Fresh vs. frozen embryo transfer in assisted reproductive techniques: a single center retrospective cohort study and ethical-legal implications.

OBJECTIVE: Several studies have shown higher pregnancy rates and better perinatal outcomes with frozen embryo transfers than with fresh techniques, with better results in patients with polycystic ovary syndrome (PCOS) but with a higher rate of pregnancy complications such as preeclampsia. This retrospective cohort study aims to compare the cumulative live birth rates, maternal and neonatal complications of fresh embryo transfers (ET) and frozen-embryo transfers (FET) in infertile women who underwent assisted reproduction techniques (ART) at the Azienda Ospedaliera Ospedali Riuniti (AOOR) Villa Sofia Cervello, Palermo, Italy. In addition, the authors have focused on the legislative and ethical complexities which such a procedure entails. PATIENTS AND METHODS: Out of 475 women undergoing in vitro fertilization programs from January 2017 to January 2021, 128 were enrolled; 70 patients underwent ET, and 58 patients FET. The main outcome measure was live birth rates. Secondary outcomes were clinical pregnancy, ongoing pregnancy, pregnancy loss, low birth weight (LBW), ectopic pregnancy, and obstetrical and perinatal complications. RESULTS: The cumulative live birth rates were similar between the fresh transfer (95.7%) and frozen transfer (93.1%). Biochemical pregnancy rates, clinical pregnancy, ongoing pregnancy, and pregnancy loss were similar between the groups. CONCLUSIONS: Obstetrical outcomes were not statistically different between the two groups; a higher preterm delivery rate was reported in the FET group. ET birth weights were notably lower for singletons compared to the freeze-all strategy. ET patients also had higher LBW rates, with a 2.5-fold higher rate compared to FET. No significant differences were found in cumulative live birth rates between ET and FET, which is consistent with earlier studies. FET protocols are linked to higher neonatal birth weight and lower risk of LBW than fresh ET. The ethical and legal quandaries inherent in such techniques, as technology moves on and outpaces current legislative frameworks, cannot be discounted.

Ovarian tissue cryopreservation and transplantation in menopause: new perspective of therapy in postmenopausal women and the importance of ethical and legal frameworks.

Menopausal transition entails a progressive decrease in hormone production by the ovaries that lead to important physical and psychological changes that could significantly affect quality of life. Hormone replacement therapy (HRT) administered from the onset of menopausal symptoms usually improves quality of life and life expectancy. Nevertheless, it is not risk-free. Ovarian tissue cryopreservation (OTC) has been investigated as a potential new strategy for delaying menopause and/or to avoid HRT. This review analyzes the critical points of HRT to assess whether OTC and subsequent reimplantation can affect postmenopausal management. We assessed available randomized clinical trials in PubMed, Cochrane Library, ISI web of science, and Scopus from August 2021 to November 2022, including studies and trials evaluating the efficacy of OTC in both cancer and menopausal patients, the efficacy of freezing techniques and the possible clinical scenarios that OTC can open, even from the standpoint of legal and ethical issues arising as such innovative techniques become mainstream. Lower duration of the graft and efficacy on estrogen secretions at a physiological and safer concentration of estrogen than conventional HRT based on hormonal supplements. OTC can reportedly trigger estrogen secretions at a lower and safer physiological concentration than conventional HRT. OTC and subsequent reimplantation remain a valid fertility-sparing approach in patients undergoing gonadotoxic treatments. Further studies are needed to better evaluate its safety and efficacy within postmenopausal therapy management and in order to lay out widely shared and evidence-based guidelines and best practices and perform such novel and innovative techniques in a legally and ethically safe fashion, in the best interest of patients and healthcare professionals.

Impact of a new carrageenan-based vaginal microbicide in a female population with genital HPV-infection: first experimental results.

OBJECTIVE: The objective of this study was to assess safety, satisfaction, and anti-viral effect of a new carrageenan-based vaginal microbicide in a population of fertile female patients with genital human papillomavirus (HPV) infection. PATIENTS AND METHODS: Forty healthy and sexually active women aged 18-45 years with genital HPV infection were enrolled. Each subject was treated with a gel formulated with 0.02% carrageenan and Propionibacterium extract (CGP) (Carvir, Depofarma SpA, Mogliano Veneto, Treviso, Italy). The subjects were evaluated at baseline, after the I cycle of therapy and after the II cycle. At final status, treatment acceptability and satisfaction were evaluated using a 5-point Likert scale. Furthermore, the rate of HPV genital infection clearance at final follow-up was evaluated. These data were compared with the HPV genital infection clearance rate in a control group of patients not subjected to any therapy. RESULTS: Overall, 68 HPV infections were detected at baseline, among 40 subjects enrolled. The HPV 16 genotype was the most frequent (12%) followed by HPV 18 (10%), and HPV 53 (9%). At the end of the study, 22 (55%) patients were very satisfied, 14 (35%) were satisfied, 3 (7.5%) were uncertain, and only 1 (2.5%) was dissatisfied, with 0 very dissatisfied. Only 2 patients complained of a local adverse event. Analysing infection clearance at the end of the study, 60% of patients became HPV negative. Among these, 13 cases were high-risk HPV infection. There were 16 patients with persistent infection ("non-responders"). No patient developed a "de novo" genital lesion. After controlling for age, the intervention had an adjusted OR of 4.9 (95% CI 1.6-15.1) to clear HPV. CONCLUSIONS: The results of this work suggest that Carvir vulvovaginal microbicide gel is safe and well-tolerated. Furthermore, this experience supports the hypothesis that CG has a role in accelerating the normal clearance of genital HPV infection in women with a positive HPV-DNA test.

Robotic versus laparoscopic sacrocolpopexy for apical prolapse: a case-control study.

The apical prolapse has always been considered the most complex of the defects of the pelvic floor, for both the difficulty of the surgical corrective technique and for the high post-surgical recurrence rate. Today, the laparoscopic sacrocolpopexy can be considered the standard treatment for apical prolapse. In the last years, several author performed robotic sacrocolpopexy, obtaining positive results. So, we developed a casecontrol study in order to compare the surgical outcome of robotic group with a control group of laparoscopic approach in patients with symptomatic apical pro-lapsed between January 2015 and December 2015 at University Hospital Policlinico "P. Giaccone" and Ospedali Riuniti "Villa Sofia-Cervello", Palermo. Our experience shows that robotic sacrocolpopexy can be considered in positive way for clinical results obtained: all procedures were executed with no complications, we noted a lower intraoperative blood loss and a shorter hospital stay than in laparoscopic group. Although the mean operative time and the economic costs are higher in robotic surgery, this study demonstrates that the use of robotic platform for repairing of symptomatic apical vaginal prolapse is feasible, safe and associated with short-term satisfactory results, representing therefore a valid alternative to laparoscopic approach.

Is vaginal fractional CO2 laser treatment effective in improving overactive bladder symptoms in post-menopausal patients? Preliminary results.

OBJECTIVE: To evaluate the role of vaginal fractional CO2 laser treatment in the relief of Overactive Bladder (OAB) symptoms in post-menopausal women. PATIENTS AND METHODS: Post-menopausal women who complained of one or more symptoms related to vulvo-vaginal atrophy (VVA), who experienced symptoms of OAB and who underwent vaginal treatment with fractional CO2 laser were enrolled in the study. At baseline (T0) and 30 days post-treatment T1), vaginal status (using Vaginal Health Index - VHI), subjective intensity of VVA symptoms (using a visual analog scale - VAS) and micturition diary were evaluated. OAB symptoms were also assessed using a validated questionnaire. RESULTS: Thirty patients were enrolled. A statistically significant improvement in VVA symptoms was observed and in VHI at T1 (p < 0.0001). A significant improvement was also identified in the micturition diary, in number of urge episodes and OAB-q (p < 0.0001). Nine of the 30 patients suffered from incontinence episodes and had improved at T1. CONCLUSIONS: We showed that fractionated CO2 laser vaginal treatment has proved to be effective in improving OAB symptoms in post-menopausal women. Moreover, it is a safe and efficacious measure for the relief of VVA related conditions. Further long-term studies are needed to confirm these preliminary results.

Appendiceal mucinous neoplasms: an uncertain nosological entity. Report of a case.

INTRODUCTION: Appendiceal mucocele is a relatively rare condition characterized by progressive dilation of the appendix caused by intraluminal accumulation of mucoid substance. Its incidence is 0.07 - 0,63% of all appendectomies performed. CASE REPORT: We report the case of a 70-year-old man who came to our observation with gravative pain in right lower abdominal region. A computed tomography abdominal scan revealed a cystic/tubular structure like an appendicular mass with wall enhancement but without calcifications suggestive of a mucocele. Into peritoneal cavity we found profuse mucinous material with a 1,5 cm size parietal nodule. We also identified a free perforation of the cecum with consensual spillage of gelatinous material mimicking a pseudomyxoma peritonei. We decided to perform a right hemicolectomy with excision of peritoneal lesion. DISCUSSION: The controversy in the pathologic terminology can give rise to a clinical dilemma in terms of the management and follow-up plans. For mucosal hyperplasia and cystadenoma simple appendectomy is curative. Only in case of large base of implantation it may be necessary the resection of the ileum and caecum or right hemicolectomy. In case of mucinous cystoadenocarcinoma authors perform a right hemicolectomy. CONCLUSION: Appendiceal mucinous neoplasms are different pathological entities. The correct surgical management depends on size and location of lesion. A preoperative diagnosis is obviously needed in order to perform the correct treatment. CT abdominal scan is the better diagnostic tool, but different authors show their inability to reach a preoperative diagnosis in the larger majority of cases.

Cervical Intraepithelial Neoplasia (CIN) in pregnancy: the state of the art.

OBJECTIVES: Cervical cancer is the most commonly diagnosed malignancy in pregnancy and cervical screening should be accordingly performed in this particular situation. Occurrence of a preneoplastic cervical disease in pregnancy has for a long time represented a challenge for the clinician, both in terms of diagnostic accuracy, treatment options and risk of obstetrical complications. For these reasons, lack of uniformity in diagnosis and management is still commonly observed and the need for evidence-based clarifications is strongly required. Consistently with the literature evidences and accordingly with international guidelines, this review aim to overview the most significant aspects of the issue and trace simple and practical indications for an evidence-based correct workout and management of these conditions. MATERIALS AND METHODS: The most significative and focused-on results from literature as well as recent international guidelines have been considered and summarized in order to clarify the key-points of the topic; epidemiology, pathophysiology, natural history, treatment modalities and procedure-related risks have been approached and discussed. RESULTS: Risk factors, prevalence and progression rate of cervical intraepithelial neoplasia in pregnancy are comparable to those observed in non-pregnant patients; thus, pregnancy does not have to be considered a condition at higher risk. Cytology, histology and colposcopic patterns must be evaluated by experienced professionals because of pregnancy-induced modifications that can lead to misinterpretations. Each diagnostic step should be directed to exclusion of invasive cervical cancer. CONCLUSIONS: Once invasive cancer has been excluded through a comprehensive diagnostic workout, treatment of cervical intraepithelial neoplasia can be safely deferred after delivery.

Nonhormonal management of postmenopausal women: effects of a red clover based isoflavones supplementation on climacteric syndrome and cardiovascular risk serum profile.

PURPOSE OF INVESTIGATION: The aim of this prospective randomized study was to evaluate a red clover based isoflavones supplementation in the treatment of climacteric syndrome and its effects on cardiovascular risk serum profile. MATERIALS AND METHODS: The study included 150 healthy postmenopausal women that were randomly assigned to receive phytoestrogens tablets, amounting in a total daily intake of 60.8 mg red clover isoflavones plus 19.2 mg soy isoflavones (n = 75), or placebo (n = 75). The authors evaluated teh following: daily number of hot flushes and Kupperman Index at baseline and after one and three months; serum total, high-density lipoprotein (HDL) and low-density lipoprotein (LDL) cholesterol, triglycerides, prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen, and antithrombin III (ATIII) at baseline and after three and six months. RESULTS: One hundred twenty-eight patients completed the study: 67 in the active group and 61 in the placebo group. The treatment led to a progressive significant reduction (p < 0.05) of the number of hot flushes in the active group compared to placebo already after one month, while Kupperman Index was statistically reduced after three months. No significant variation in total cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides, PT, PTT, fibrinogen, and ATIII were found. CONCLUSION: The present findings suggest that a red clover based isoflavones supplementation in healthy postmenopausal women is promptly effective on climacteric syndrome, improves neurovegetative symptoms, safe on cardiovascular risk serum profile, and does not modify lipids and coagulation.

Laparoscopic, three-port and SILS cholecystectomy: a retrospective study.

INTRODUCTION: The aim of this study was to compare the results of classic laparoscopic, three-port and SILS cholecystectomy. MATERIALS AND METHODS: We conducted a retrospective study of data collected between January 2010 and December 2012 pertaining to 159 selected patients with symptomatic gallstones. 57 underwent laparoscopic cholecystectomy, 51 three-port cholecystectomy and 48 SILS cholecystectomy. We then compared the groups with respect to mean operating time, intraoperative complications, postoperative pain, duration of hospitalization and final aesthetic result. RESULTS: The mean operating time was significantly higher in the SILS cholecystectomy group (93 minutes) than in the other two groups. There were no intraoperative complications. There were no significant differences in the duration of hospitalization among the three groups. Patients in the SILS cholecystectomy group reported significantly less pain 3, 6 and 12 hours after surgery. The aesthetic results at 1 and 6 months' follow-up were also decidedly better. CONCLUSIONS: On the basis of this study, SILS cholecystectomy is a feasible, safe procedure. In any case, it should be used in selected patients only and carried out by a dedicated team with strong experience in laparoscopy. The main advantages of this technique are a reduction in post-operative pain and improved aesthetic result, at the price, however, of its greater technical difficulty and longer operating times. Future studies are in any case necessary to evaluate any other benefits of this method.

Laparoscopic sacrocolpopexy in the treatment of vaginal vault prolapse: 8 years experience.

OBJECTIVE: The aim of this study was to evaluate the long-term results of a laparoscopic sacrocolpopexy for the treatment of vaginal vault prolapse. STUDY DESIGN: Between January 1999 and January 2007, 165 laparoscopic sacrocolpopexy procedures, using a polypropylene mesh, were performed on women affected by vaginal vault prolapse. Intraoperative complications included: 5 bladder injuries and 3 sigmoid perforations. Postoperative complications included: 10 cases of fever, 5 cases of lumbosciatica, 15 cases of detrusor overactivity, 2 cases of vaginal haematoma, and 5 cases of minimal dispareunia. At 1, 6 and 12 months after surgery, a clinical evaluation was carried out for all patients. After this period, we contacted the women annually. RESULTS: We treated 165 women, with an average age of 67 (range 58-76 years; S.D. 19.22), average parity of 3 (range 2-5), and average body mass index of 28 (range 24-30). In many of them, more than one additional procedure was performed. At a median follow-up of 43 months (range 6-96 months), out of a total of 138 patients (27 were lost at follow-up), we obtained successful treatment in 131 women (success rate of 94.9%), with a high rate of satisfaction from the procedure. Recurrent vaginal vault prolapse was registered in seven women (5.07%): in 3, the vaginal vault collapsed after a period ranging from 7 to 20 days, caused by the use of a Vyprol mesh (hence use of same was suspended), and in a further three women the mesh detached after less than 1 month. Finally, in one case, we reported an erosion between the first and the second follow-up and the mesh was visualized in the vagina. CONCLUSIONS: Our study shows that laparoscopic sacrocolpopexy, in the hands of an expert surgeon, can be considered a safe, effective procedure for the treatment of vaginal vault prolapse, allowing long-term anatomical restoration (94.9% success rate).

Bladder endometriosis: laparoscopic treatment and follow-up.

OBJECTIVES: This study aims to show the treatment outcome in women affected by isolated bladder endometriosis who underwent laparoscopic surgery in our units. Only women with deep nodules located in the bladder were selected, thus excluding women with deep lesions located in other sites. STUDY DESIGN: Between March 2005 and 2007, women with deep vesical endometriosis, referring to the Departments of Obstetrics and Gynaecology of University Hospitals "G. Martino"of Messina, "Paolo Giaccone"of Palermo and "San Paolo"of Milano, were respectively recruited. A preoperative assessment of the pathology was performed. Women who were concomitantly diagnosed deep nodules of the rectovaginal septum and/or endometriotic ovarian cysts were excluded. A medical therapy with oral contraceptive and/or GnRH analogues was first proposed to the patients affected. If medical treatment failed, a laparoscopic treatment was suggested. We performed a segmental resection of the involved wall or an extramucosal dissection of the bladder according to the cases. A clinical and an instrumental evaluation by ultrasound was performed every 6 months after surgery for the first year and subsequently every 12 months. At the time of referral, patients were also questioned about any recurrence of symptoms. RESULTS: Eight women, with a mean age of 33.8 (range 30-37 years; S.D.=2.5) and a mean parity of 1 (range 0-2) were recruited. Medical therapy failed in all cases and the women underwent laparoscopic treatment. Surgery was complete in all cases without a need for ureteral cannulation. No intraoperative complications occurred. The mean estimated blood loss was 98 ml (range 40-200 ml). All patients underwent at least the first follow-up assessment. In none of the women, recurrence of bladder endometriotic nodules was documented. In contrast, urinary symptoms were reported in three cases. Nevertheless, all the patients reported improvement of symptoms and declared to be satisfied. CONCLUSIONS: We recommend surgical eradication of bladder lesions. Laparoscopic treatment, in the hands of an expert surgeon, is the management of choice. It offers the best approach to the diagnosis allowing good long-term results, with a less invasive approach. Large multicentric studies are however required prior to drawing definite conclusions.

Total laparoscopic hysterectomy versus total abdominal hysterectomy: an assessment of the learning curve in a prospective randomized study.

The present randomized study was undertaken in order to compare the short-term results between total laparoscopic hysterectomy and abdominal hysterectomy in a centre with experience in laparoscopic surgery. From January 1997 to September 1998 inclusive, 102 women aged 44-71 years were randomly assigned to either total laparoscopic hysterectomy (n = 51 patients) or abdominal hysterectomy (n = 51 patients). The patients' demographic characteristics were similar in both groups. Average intra-operative blood loss was lower in laparoscopic hysterectomy than in abdominal hysterectomy (P

Minilaparoscopic hysterectomy.

Minilaparoscopic surgery was performed in a 38-year-old woman scheduled for hysterectomy and ovarian cystectomy. Image resolution was similar to that of conventional laparoscopy. There were no intraoperative or postoperative complications. Since it has many advantages and few complications, minilaparoscopy appears to be an attractive way to decrease morbidity associated with conventional laparoscopy. (J Am Assoc Gynecol Laparosc 5(4):97-100, 1998)

Evaluation of cardiovascular risk factors in overweight and obese subjects.

Twenty obese subjects (Males = 8, Females = 12; average age = 39.5 +/- 2.5 years; B.M.I. = 36.2 +/- 2.5), 20 overweight subjects (Males = 8, Females = 12; average age = 38.5 +/- 2 years; B.M.I. = 28.8 +/- 0.4) and 20 non obese healthy subjects as controls, matched for sex and age (Males = 8, Females = 12; average age = 37.5 +/- 2 years; B.M.I. = 22.4 +/- 0.8) were selected. We determined: blood glucose, triglycerides, total cholesterol, HDL-cholesterol, Apolipoproteins A1 and B, Factor VII, fibrinogen and plasminogen. Before and after a venous occlusion test were also measured: t-PA Antigen, PAI activity and haematocrit. Metabolic, coagulative and fibrinolytic pathological changes were observed in overweight and obese subjects and the interaction of these risk factors may contribute to the pathogenesis of atherosclerosis vascular disease and to the high rate of thromboembolic events reported in obesity.