Comparison of dydrogesterone plus progesterone gel with subcutaneous aqueous progesterone plus progesterone gel for luteal phase supplementation of subsequent in vitro cycle in women after previous cycle failure.

OBJECTIVES: The luteal phase supplementation (LPS) of the in vitro fertilization (IVF) cycle is crucial to increase the chance of a live birth. There is no preferred progestogen for use in the general population. The optimal progestogen regimen in the event of prior IVF failure is unknown. The aim was to compare the live birth rate for dydrogesterone plus progesterone gel versus aqueous progesterone plus progesterone gel in LPS of the IVF cycle in women with at least one previous IVF failure. MATERIAL AND METHODS: A prospective randomized single-center study enrolled women with at least one previous IVF failure undergoing another IVF cycle. Women were randomly assigned in a 1:1 ratio to 2 arms depending on LPS protocol: dydrogesterone (Duphaston®) + progesterone in vaginal gel (Crinone®) vs aqueous progesterone solution in subcutaneous injection (Prolutex®) + progesterone in vaginal gel (Crinone®). All women underwent fresh embryo transfer. RESULTS: The live birth rate with one prior IVF failure was 26.9% for D + PG vs 21.2% for AP + PG (p = 0.54), and with at least two IVF failures: 16% for D + PG vs 31.1% for AP + PG (p = 0.16). There were no significant differences in live birth rates between protocols, regardless of the number of prior IVF failures. CONCLUSIONS: In light of the evidence from this study that neither of the two LPS protocols is more effective in women with prior IVF failure, other factors, such as potential side effects, dosing convenience and patient preference, should be considered when choosing a treatment.

Nonsteroidal anti-inflammatory drug with a local anesthetic compared to nonsteroidal anti-inflammatory drug alone significantly reduce the pain associated with vaginoscopic office hysteroscopy.

INTRODUCTION AND OBJECTIVES: Pain is the most common cause of office hysteroscopy (OH) failure. There is no consensus on alleviation of pain during OH. The aim was to compare the effectiveness of pain-relieving methods during OH. STUDY DESIGN: A prospective randomized open-label trial included women subjected to OH. All women received 100 mg of ketoprofen intravenously pre-procedure. Women were randomly assigned to 3 arms: A) no local anesthesia, B) infiltration anesthesia with 20 ml of 1% lidocaine solution, C) paracervical block with 20 ml of 1% lidocaine solution. Karl Storz Bettocchi® rigid hysteroscope with a 5 mm operative sheath was used. Intensity of pain in numeric rating scale (NRS), intensity of cervical bleeding, frequency of vasovagal episodes, and failure rate were compared. RESULTS: The study involved 201 women, 67 in each arm. NRS value during OH was higher in arm A than in B and C (6.3 vs. 5.1 vs. 5.0; p = 0.01). NRS value after OH did not differ and in all arms pain was imperceptible (p = 0.007). Cervical bleeding was more frequent in arm B than in A and C (76.1% vs. 33.4% vs. 35.9%; p < 0.0001), but its intensity did not differ from the other arms (p = 0.3). Vasovagal episode was most common in arm B (p = 0.048). There was no difference in the failure rate between the arms (p = 0.08). CONCLUSIONS: The paracervical block, albeit technically the most laborious, has proven to be the most beneficial for the patient in terms of overall comfort and for the surgeon regarding feasibility.

Association of Subclinical Hypothyroidism with Present and Absent Anti-Thyroid Antibodies with PCOS Phenotypes and Metabolic Profile.

BACKGROUND: Polycystic ovary syndrome (PCOS) and subclinical hypothyroidism (SCH) often coexist, but implications of the co-occurrence of two disorders have not yet been established. The objective is to conclude whether SCH with present or absent anti-thyroid antibodies (ATA) impacts on the PCOS phenotype and alters biochemical or clinical parameters. METHODS: A retrospective cohort study was conducted in a tertiary reference center. Clinical and biochemical parameters of women with PCOS were analyzed. RESULTS: A total of 367 women with PCOS were included in the study, 114 (31.1%) of whom were diagnosed with SCH and 16 (4.4%) with autoimmune thyroiditis (AIT). Among all parameters studied, the strongest relationship with SCH was confirmed for insulin resistance and dyslipidemia. SCH was an independent risk factor for insulin resistance. In SCH the additional presence of ATA did not exacerbate the metabolic disorders. There was no significant association of any PCOS phenotype with SCH, nor with the presence of circulating ATA. There was no significant difference in hormonal parameters and mFerriman-Gallwey scale score between women with PCOS with and without SCH. CONCLUSIONS: SCH alters metabolic, but not hormonal, parameters in PCOS. The diagnosis of SCH does not exclude the diagnosis of PCOS. The potential effect of positive ATA was insignificant.

Male factor infertility in the Comprehensive Procreational Health Protection Program at the University Hospital in Cracow.

OBJECTIVES: Quality of semen is one of the most important factors contributing to couples' chance of natural conception. There are many confirmed or potential factors that influence semen analysis results. To estimate the incidence and analyze male factor infertility. MATERIAL AND METHODS: The retrospective observational study was in the Clinical Department of Gynecological Endocrinology and Gynecology, University Hospital in Krakow. The study included men from subfertile population, aged ≥ 18 years, without prior diagnosis and obvious cause of infertility, whose initial seminograms were used to characterize the population. Seminograms of men remaining in the follow-up were used to analyze the variability of sperm parameters in relation to lifestyle modification and the use of fertility supplements containing antioxidants. Control semen tests were performed at 1-3-month intervals. RESULTS: The study included 870 men. In 68.5% of men, at least one abnormal sperm parameter was found and 40.7% had complex sperm abnormalities. Averaged values of sperm parameters of men from subfertile couples were within the WHO reference ranges, except for the normal morphology, whose median was 3.8%. No significant differences in the selected sperm parameters after the implementation of conservative management were observed. The percentage of pregnancies not resulting from IVF in the follow-up population was 7.7%. CONCLUSIONS: One semen sample is representative of an individual in the diagnostics of male infertility. Expectant management and lifestyle modification should not be proposed as first-line treatment when more effective procedures are available.

Current management of cervical cancer in Poland-Analysis of the questionnaire trial for the years 2002-2014 in relation to ASCO 2016 recommendations.

OBJECTIVES: To assess the survival of patients with cervical cancer (CC). Since the recommendations concerning cervical cancer management adopted by Polish medical societies do not differ significantly from the ESGO or non-European guidelines, and the fact that evaluation of the system for CC treatment in Poland, as well as the mortality rate of Polish women with CC, which is 70% higher than the average for European Union (EU) countries, justifies the hypothesis that treatment of CC in Poland deviates from the Polish and international recommendations. This article puts forward the current management of cervical cancer in Poland and discusses it in the context of ASCO guidelines. MATERIAL AND METHODS: A survey retrospective multicenter analysis of the medical records of 1247 patients with cervical cancer who underwent treatment for disease and who had completed at least two years of follow-up. RESULTS: Although concurrent radiotherapy and chemotherapy is a standard treatment of FIGO IB to IVA cervical cancer patients in enhanced- and maximum-resources settings, in our analysis, we found that the percentage of women subjected to chemotherapy was lower than in countries where total survival rates were lower. CONCLUSION: Within the IA to II A cervical cancer patients studied group, the methods of treatment remained in line with ASCO guidelines for countries with the highest standard of care. Although concurrent radiotherapy and chemotherapy is a standard treatment of FIGO IB to IVA cervical cancer patients in enhanced- and maximum-resources settings, in our analysis, we found that the percentage of women subjected to chemotherapy was lower than in countries where total survival rates were lower. Our findings, together with the inconsistencies within the cervical cancer screening program, may be one of the explanations of poorer survival rate of women with cervical cancer in Poland.

Occult uterine leiomyosarcoma in women undergoing abdominal and minimally invasive surgeries for myomas.

OBJECTIVES: To estimate (i) the incidence of occult uterine leiomyosarcoma (LMS) in patients operated on for presumedmyomas, and (ii) the proportion of occult LMS to preoperatively diagnosed LMS in a tertiary center. MATERIAL AND METHODS: An Institutional Review Board-approved retrospective cohort study was performed. The electronicdatabase of 30,476 patients was searched for women who had undergone surgery due to presumed myomas (N = 2675) as well as those with uterine LMS recognized via histology (N = 10) between January 2010 and December 2016. RESULTS: Six of the 2675 treated women had occult LMS (incidence 1:446; 0.002; CI 0.0-0.013), and one underwent power morcellation (incidence 1:951; 0.001; CI 0.0-0.006). Parallel searching revealed that 6 of the 10 cases (60%) with uterine LMS recognized via histology were diagnosed postoperatively, whereas 4 of the 10 (40%) were diagnosed preoperatively. The incidence of LMS morcellation during laparoscopy was 1:951 and, when all MIS cases were included, 1:1178. The patient who underwent LMS morcellation was operated in the general surgery ward 5 years after laparoscopy (omental recurrence). CONCLUSIONS: These results are similar to the first and recent conservative FDA estimations, but two-times lower for procedures with laparoscopic morcellation and all MIS procedures than for abdominal. Because above half of LMS may be recognized after surgery, the risk of occult LMS and the delay of targeted surgical treatment should be included in all informed consent forms for conservative management of presumed myomas without histology.

Occult uterine malignancy during laparoscopic supracervical hysterectomy.

OBJECTIVES: To estimate the incidence of occult uterine malignancies during laparoscopic supracervical hysterectomy (LSH). MATERIAL AND METHODS: Retrospective cohort study based on archival data (2010-2016) of the Department of Gynecology and Oncology, Jagiellonian University. RESULTS: Medical records of 696 women, who underwent LSH were analyzed. Two occult sarcomas (2/696; 0.29%, 0.003, 95% CI: 0.001 to 0.01), including one case of low-grade endometrial stromal sarcoma (ESS) with co-occurring atypical endometrial hyperplasia (AH) and one case of high-grade ESS were found postoperatively. One case of invasive primary fallopian tube cancer (1/696; 0.14%, 0.001, 95% CI: 0.00 to 0.008) and additional three cases of AH (3/696; 0.57%, 0.004, 95% CI: 0.001 to 0.013) were also identified. No case of EC was documented. One hundred sixty nine (24.3%) women of 696 had an endometrial sampling prior LSH including these with ESS. We did not observe worsening of the prognosis and all patients with confirmed malignancy are still alive and free from recurrence in 2-5 years of observations. CONCLUSIONS: Most commonly the occult malignancy would have not been recognized if the surgery had not been conducted. When appropriate diagnostics is conducted, rare incidents of malignant tissue morcellation should not be considered as a professional misconduct but as a possible adverse event. Patients should be informed about the risk of malignancy according to available estimations and that endometrial sampling cannot eliminate such a risk. A consensus regarding safe indications, required diagnostics, and justifiability of mandatory use of contained morcellation for LSH should be developed.

Laparoscopic Intervention in Acute Crohn's Disease Involving an Ovary.

Crohn's disease (CD) is a chronic inflammatory disorder that may involve any part of the gastrointestinal tract. Acute manifestations in female internal reproductive organs are rare and have been described in only a few cases. A 27-year-old nulligravida woman diagnosed with CD presented with pelvic pain, fever, and a palpable mass (confirmed by ultrasound) in the right lower quadrant of the abdomen. She underwent diagnostic laparoscopy because of worsening symptoms suggestive of a tubo-ovarian abscess. The right adnexa were excised after adhesiolysis. Pathologic examination revealed an ovarian granuloma consistent with CD. This case shows that a laparoscopic approach is possible for active CD, with all the benefits of a minimally invasive approach. Although the involved ovary was removed, similar to previous reports using laparotomy, conservative therapy should be considered if preoperative diagnosis can be made. Improvements in preoperative diagnosis and development of management guidelines is critical for ovarian preservation and conservative treatment options.

[Analysis of histological type and staging of cervical cancer as prognostic factors among women treated in the Department of Gynecology and Oncology, Jagiellonian University in the years 2001-2014].

Introduction: Cervical cancer (CC) is the fourth most common, in terms of incidence of new cases, cancer in women and the third leading cause of cancer deaths in women worldwide. Survival of patients with CC depends on many factors, including the type of cancer, grading, FIGO staging and treatment. Material and Methods: Analysis of survival of 524 patients diagnosed with invasive and non-invasive CC depending on histopathologic diagnosis, clinical staging, tumor grading and combination of therapy. Results: The 2-fold increase in the risk of death at diagnosis in order of HSIL> ca planoepitheliale> adenocarcinoma> sarcoma was noted. Grading 2 and 3 significantly reduces the average survival in patients diagnosed with CC. The higher staging, the shorter the average survival. Each pass by one FIGO stage was shown to increase the risk of death by 46%. The risk of death increases by 4% with every year of woman's life. The longest average survival, 72 months, characterized a group of women undergoing curettage, followed by radical hysterectomy/ trachelectomy and lymphadenectomy without adiuvant radio-/ chemotherapy. The shortest survival, 26.9 months, was observed in the group treated with curettage followed by chemoradiation. Conclusions: Histopathology, clinical staging, grading, age and combination of treatment proved to be significant factors affecting survival in women with CC.

Endometrial cancer and hyperplasia rate in women before menopause with abnormal uterine bleeding undergoing endometrial sampling.

Introduction: Abnormal uterine bleeding (AUB) is the most common symptom of endometrial cancer (EC) and endometrial hyperplasia with (AH) or without (EH) atypia. Risk of malignancy and hyperplasia is significantly lower in premenopausal than in postmenopausal women. Only 10% of EC occurs before menopause. Obesity and age are well-recognized risk factors of endometrial cancer. Endometrial sampling is recommended in women at high risk of endometrial malignancy. The primary objective was to determine the incidence of EC, AH and EH in premenopausal women undergoing dilation and curettage (D&C) because of AUB. Additional objective of the study was to estimate the risk of EC and AH in overweight and obese women with two types of AUB: heavy menstrual bleeding (AUB-HMB) and intermenstrual bleeding (AUB-IMB), according to PALM-COEIN classification. Material and Methods: Retrospective study in the population of women undergoing D&C in tertiary hospital because of AUB between Jan-2016 and Dec-2016. The incidence of EC, AH, EH was established. The influence of the variables: age, BMI, AUBHMB/ AUB-IMB on the occurrence of abnormal histology (EC, AH, EH) was evaluated. Finally, the model built by using backward stepwise regression and mechanism of v-fold cross-validation, showed no statistically significant relationship. Results: EC was detected in 2/213 cases (0.9%; 95% CI 0.0003 to 0.036), AH in 3/213 cases (1.4%), giving a total of 5/213 (2.3%) women with AH or EC. EH was detected in 16/213 (7.5%) women. High BMI raises the chance of AH diagnosis: OR 1.16 (95% CI 1.05- 1.28). The presence of HMB compared to IMB reduces the chance of EH: OR 0.24 (95% CI 0.07-0.9). IMB increases the chance for the diagnosis of EH 4.11 times compared to HMB (OR 4.1, 95% CI 1.1-14.9; p = 0.016). Conclusions: EC in premenopausal women with AUB undergoing D&C is rare. There is a need to search for more effective methods of selection of patients than commonly used. Age and BMI do not seem to be factors that should be used to select patients.

Leiomyosarcoma in the mandible: A rare case report.

Leiomyosarcoma (LMS) is a malignancy which very rarely occurs in maxillofacial location, and the course of the disease is not very characteristic.In this case report, we present a 58-year-old female patient with a painless tumor of the left angle of the mandible causing slight asymmetry of the face. She also reported that she observed deterioration in fitting of the lower denture in the oral cavity for several months, which she had used successfully for 5 years.On the basis of clinical tests, histopatological examination, and imaging (CT, MRI, ultrasound, pantomography), the patient was diagnosed with primary malignant leiomyosarcoma (LMS) of the mandibular corpus and ramus on the left side. The patient received combined surgical and oncological treatment. The first stage was a surgery, and then adjuvant radiotherapy was applied on the site of the resected tumor-a total dose of 60 Gy in 35 fractions. The patient's postoperative course was uneventful. She also underwent adjuvant therapy well. In the period of 3-year follow-up, no signs of recurrence were observed.The findings may extend our knowledge and experiences in the treatment of leiomvosarcoma in the craniofacial area.

[Significance of vitamins A and E in the cervical intraepithelial neopiasia--CEN]. / Rola witaminy A i witaminy E w zachowaniu sie sródnablonkowej neoplazji szyjki macicy (CIN).

UNLABELLED: Cervical intraepithelial neoplasia--CIN affects women in their repro- ductive life period. CIN may proceed squamous cervical cancer. CIN is divided into: CIN1, CIN2, CIN3. CIN3 comprises cervical cancer in situ- CIS which is the true precancer state within the cervix. CIN, depending on grade may progress, regress or persist for many years. According to a few publication vitamins C, E and A may protect against carcinogenesis within the cervix. The aim of this paper was evalua- tion of vitamins A and E serum concentration of cervical intraepithelial neoplasia patients. The study material consisted of 289 women aged 25-60 years diagnosed with CIN and early invasive cervical cancer IA. The subjects of the study were selected amongst participants of National Cervical Cancer Screen- ing Program attending Department of Gynecology and Oncology of Jagiellonian University Medical College in Krakow. The control group consisted of 44 women aged 28-56 years diagnosed and treated in the same centre and period due to a non oncologic gynecologic conditions. Serum vitamin A and E was measured with HPLC method with ultraviolet detector (UV) (254 nm). RESULTS: Medium serum vitamin A concentration in the study group was 2.67 ± 1.15 mg/l and was significantly (p < 0.001) lower than in control group -3.81 ± 1.62 mg/l. Mean serum vitamin E concentration in the study group was 3.95 ± 1.93 mg/l and was also significantly (p < 0.001) lower than in control group (8.63 ± 2.84 mg/l). To conclude, the observed significantly lower vitamins A and E serum concentrations may be related to the cervical neoplasia process. The normal vitamin A and E serum levels may have a protective effect against cervical carcinogenesis.