Current opportunities and new horizons into the genetic study of infertility.

INTRODUCTION: An estimated 12.5% of couples experiencing fertility problems and almost 12% of reproductive age women have turned to health services at least once due to infertility. First trimester miscarriage is the most common clinical manifestation of infertility associated with a genetic cause. PATIENTS, MATERIALS AND METHODS: The scientific research was conducted at A.S. Medical Center in Bucharest, Romania, between January 2016 and December 2018, on a representative group of 1264 Caucasian patients diagnosed with infertility, from which the study group was selected, consisting of 273 patients who were further genetically investigated. RESULTS: Chromosomal instability, identified in 14% of patients, has been encountered most frequently in women (7%), and least often in fetuses (2%), unlike other chromosomal anomalies, identified in 55% of patients, which were more common in fetuses (27%) and least frequently in men (9%). Recurrent pregnancy loss due to genetic causes was identified in 53% of cases, being determined by chromosomal instability in 16% of cases and by other chromosomal anomalies in 37% of cases. Infertility due to a genetic cause was identified in 83% of cases, being determined by chromosomal instability in 17% of cases and by other chromosomal anomalies encountered in 66% of cases. In genetic risk pregnancies in evolution, fetal chromosomal anomalies were detected in 94% of cases, the most frequent being aneuploidy and polyploidy. Cytogenetic studies carried out on tissue fragments taken from aborted products of conception revealed the presence of a genetic cause in 57% of cases, an abnormal chromosome number being the most common (36%). The analysis of microdeletions of the long arm of the Y chromosome indicated that 5.5% of men with infertility are affected by this condition. CONCLUSIONS: Although genetic tests are considered complex and expensive laboratory investigations, they are crucial in identifying the etiology of over 40% of infertility cases associated with genetic factors, as well as in the correct and effective management of infertility.

Prenatal diagnosis of syndromic alobar holoprosencephaly associated with digynic triploidy fetus.

Holoprosencephaly (HPE) is a dramatic human brain malformation sequence with an extreme variable phenotypic spectrum and genetic heterogeneity, variable degree of severity and unknown etiology, in many cases. HPE is classified into syndromic, chromosomal, and non-syndromic, non-chromosomal. The most cases of HPE are syndromic. We present an atypical case of syndromic alobar HPE associated with digynic triploidy fetus, prenatally diagnosed, early at 18 weeks of gestation, by ultrasound (US) and complex genetic investigations. The US examination was performed with a specialized US machine, General Electric Voluson E10 OLED BT18, using two-dimensional (2D) scanning, three-dimensional (3D) image reconstruction, four-dimensional (4D) spatiotemporal image methodology and the highest power Doppler US technology. A detailed US examination of the fetus revealed several major abnormalities of the fetal head and severe facial malformations. Based on the antenatal US findings, the fetus was diagnosed with alobar HPE. After a careful examination and genetic counseling, additional cytogenetic investigations and molecular genetic analyses were performed, which revealed an abnormal number of 69 chromosomes, digynic triploidy (69,XXY). Two days later, the parents choose to interrupt the current gestation because of major fetal malformations. The pathological examination of the embryo reaffirmed the antenatal diagnostics.

Impact of genetic testing and family health history of cystic fibrosis in the early prenatal diagnosis and prevention of a new case of genetic disorder.

Cystic fibrosis (CF) is a multi-system autosomal recessive disorder, results of mutations in the CF transmembrane conductance regulator (CFTR) gene, located on the long arm of chromosome 7. We present a special family couple with particular medical history of CF, who comes to our Clinic for genetic tests and a prenatal genetic counseling, to prevent the birth of a new affected CF child. Genetic analysis showed that the first affected child, a daughter, is compound heterozygous for two clinically significant recessive mutations: c.1521_1523delCTT; p.Phe508del, inherited from her mother, who carries the same CFTR mutation, and c.1853_1863delTTTTGCATGAA; p.IIe618Argfs 2, inherited from her father, who is heterozygous, healthy carrier, for the same CFTR mutation. In our case report, early prenatal genetic testing, pre- and post-test genetic counseling was crucial in the management of the present pregnancy, to prevent the birth of a new affected CF child.

The crucial role of SRY gene in the determination of human genetic sex: 46,XX disorder of sex development.

Prenatal diagnosis of disorder of sex development (DSD) is very rare and is estimated to occur in 1∕2500 pregnancies. A group of DSDs are the 46,XX testicular DSD. Today, the incidence of 46,XX testicular DSD is estimated at 1∕20 000 newborn males. A majority of males with DSD have an unbalanced X;Y exchange involving the pseudoautosomal region, with translocation of the sex-determining region of the Y (SRY) gene onto Xp23.3. We present a rare case of very early prenatal diagnosis and management of a fetus with SRY-positive 46,XX testicular DSD.

Delayed interval delivery in twin pregnancy - case reports.

The implementation of assisted reproduction has increased the incidence of multiple pregnancies. Prenatal death of one fetus in the second trimester of twin pregnancy confronts the obstetrician with a difficult problem with regard to the management of pregnancy. The scarcity of the condition and the absence of the large-scale studies make it difficult to advise the parents on the prognosis and optimal management. The unavoidable birth or death of one premature neonate has led to the aim of delayed interval delivery for the other twin. We present in this report two cases of twin pregnancies with delayed-interval delivery and favorable outcomes for the surviving twins. The twin pregnancies conceived by in vitro fertilization (IVF) in HitMed Medical Center, Craiova, Romania. In the first case, one fetus dismiss in utero at 20 weeks of gestation. The second fetus was successfully delivered by Caesarean section, at 36 weeks. In the second case, the first fetus was delivered at 22 weeks. To save the surviving fetus, ligation of the umbilical cord at the cervical level was performed. The second fetus was delivered at 31 weeks by Caesarean section, in good conditions. We describe our management of the cases and the deliveries and the neonatal outcomes. In multiple gestation, prolongation of pregnancy after preterm dismiss in utero or even after delivery of one fetus is feasible in a closely monitored environment.

Pregnancy resulting from IMSI after testicular biopsy in a patient with obstructive azoospermia.

In this article, we report a case of pregnancy obtained in an infertile couple diagnosed with severe male factor infertility. The couple attended for fertility examination reporting a history of 10 years of infertility. The cause of infertility was obstructive azoospermia. The treatment consists of in vitro fertilization (IVF). The ovarian stimulation of female patient was done with antagonist protocol and after ovarian puncture was obtained nine oocytes. The urologist performed testicular sperm extraction (TESE). There were selected nine sperm cells by intra-cytoplasmic morphologically selected sperm injection (IMSI). For this purpose, we used an inverted microscope with high magnification equipped with ×60 air objectives with modulation contrast illumination. After intracytoplasmic sperm injection (ICSI) of sperm into the oocytes there were obtained six normal embryos from which three embryos were transferred into the uterus. A singleton pregnancy was achieved which was completed with birth of a healthy baby in time. This successful outcome shows that use of IMSI and ICSI procedures are really useful in selection of best spermatozoa obtained by TESE in treatment of obstructive azoospermia.

Borderline Brenner tumors associated with ovarian cyst - case presentation.

Borderline Brenner tumors represent quite a rare entity of ovarian tumors (about 2%) that develop from the surface ovarian epithelium. They are formed from papillary structures made of fibrovascular conjunctive axes covered by a transition epithelium, similar to the urinary bladder epithelium. According to the WHO classification, Brenner tumors present the following forms: benign, borderline and malignant. The benign ones are the most frequent, representing about 95%, the borderline represent about 5%, and the malignant ones less than 1%. We present the case of a 64-year patient who was diagnosed with right ovary cyst. The histopathological examination highlighted the presence of a borderline Brenner tumor at the same time with the cystic lesion, on the same ovary. The surgical treatment led to a complete cure of the patient, so that the yearly ultrasound reexamination did not trace the presence of any tumoral relapse.

Placenta changes in pregnancy with gestational diabetes.

Placental damage may be responsible for the fetal complications in pregnancies complicated by diabetes. We have analyzed the prevalence of gestational diabetes (GD) in a population of 109 pregnant women, the risk factors and the placental changes associated with gestational diabetes. Tests carried out were oral glucose tolerance test at 24-28 weeks of gestation, using the IADPSG (International Association of Diabetes and Pregnancy Study Groups) criteria for gestational diabetes, glycated hemoglobin, fasting insulin, total cholesterol, high density lipoprotein (HDL)-cholesterol, low density lipoprotein (LDL)-cholesterol, triglycerides, two-dimensional (2D) ultrasound and, also, there were analyzed macro and microscopic placental fragments from pregnant women with÷without GD. It has been recorded the weight of placenta at birth and there were analyzed the possible pathological changes. The prevalence of GD was 11.9%. We have applied the direct logistic regression to determine the impact of some factors over the probability of association with gestational diabetes. The most powerful predictor was the placental maturity grade, the patients with decreased maturity grade having chances 52.6 times higher than those with an increased placental maturity grade to associate gestational diabetes. Sizes of placentas in patients with gestational diabetes mellitus were significantly increased than in patients without this diagnosis (p=0.012) from week 24-28. Pathological changes were discovered in six of the 13 placentas of women with gestational diabetes mellitus, independent of the level of glycated hemoglobin (p=0.72). The level of hyperglycemia is only partially associated with the presence of placental changes, which may be caused by other maternal factors.

Heterotopic mesenteric ossification of ileostomy - "intraabdominal myositis ossificans".

UNLABELLED: Heterotopic mesenteric ossification is a rare clinical entity with less than 40 reported cases. Moreover, heterotopic mesenteric ossification around a stoma is described in fewer cases. CASE PRESENTATION: An 81-year-old male patient, who underwent a sigmoidectomy two years ago for a sigmoid colon cancer, was admitted in our Department in order to be investigated for a local recurrence of his disease. Because of unresectable pelvic lesions, the patient was taken in the operating room for a palliative double barrel ileostomy. The patient presented two weeks after the ileostomy clinical signs suggesting its obstruction. A revision of the ileostomy is performed. Macroscopically, the end part of the ileostomy was inflamed and resected. Histological findings revealed heterotopic ossification of the mesentery. CONCLUSIONS: The surgeon should be alert to the possibility of heterotopic ossification, especially within a previously operated wound and be prepared for the difficulties it may cause during reopening of an incision, during the operation itself, at closure of the wound and, if not removed, also in the postoperative setting.

The experience of our Clinic in laparoscopy for adnexal masses and the correlation between ultrasound findings and pathological results.

INTRODUCTION: An adnexal mass (mass of the ovary, Fallopian tube, or surrounding connective tissues) is a common gynecological problem. Ovarian pathology can occur at any time from fetal life to menopause. Sonography is a clinically important imaging modality for assessing whether an adnexal mass is likely benign or possibly malignant. Most ovarian surgeries are for benign disease and can be performed laparoscopically. PATIENTS, MATERIALS AND METHODS: We retrospectively evaluated all the patients from our Clinic who underwent laparoscopy for adnexal tumors in the last three year. We were studying the correlation of the preoperative ultrasound examination and the pathological result for each case. RESULTS: In this study, there were included 71 patients who underwent a laparoscopic intervention for adnexal tumors. The average age was 33 years old (range 18 and 60 years old). The ultrasound findings were ovarian endometriosis in 23.9% of cases, left ovarian cysts (22.5%) and right ovarian tumors (18.3%), and the lowest percentage was of left ovarian tumors (8.5%). Regarding the histopathological examination, we found the following results: ovarian endometriosis (32.4%), ovarian functional cysts (15.5%), serous ovarian cysts (15.5%), salpingitis (12.7%), ovarian myoma (7%), papillary serous ovarian cysts (4.2%), ovarian teratoma cysts (9.9%), one case (1.4%) of ovarian carcinoma and one case (1.4%) of borderline serous tumor. In this study, we observed that it was a strong correlation between the ultrasound finding and the pathological result for adnexal tumors (p<0.001). CONCLUSIONS: The laparoscopy was performed in our Clinic for adnexal masses with benign characters in ultrasound examination. The histopathological examination confirmed the diagnosis, being only one case of ovarian carcinoma in this study.

Diagnosis problems in a case of ovarian tumor - case presentation.

Ovarian epithelial tumors are the most common ovarian neoplasms, standing for more than half of all ovarian tumors. Borderline ovarian tumors represent a distinct group recognized by the World Health Organization (WHO), histologically distinct low ovarian carcinomas. They are tumors with low grade of malignancy with good progress and prognosis. The authors present a case of an ovarian tumor with diagnosis problems. It was the case of a 38-year-old patient with no genital pathological history, presenting hypogastric pain, dysmenorrhea, abdominal distension. The imaging performed examinations suggested an ovarian tumor with potential malignancy. The symptoms were nonspecific and the treatment was surgical. The piece was processed by paraffin inclusion and microscopically examined. Although the imaging examinations may be suggestive for potentially malignant lesions, the histopathological relation with the immunohistochemical one is the one that establishes the diagnosis. Following these examinations, there was established an ovarian borderline tumor. This is included in the lesions with low malignancy, the further evolution of the patient being a good one. The purpose of this presentation was the warning of the importance of histopathological examination linked with the immunohistochemical one, although the imaging may present lesions with malignancy criteria. Also, it was performed a literature review of borderline tumors in young women in terms of diagnosis and therapeutic conduct.

Investigation of inflammatory activity in ulcerative colitis.

Inflammatory bowel diseases (IBDs), ulcerative colitis and Crohn's disease are lifelong disorders, characterized by the chronic inflammation of all or part of our digestive tract. Cytokines have an essential role in the pathogenesis of IBDs, because they control the inflammatory response, and the disequilibrium of pro-inflammatory/anti-inflammatory cytokines may lead directly to tissue destruction. Histopathologically, these diseases are characterized by the extent and the distribution of mucosal architectural abnormality, the cellularity of the lamina propria and the present cell types, but these features frequently overlap. We performed a prospective study, which included 46 patients diagnosed with ulcerative colitis (UC) (gender ratio 25 males/21 females, mean age 44.8 years) and 30 subjects, with similar demographic characteristics, which were selected from the patients investigated for other digestive disorders, unaffected by UC. Serological investigations were performed by quantitative determination of IL-17, IL-13, and CRP using ELISA sandwich technique. We have achieved significantly higher concentrations of IL-13, IL-17 and CRP in the serum of patients with UC, compared to the control group. We have found in our study correlations between ulcerative colitis activity and serum levels of interleukins, IL-13 and IL-17. Because IL-17 serum levels were significantly correlated with the disease severity and only cytokine had a significantly statistic correlation with high serum levels of CRP in UC patients, IL-17 can be considered an important progress inflammation marker of this disease.

Peritumoral inflammatory reaction in colon cancer. Histological and immunohistochemical study.

Colorectal cancer is one of the most frequent malignancies with an increasing incidence and prevalence. As in other malignancies, nor etiology, neither pathogenesis of colorectal cancer are well known. The link between inflammation and colorectal cancer has become a major concern in the past 20 years, since several clinical trials have shown that patients with chronic inflammatory intestinal diseases have a much higher risk of colorectal neoplasm development. In our study, we analyzed peritumoral inflammatory reaction from histological and immunohistochemical point of view, in 23 cases of stage III colon adenocarcinoma, operated during 2014. The immunohistochemical techniques were used in order to emphasize B-lymphocytes, T-lymphocytes, macrophages, mast cells and blood vessels. In all cases, we have noted the involvement of inflammatory cells present in peritumoral and tumoral stroma, in variable degrees, regardless the differentiation of the neoplasm or other known histological feature. In particular, the macrophages were the most numerous, especially in areas of tumoral necrosis, but also present in the lumen of tumoral glands, or even within tumoral cell islands. Mast cells appeared more abundant in the tumor stroma around blood vessels and were absent in the areas of tumor necrosis, while B-cells were almost absent. Tumor stroma showed a well-developed vascular network, consisting mainly of small vessels that do not seem to correlate with the intensity of the inflammatory reaction.