNEX V: 100% (95%CI, 69.2-100). Thus, for an ADNEX MR score greater than or equal to 4, the sensitivity was 91.7% (95%CI, 73-99) and the specificity 92.7% (95%CI, 86.7-96.6) for the diagnosis of a malignant or borderline ovarian tumor. The area under the ROC curve was 0.92 (95% CI%, 0.86-0.98). CONCLUSIONS: MRI, coupled with the use of the ADNEX MR scoring system, can accurately classify adnexal masses into low-risk (ADNEX MR score <4) or high-risk (ADNEX MR score ≥4) group, thereby allowing for appropriate preoperative counseling and planning for surgery.

Giant pararectal epidermoid tumor mimicking ovarian cyst: combined laparoscopic and perineal surgical approach.

Epidermoid cysts are benign tumors that can develop in any part of the human body. Pelvic cysts adjacent to the rectum develop rarely, and few cases have been described in the literature. We report the case of a 58-year-old woman who underwent laparoscopic and perineal excision of a giant pararectal cyst that was discovered during laparoscopy performed for preoperative provisional diagnosis of an adnexal mass detected on an imaging study. To our knowledge, this is the second case of a pararectal cyst excised using combined laparoscopic and perineal approaches. In the hands of skilled laparoscopic surgeons, we suggest a combined laparoscopic and perineal approach for excision of giant pararectal cystic tumors to avert laparotomy.