Enthalpy of collagen interfibrillar bonds in fetal membranes.

During pregnancy, the fetal membrane (FM) is subjected to mechanical stretching that may result in preterm labor. The structural integrity of the FM is maintained by its collagenous layer. The disconnection and reconnection of molecular bonds between collagen fibrils are the fundamental processes that govern the irreversible mechanical and supermolecular changes in the FM. Here, we study the activation enthalpy of interfibrillar bonds in ex-vivo human FM. We analyze the strain-rate and temperature dependence of the irreversible deformations in FM subjected to inflation tests, which apply mechanical conditions similar to those experienced by the FM prior to and during the initiation of labor contractions. The obtained activation enthalpy of interfibrillar bonds matches the typical enthalpy values of polyvalent ionic bonds, implying on another important role that ions like Ca and Mg may play in the gestation and labor.

Collagen bundling and alignment in equibiaxially stretched human amnion.

We study irreversible collagen arrangement processes in ex-vivo human amnions subjected to inflation tests, which simulate the mechanical conditions prior to and during the initiation of labor uterine contractions. The investigation is focused on the center of the membrane where the stresses are maximal and equibiaxial. Second harmonic generation reveals an unexpected collagen rearrangement in the compact layer that is responsible for the structural integrity of the fetal membrane. The observed bundling and alignment of the collagen fibers indicate a deviation from the expected equibiaxial stress state. The statistical analysis of the fiber orientations provides information on two driving forces for collagen alignment: microscale flaws and macroscale deviation from the equibiaxial strain. As the pressure increases, the macroscale effect becomes dominant, and a high density of fibers that are aligned along a specific direction is observed. A model that explains these observations and relates them to the material properties is presented. The results of this study indicate that a temporal increase in intrauterine pressure or uterine cervix dilatation causes irreversible changes in collagen molecular connections that may lead to biological changes, such as the initiation of term and preterm labor.

Ectopic pregnancy risk factors for ART patients undergoing the GnRH antagonist protocol: a retrospective study.

BACKGROUND: In-vitro fertilization is a known risk factor for ectopic pregnancies. We sought to establish the risk factors for ectopic pregnancy in GnRH antagonist cycles examining patient and stimulation parameters with an emphasis on ovulation trigger. METHODS: We conducted a retrospective, cohort study of 343 patients undergoing 380 assisted reproductive technology (ART) cycles with the GnRH antagonist protocol and achieving a clinical pregnancy from November 2010 through December 2015. RESULTS: Significant risk factors for ectopic pregnancy in the univariate analysis included prior Cesarean section (CS), endometriosis, mechanical factor infertility, longer stimulation, elevated estradiol and progesterone levels, GnRH agonist trigger, higher number of oocytes aspirated, and insemination technique. Independent risk factors for ectopic pregnancy in the multivariate analysis included GnRH agonist trigger, higher number of oocytes aspirated, insemination technique, and prior Cesarean section. CONCLUSION: Excessive ovarian response, IVF (as opposed to ICSI), prior Cesarean section and GnRH agonist trigger were found to be independent risk factors for ectopic pregnancy. Caution should be exercised before incorporating the GnRH agonist trigger for indications other than preventing OHSS. When excessive ovarian response leads to utilization of GnRH agonist trigger, strategies for preventing ectopic pregnancy, such as a freeze all policy or blastocyst transfer, should be considered. Further studies should elucidate whether adjusting the luteal support can reduce the ectopic pregnancy risk.

Empty follicle syndrome: successful treatment in a recurrent case and review of the literature.

Empty follicle syndrome is a condition in which no oocytes are retrieved after an apparently adequate ovarian response to stimulation and meticulous follicular aspiration. It is a rare condition of obscure etiology. A patient with primary infertility who underwent seven assisted reproductive technique cycles is described. In spite of a satisfactory ovarian response, aspiration yielded no oocytes in four cycles and 1-4 low quality oocytes in three cycles. In the index treatment cycle, ovulation was triggered using GnRH agonist 40 h prior to ovum pickup and hCG was added 6 h after the first trigger. Eighteen oocytes were recovered, of which 16 were mature and were inseminated by ICSI. Two embryos were transferred 48 h after aspiration and nine embryos were cryopreserved. The patient conceived and delivered a healthy boy at 38 weeks of gestation. The literature is reviewed and possible etiologies and treatment options of this enigmatic syndrome are suggested.

Effect of primary human endometrial stromal cells on epithelial cell receptivity and protein expression is dependent on menstrual cycle stage.

BACKGROUND: Successful implantation requires a receptive endometrium. We hypothesized that effects of endometrial stromal cells (ESC) on epithelial cell receptivity and trophoblast-endometrium interaction are menstrual cycle dependent. METHODS: An endometrial in vitro 3D co-culture model of primary human ESC with the endometrial epithelial cell line (RL95-2) was constructed. Co-cultures were prepared using primary ESC from biopsies taken before the window of implantation (ESCbw) and during the window of implantation (ESCw), on cycle days 10-17 and 19-23, respectively. RL95-2 served as a constant parameter upon which the influence of ESC from different phases of the cycle was investigated. proMMP-2 (MMP, matrix metalloproteinase) and proMMP-9 secretion was tested in response to progesterone. Progesterone receptor B (PR-B) and plexin B1 protein expression and mRNA levels were investigated using immunofluorescence and RT-PCR, respectively. RESULTS: Progesterone increased proMMP-2 secretion in primary ESCbw (P = 0.0046) but decreased proMMP-2 and proMMP-9 secretion in ESCw (P < 0.0005). In the presence of ESCbw, JAR spheroid attachment rate to overlying RL95-2 cells was decreased (P < 0.0001), whereas in the presence of ESCw, attachment rate was unchanged. Progesterone treatment restored epithelial cell receptivity in co-culture with ESCbw (P = 0.00004). A correlation between spheroid attachment rate and plexin B1 mRNA level was observed (P = 0.01). PR-B protein and mRNA level were influenced by the interplay between RL95-2 and stromal cells. CONCLUSION: The effects of human primary ESC on epithelial cell receptivity and trophoblast-endometrium interaction depended upon whether the ESC were taken before or during the window of implantation.

Lack of association between unexplained elevated maternal serum alpha fetoprotein and/or human chorionic gonadotropin and the occurrence of placental thrombotic lesions.

OBJECTIVE: To investigate the significance of unexplained elevated maternal serum alpha fetoprotein (MSAFP) and/or human chorionic gonadotropin (HCG) on the occurrence of placental thrombotic changes. STUDY DESIGN: Between January 2007 to April 2009, placentas of all women who delivered and had unexplained elevated MSAFP and/or HCG (above 2 MOM) were sent to histological examination. Women were divided into 2 groups. Group A included women who had uneventful pregnancies and delivered at term. Group B included women with antepartum complications attributed to thrombosis. Women in both groups (A and B) had elevated MSAFP and/or HCG. Group C was a frequency matched group of women who had normal MSAFP and HCG levels with uneventful pregnancies and delivered at term. MAIN OUTCOME MEASURE: Incidence of placental thrombotic lesions in each group. RESULTS: Of 9695 women who delivered during the study period there were 76 women with elevated MSAFP and or HCG, 48 in group A and 28 in Group B. Group C, included 30 women. The number of placentas in which any thrombotic lesion was identified was 22 (45.8%), 19 (67.9%) and 10 (33%) respectively. Changes differed significantly only between group B and C (p = 0.03). Although the rate of changes in group A was higher than in group C it did not reach statistical significance even when considering only women with two abnormal results (MSAFP and HCG) or when a cutoff of 2.5 MOM or more was set. CONCLUSION: Placental histopathological changes are associated with pregnancy complications and can only marginally be attributed to unexplained elevated MSAFP and/or HCG.

p53 Mediates epidermal growth factor (EGF) induction of MMP-2 transcription and trophoblast invasion.

Trophoblast invasion is a highly restricted process, regulated by growth factors, hormones and cytokines. Trophoblast invasion is attainable due to proteolytic degradation of the epithelial basement membrane and the extracellular matrix by proteolytic enzymes like the matrix metalloproteinases (MMPs) particularly MMP-2. Epidermal growth factor (EGF), a major mediator of implantation, has been documented to induce MMP-2 and trophoblast invasion. The aim of this study was to investigate the transcriptional regulation of MMP-2 in EGF- stimulated invasive trophoblast cells, using JAR choriocarcinoma cell line and 6-8w 1st trimester trophoblasts. MMP-2 expression was induced by EGF within 1 hour. Gelshift and supershift assay were used to explore transcription factors involved in MMP-2 regulation. EGF induced binding activity and expression of phophorylated p53, AP-2alpha and -gamma, C/EBPepsilon and -lambda to their responding sequences, found in the MMP-2 promoter. Additionally EGF induced binding activity to SP-1, but reduced the expression of SP-1 and SP-4. Inhibition of p53 by antisense reduced both basic and EGF- induced MMP-2 expression. In summary: MMP-2 transcriptional regulation by EGF in invasive trophoblasts is mediated through several binding sites and transcription factors including p53, AP-2alpha and -gamma, C/EBPepsilon and -lambda and SP-1. p53 mediates both basic and EGF-induced MMP-2 transcription.

GnRH agonist therapy as ovarian protectants in female patients undergoing chemotherapy: a review of the clinical data.

BACKGROUND: Cancer survival rates in young women are improving due to progress in treatment. This includes aggressive chemotherapy, a treatment that often poses a threat to fertility. GnRH agonists were proposed as ovarian protectors during gonadotoxic therapies. This study was undertaken in order to determine the clinical evidence concerning this issue. METHODS: The medical literature was searched for studies that reported on ovarian function after the administration of GnRH agonists concomitant with chemotherapy. Twelve studies met the predetermined selection criteria. RESULTS: Data on ovarian function were obtained for 579 women who received chemotherapy. Among 345 women who received GnRH agonist co-treatment, ovarian function was preserved in 91% and 9% had premature ovarian failure. In 234 women who did not receive GnRH agonist co-treatment, ovarian function was preserved in 41% and failed in 59%. Only two of the studies were randomized. The control and the GnRH agonist groups differed in several important characteristics: the follow-up times were not equal, different treatment protocols were utilized and end-points were poorly defined and inconsistent between the studies. CONCLUSIONS: The effectiveness of GnRH agonists as fertility-preserving agents is debatable. A thorough literature search has found insufficient evidence to show that GnRH agonist co-treatment is effective in protecting the ovary from the damage of chemotherapy. A large randomized controlled trial with adequate follow-up is needed.

Evidence for blood chimerism in dizygotic spontaneous twin pregnancy discordant for Down syndrome.

BACKGROUND: A monochorionic-diamniotic placenta (MCDAP) is rare in dizygotic (DZ) twinning. All reported cases have been documented in pregnancies achieved by the induction of ovulation alone or during the IVF cycle. METHODS AND RESULTS: We report a spontaneous pregnancy in a 39-year-old patient with evidence of MCDAP in DZ twins, discordant for trisomy 21. The first and second-trimester sonographic scans indicated male twins with MCDAP. Amniocentesis, performed because of advanced maternal age, revealed a normal karyotype in one fetus, and trisomy 21 in the other. Molecular studies, performed in order to confirm the zygosity and chorionicity, demonstrated that the fetuses were DZ. In order to identity the affected twin, a detailed sonographic examination was repeated, but no abnormal findings associated with Down syndrome were demonstrated in any of the fetuses. Therefore, umbilical cord blood samples were obtained from both fetuses. Chromosomal analysis revealed in both fetuses two cell lines: a normal cell line of 46,XY and a 47,XY,+ 21 cell line, in 65 and 80% of the cells, respectively. This result was independently confirmed by both FISH and G-banding. DNA extracted from both cord blood samples demonstrated an admixture of two distinct genotypes in each sample. CONCLUSIONS: We propose that this case represents a monochorionic-dizygotic twin pregnancy with blood chimerism. The most plausible mechanism underlying this phenomenon is placental fusion early in pregnancy, resulting in an architecturally single placenta originating from two distinct zygotes. The newly formed blood vessels created anastomoses between the DZ twins and allowed reciprocal blood chimerism between the normal and the trisomic twin.

Hysteroscopy may be justified after two miscarriages.

BACKGROUND: Recurrent pregnancy loss is traditionally investigated after three or more consecutive pregnancy losses. Although there is a trend to start investigation after two miscarriages, data are not available to date to justify this approach. We sought to compare the frequency of uterine anomalies between women referred to hysteroscopy for repeated miscarriages after two, and three or more, miscarriages respectively. METHODS: A retrospective analysis of acquired and congenital uterine anomalies in all patients undergoing hysteroscopy for repeated pregnancy loss at an academic and referral medical centre. RESULTS: Hysteroscopy was performed on 165 women referred for recurrent pregnancy loss: 67 after two and 98 after three or more consecutive miscarriages. The rate of uterine anomalies did not differ significantly and was 32 versus 28% respectively. CONCLUSIONS: Hysteroscopy may be justified following two spontaneous pregnancy losses.

Differential activity of the gelatinases (matrix metalloproteinases 2 and 9) in the fetal membranes and decidua, associated with labour.

Degradation of the extracellular matrix in fetal membranes has been implicated in the rupture of fetal membranes, the process of parturition and placental detachment from the decidua after parturition. In this study we assessed labour-associated changes in gelatinase activity in cultured human amnion, chorion and decidua, as well as in amniotic fluid. We found that in media conditioned by decidua, following the establishment of uterine contractions, matrix metalloproteinase-2 (MMP-2) activity is increased while the protein tissue inhibitors of matrix metalloproteinase-1 (TIMP-1) level is decreased. The formation of a 130 kDa gelatinase band was also significantly increased after contractions began. In media conditioned by chorion, the initiation of uterine contractions did not change MMP activity or TIMP-1 levels. However, an increase in MMP-9 activity and a decrease in TIMP-1 protein levels were observed following the establishment of uterine contractions in media conditioned by amnion. We suggest that this differential spatial regulation provides a form for modulatory hieratical activity of the MMPs in the onset of labour allowing rupture of the membranes while avoiding premature placental separation.

Pregnancy outcome after laparoscopy or laparotomy in pregnancy.

STUDY OBJECTIVE: To assess obstetric performance and fetal outcomes after laparoscopy or laparotomy performed during pregnancy. DESIGN: Nationwide, multicenter, retrospective chart review (Canadian Task Force classification II-2). SETTING: Seventeen hospitals throughout Israel: 12 university or university-affiliated hospitals and 5 general hospitals. PATIENTS: Three hundred eighty-nine pregnant women. INTERVENTION: Laparoscopy or laparotomy for various indications. MEASUREMENTS AND MAIN RESULTS: Of 192 laparoscopies performed, 141 were during the first, 46 during the second, and 5 during the third trimester; respective figures for 197 laparotomies were 63, 110, and 24. No intraoperative complications were reported for either procedure. Six and 25 women had complications after laparoscopy and laparotomy, respectively. There was no significant difference in abortion rates between groups. Mean gestational age at delivery and mean birthweight were comparable between groups. No significant difference was found in frequency of fetal anomalies between groups or when compared with the Israel register of anomalies. CONCLUSION: Operative laparoscopy seems to be as safe as laparotomy in pregnancy.

Ultrasound-guided umbilical cord occlusion using bipolar diathermy for Stage III/IV twin-twin transfusion syndrome.

OBJECTIVES: To evaluate bipolar diathermy as a technique for selective fetocide in the treatment of advanced (Stage III/IV) twin-twin transfusion syndrome (TTTS). METHODS: A prospective observational study in two tertiary referral fetal medicine centres: Queen Charlotte's Hospital, London, UK and Haemek Hospital, Afula, Israel. Fifteen cases of TTTS (14 twins and one triplet pregnancy) were treated by selective occlusion of either the donor (n=8) or recipient's (n=7) umbilical cord using ultrasound-guided bipolar diathermy. Following each procedure, patients were scanned serially for fetal growth, liquor volume and umbilical Doppler measurements. Procedural complications and obstetric outcome were recorded. Postnatal placental injection studies were performed. RESULTS: Overall co-twin survival in Stage III/IV TTTS was 13/14 (93%). There were no treatment failures. The incidence of preterm prelabour rupture of membranes (PPROM) within 3 weeks of the procedure was 3/15 (20%). In those cases where pre-procedure umbilical artery Dopplers were abnormal, the Doppler findings normalised post-procedure in all non-cord-occluded fetuses. Growth velocities of surviving donors were similar to those of surviving recipients. CONCLUSIONS: Bipolar diathermy appears an effective technique for the selective reduction of monochorionic twins complicated by severe as well as preterminal TTTS, with recipient and donor fetuses being equally appropriate choices for fetocide. We suggest that for advanced-stage disease where the parents can contemplate this option, cord occlusion as a single preemptive procedure maximises the opportunity for intact survival of a single survivor.

Laparoscopic subtotal hysterectomy and bilateral adnexectomy in a child with congenital adrenal hyperplasia.

OBJECTIVE: To report the results of a subtotal hysterectomy and bilateral adnexectomy in a child with congenital adrenal hyperplasia due to 21-hydroxylase deficiency. DESIGN: Case report. SETTING: Gynecology department, Afula, Israel. PATIENT(S): An 11-year-old child with a female genotype and saltwasting type congenital adrenal hyperplasia who was being raised as a boy. INTERVENTION(S): Laparoscopic subtotal hysterectomy and bilateral salpingo-oophorectomy were performed. MAIN OUTCOME MEASURE(S): Surgical efficiency, operating time, recovery, and aesthetic result. RESULT(S): The procedure was performed without complications in 26 minutes, and the child was dismissed the following day. Three 5-mL abdominal incisions were required. CONCLUSION(S): Laparoscopic subtotal hysterectomy and bilateral adnexectomy can be safely performed in children and is the procedure of choice in the rare cases in which it is indicated.

Doppler fetal echocardiography in endocardial fibroelastosis.

BACKGROUND: Endocardial fibroelastosis is a congenital heart disease known to cause congestive heart failure in early infancy. We report a case using new modalities for early prenatal diagnosis of endocardial fibroelastosis causing fetal heart failure. CASE: A multipara with two children, who died of endocardial fibroelastosis, was referred for fetal echocardiography at 20 weeks' gestation. A mildly asymmetric four-chamber view with slightly enlarged atria and no other fetal heart abnormalities suggested endocardial fibroelastosis. Doppler studies demonstrated abnormal cardiac function with extremely low atrioventricular E/A ratio, defined as the ratio between the rapid ventricular filling (E wave) and the atrial systole (A wave), and abnormal venous flow velocity waveforms establishing the diagnosis. On a repeat scan 2 weeks later, the abnormal morphologic signs suggesting endocardial fibroelastosis were more prominent, and pregnancy was terminated. CONCLUSION: When morphologic signs are not definitive, Doppler studies of the fetal heart may be useful in making the diagnosis of endocardial fibroelastosis.

Matrix metalloproteinase (MMP)-2 and MMP-9 and their inhibitor, TIMP-1, in human term decidua and fetal membranes: the effect of prostaglandin F(2alpha) and indomethacin.

Degradation and breakdown of gestational membranes and the adjacent decidua are essential processes for the advancement of labour. We have assessed the effect of prostaglandin (PG) synthesis on the expression and activity of matrix metalloproteinase (MMP)-2 and MMP-9 and tissue inhibitor of metalloproteinases (TIMP-1) in fetal membranes at the edge of the placenta and decidua, by using ex-vivo organ culture of the tissues in the absence or presence of PGF(2alpha) (0.1, 1.0 and 10 microg/ml) or a PG synthesis inhibitor, indomethacin (10(-4)-10(-6) mol/l). Conditioned media were assessed for MMP by zymography on gelatin containing sodium dodecyl sulphate-polyacrylamide gels and for TIMP-1 by Western blot analysis. Compared to the membranes, decidua produced significantly more MMP-2 and MMP-9 as well as TIMP-1. PGF(2alpha) caused a 2.4- and 1.9-fold increase in the production of MMP-2 and MMP-9 in the decidua, respectively (P < 0.05), and an 11.3-fold increase of the active form of MMP-2 (62 kDa) which could hardly be detected in basal culture conditions (P < 0.01). PGF(2alpha) decreased TIMP-1 production by 70% in the decidua. The production of MMP-2 and MMP-9 and TIMP-1 by the amniotic and chorionic membranes was not affected by PGF(2alpha). Indomethacin decreased the production of MMP-2 and MMP-9 by 78 and 35% in chorion, and by 70 and 58% in amnion, respectively (P < 0.05), but did not affect production in decidual tissue. Indomethacin increased the production of TIMP-1 in chorion and amnion [by 4.1- and 4.5-fold respectively (P < 0.01)], but had no effect on decidua. Cumulatively, PGF(2alpha) increases decidual gelatinolytic activity. Meanwhile the inhibition of PG production by indomethacin reduces total gelatinolytic activity in fetal membranes, possibly accounting for some of its labour-arresting property.

Can we abandon routine evaluation of serum estradiol levels during controlled ovarian hyperstimulation for assisted reproduction?

OBJECTIVE: To assess whether abandoning measurement of serum estradiol (E2) and spacing ultrasound evaluations at greater intervals had an effect on the results of assisted reproduction technology (ART). DESIGN: A retrospective comparison of two consecutive periods. SETTING: Division of Assisted Reproduction Technology, Department of Obstetrics and Gynecology, Ha'Emek Medical Center, Afula, Israel. PATIENT(S): One thousand nine hundred and eighty-five controlled ovarian hyperstimulation (COH) cycles for ART were initiated during the years 1996 to 1999. INTERVENTION(S): During the first 2 years an intensive follow-up protocol was used that included E2 blood levels measurements. In the next 2 years a less intensive protocol was adopted that did not use E2 measurements. MAIN OUTCOME MEASURE(S): ART results and the rate of ovarian hyperstimulation syndrome (OHSS). RESULT(S): The patients' background characteristics did not differ between the two periods. The cancellation rate was not different (9.8% vs. 7.2%). There was no difference in the duration of stimulation or the amount of gonadotropins used. The number of oocytes retrieved (12.1 +/- 9.3 vs. 9.6 +/- 6.3), fertilization rates (74% vs. 75%), and clinical pregnancy rates (26.2% vs. 27.9%) did not differ. The incidence of severe ovarian hyperstimulation syndrome was not significantly different between the two periods. CONCLUSION(S): Controlled ovarian hyperstimulation for ART can be done reliably without routine, serial serum E2 measurements without compromising the treatment results.

A randomized, double-blind clinical trial using fixed daily doses of 100 or 200 IU of recombinant FSH in ICSI cycles.

The effect of 100 and 200 IU per day recombinant FSH (rFSH) on numbers of oocytes retrieved and the total dose used in ovarian stimulation before intracytoplasmic sperm injection was investigated in a double-blind, randomized multicentre trial. A total of 91 women was treated with a low-dose protocol and 88 with a high-dose regimen at five centres. For each started cycle, significantly more oocytes were retrieved in the 200 IU group than in 100 IU group (12.0 versus 5.7, P < 0.001); total rFSH consumption was 1121 and 1875 IU in the low- and high-dose groups respectively. Significant variations were noted between centres with regard to numbers of oocytes collected per started cycle, ranging from 2.8 to 7.2 in the 100 IU group and from 9.0 to 19.1 in the high-dose group. Exploratory analyses of secondary outcomes suggested there were no differences in vital pregnancy rates per started cycle (19.2 versus 16.9%) and per embryo transfer (26.2 versus 19.3%) in the low- and high dose groups respectively. There were four hospitalizations due to ovarian hyperstimulation syndrome, all in the 200 IU group.

[Laparoscopy as part of the evaluation and management of ovarian and cervix neoplasms].

INTRODUCTION: Surgery is the treatment of choice in most early stages of cervical cancer and advanced stages of ovarian cancer. Failing to preoperatively diagnose para-aortic and parametrial metastases in cervical cancer or a non-resectable, ovarian cancer, may results in a superfluous laparotomy. AIM: To evaluate the advantage of using laparoscopy in cervical and ovarian cancer. PATIENTS AND METHODS: Study population includes patients with ovarian or cervical cancer referred between 1997-1999. A CT scan and a trans-vaginal sonography were used to detect involvement of pelvic and para-aortic lymph nodes, parametrium and other metastases. In patients with cervical cancer, para-aortic lymph node dissection was laparoscopically performed. When para-aortic nodes were negative and parametrium was clear, radical hysterectomy and pelvic lymph nodes dissection was conducted through laparotomy. When para-aortic lymph nodes or parametrium were positive, patients were referred for radiation therapy. In ovarian cancer patients, the upper abdomen and the pelvis were examined laparoscopically to evaluate the possibility of optimal debulking surgery. Staging was done for patients who were not candidates for optimal debulking surgery and second debulking surgery was considered. RESULTS: Nine patients with stage 1b-11a cervical cancer were included. Preoperatively, 2 of them were suspected for lymph node involvement. Following laparoscopy one was confirmed to have para-aortic lymph node involvement and the other did not. In the remaining 8 patients, one was found to have parametrial involvement and laparotomy was avoided, while the rest were treated surgically. Eighteen ovarian cancer patients were included in this study. Laparoscopy revealed an extensive disease in 7 patients and therefore staging laparoscopy was completed. In the remaining 11 patients, laparotomy was performed, operable disease was found and complete debulking surgery was conducted. In only one patient of the 11 complete debulking surgeries was not possible. CONCLUSIONS: In accordance with the experience and skills of the surgical team, we propose utilizing laparoscopy in cases where laparotomy may be avoided.