Ultrasound-guided embryo transfer: summary of the evidence and new perspectives. A systematic review and meta-analysis.

Despite the purported advantages of ultrasound guidance during embryo transfer, and the large number of clinical trials published on this topic, recommendations for the use of this technique in daily clinical practice are still under debate. We designed a meta-analysis based exclusively on evidence from published randomized controlled trials, with the aim of analysing the effect of trans-abdominal ultrasound guidance during embryo transfer versus clinical touch and of transvaginal ultrasound guidance (TV-US) versus the trans-abdominal approach on IVF outcomes. On the basis of 14 randomized trials, we found a moderate quality of evidence supporting the beneficial effects of transabdominal guidance during embryo transfer compared with conventional clinical touch in clinical pregnancy and ongoing or live birth rates. No significant differences were found in miscarriage and ectopic pregnancy rate, with low or very low quality of evidence, respectively. On the basis of three randomized trials, we found the quality of evidence supporting the equivalence of transvaginal versus transabdominal approach in clinical pregnancy and ongoing or live birth rates to be low. Finally, larger randomized controlled trials are necessary to explore the possible benefits of TV-US, three-dimensional ultrasound imaging modality, and uterine length measurement before transfer.

Female stress urinary incontinence: clinical efficacy and satisfaction after transobturator adjustable tape sling. An observational longitudinal cohort study.

We performed an observational longitudinal cohort study on patients affected by stress urinary incontinence (SUI) and surgically treated with a transobturator adjustable tape sling (TOA) in order to evaluate this surgical procedure in terms of efficacy, safety, quality of life (QoL) improvement, and patient satisfaction. For all patients, we recorded: general features, preoperative SUI risk factors, obstetrics history, preoperative urodynamic tests, intraoperative/postoperative complications, number of postoperative sling regulations, postmicturition residue, and hospital stay. All patients were asked to complete the validated short version of the Urogenital Distress Inventory (UDI-6) questionnaire 18 months after discharge to evaluate the efficacy of the TOA system. We added 2 adjunctive items to the UDI-6 in order to evaluate patient satisfaction and QoL. All 77 surgical procedures were performed under locoregional anesthesia without complications. Postoperative TOA regulations were performed in 46.8% of patients immediately after the procedure and in 14.3% during hospitalization. Before discharge, postmicturition residue was negative in 67 cases and less than 50 cc in 10 cases. Mean hospital stay was 2.18 days. From the questionnaire evaluation, we found that after the procedure, 90.9% of patients showed a complete regression of urinary symptoms, 1.3% obtained considerable relief from preoperative symptoms, and 6.6% reported poor or absent symptom improvements; 75.3% of patients were totally satisfied and 5.2% totally disappointed. The possibility of modulating postoperative sling tension and reusing the surgical materials in association with short hospitalization as well as high patient satisfaction render TOA a safe, effective, and low-cost technique for the treatment of female SUI.

Cervicoisthmic pregnancy near cesarean scar after oocyte donation in premature ovarian failure: literature review starting from a single case.

OBJECTIVE: This study aimed to identify the best management options in decision making in cases of cervicoisthmic and cesarean scar pregnancies and rare forms of ectopic pregnancies with high rates of pregnancy-related morbidity in the first trimester, more commonly associated with assisted reproductive medicine. MATERIALS AND METHODS: We performed a literature review of the description of a case report of a cervicoisthmic pregnancy near a cesarean scar in a premature ovarian failure woman. She obtained pregnancy after ovum donation, hormonal therapy, and in vitro fertilization. The researchers focused on the MEDLINE/PubMed database articles on ectopic pregnancies, particularly on cesarean scar pregnancies, cervical pregnancies, and ectopic pregnancies after in vitro fertilization in English-language journals published from January 1996 to December 2011. RESULTS: The conservative or nonconservative options for medical or surgical treatments are disposables. Moreover, in literature, no consensus was found about the best treatment method. CONCLUSIONS: Obstetricians should pay great attention to a possible cesarean scar pregnancy in patients with risk factors in their medical history. Until now, the rarity of these findings does not allow the definition of a commonly accepted management, so the best personalized approach may be guided by early recognition, close surveillance, and appropriate counseling. Further investigations are necessary to recognize high-risk factors for all ectopic pregnancies and those unique to cesarean scar ectopic pregnancies.

Secondary amenorrhea in severe Asherman's syndrome: step by step fertility retrieval by Bettocchi's hysteroscope: some considerations.

The aim of this report was to define the best diagnostic and therapeutic approach when secondary amenorrhea is related to undiagnosed Asherman syndrome. We present a single case of secondary amenorrhea with a previous diagnosis of alterated hypothalamic-hypophysary regulation, with a component of ovarian function in probable reduction, which was evaluated in our department and resulted affected by Asherman's syndrome IV stage. We describe step by step the diagnosis and treatment of a previously misdiagnosed case of severe Asherman's syndrome. An appropriate diagnosis and adequate treatment are mandatory to allow menses and fertility to be restored when severe Asherman's syndrome occurs.

Cyclic variations of bone resorption mediators and markers in the different phases of the menstrual cycle.

Female hormones are very important in regulating bone homeostasis; the drop of estrogen levels occurring at menopause is linked to a dramatic prevalence of bone resorption on formation. Only a small number of studies investigated the relationship between changes in circulating female sex hormones and the markers and mediators of bone homeostasis and they showed conflicting results. To explore such relationships we studied 20 young fertile healthy women, aged between 19 and 32 years. None had received hormone treatment for at least 6 months. We assayed luteinizing hormone, follicle-stimulating hormone, progesterone and 17ß-estradiol, as well as the levels of osteoprotegerin (OPG), C-terminal telopeptide of collagen type I (CTx) and RANKL (receptor activator of nuclear factor-B ligand) in samples drawn from every subject at four different times during the menstrual cycle when estrogens are lowest, at the start of the cycle: T 0 (2-4th day); when estrogens are highest, in the pre-ovulatory period: T 14 (12-14th day); when progesterone activity is highest, in the advanced luteal phase: T 26 (24-26th day); and again at the start of the next cycle: T 01 (2-4th day). We observed that CTx levels are highest at the start of the cycle, decreased significantly from T 0 to T 26 (pfwe = 0.0455) and then increased from T 26 to T 01 (pfwe = 0.0415); OPG, on the other hand, which was also highest at the start of the cycle, decreased significantly from T 0 to T 14 (pfwe = 0.02) and then increased, though not significantly, from T 14 to T 01; no variation was observed in RANKL values at any time. We observed inverse correlations between estradiol and OPG levels, which became highly significant at T 01 between estradiol nadir and OPG peak levels (pfw = 0.0095). Furthermore, the increase of estradiol from T 0 to T 14 was negatively correlated with the concomitant decrease of OPG (pfwe = 0.0277), as was the fall of estradiol from T 26 to T 01 with the OPG peak levels, both at T 01 (pfw = 0.0045) and at T 0 (pfwe = 0.0381). We also observed direct correlations between the OPG levels and the variations of progesterone in the preceding intervals, but they never attained statistical significance. We conclude that OPG and CTx fluctuation during the menstrual cycle are likely due to the physiological variations of sex steroids levels.

Laparoscopic surgical treatment of diaphragmatic endometriosis: a 7-year single-institution retrospective review.

BACKGROUND: Diaphragmatic endometriosis is a rare condition that may cause invalidating epigastric or thoracic pain and catamenial pneumothorax. During the past decades, laparoscopy has been proposed as an optimal tool for diagnosis and surgical eradication of the disease. METHODS: We present a retrospective series of consecutive patients affected by diaphragmatic endometriosis, treated by laparoscopy at our institution, during a period of 7 years. RESULTS: Among 3,008 patients with pelvic endometriosis, 46 cases with intraoperative diagnosis of diaphragmatic endometriosis were identified. Operative findings showed multiple diaphragmatic lesions in 32 (69.5 %) patients and single lesions in 14 (30.4 %). Diaphragmatic implants were distributed on the right side in 40 (86.9 %) patients; in 5 patients (10.8 %) they were bilateral and 1 patient had a single lesion on the left hemidiaphragm. Most of the symptomatic patients were treated by complete excision of the nodules, whereas only three patients referring right upper-quadrant abdominal pain and right shoulder catamenial pain had superficial diaphragmatic endometriosis and were treated by diathermocoagulation. CONCLUSION: Diaphragmatic endometriosis should be included in the concept of complete eradication of endometriosis. This kind of surgery has been shown to be feasible and cost-effective; however, it should be managed in a referral center, by an expert laparoscopic gynecologist with knowledge of oncological surgical techniques, with the support of a general surgeon and a trained anesthesiologist.

Can the impact of pelvic inflammatory disease on fertility be prevented? Epidemiology, clinical features and surgical treatment: evolution over 8 years.

OBJECTIVE: To assess the epidemiological features and the trend of care of patients diagnosed with pelvic inflammatory disease (PID) and to assess most predictive parameters of severe disease, for which surgical management is warranted, in particular when surgery is certain to cause permanent infertility. STUDY DESIGN: The study population was divided into 3 groups: medical therapy only, conservative surgery, and destructive surgery (surgical procedures that impaired fertility). Data from the 3 groups were compared with respect to general and medical history data, clinical signs on admission, laboratory tests, and ultrasound findings. The p value was considered significant when < 0.05. RESULTS: The non-Italian women in the study appeared to be more at risk of developing PID and were overrepresented in the surgically treated groups. C-reactive protein (CRP) and D-dimer values most likely correlated with disease severity. Ultrasound evidence of ovaritis generally led to medical therapy. Conversely, when sonography revealed pyosalpinx or tuboovarian abscesses, surgery was performed. CONCLUSION: Clinical presentation is fundamental in diagnostic counseling but should be supplemented with further laboratory tests to detect inflammation and sonograms. The latter, along with CRP and D-dimer assays, may represent useful parameters to consider when planning patient management because they appear indicative of the need for surgical treatment.

A prospective, case-control study on the lipid profile and the cardiovascular risk of menopausal women on oestrogen plus progestogen therapy in a northern Italy province.

PURPOSE: To evaluate the effects of oestrogen plus progestogen therapy (EPT) on the lipid metabolism of menopausal patients. METHODS: We conducted a prospective study on 223 patients with clinical and blood chemistry diagnosis of menopause, who were eligible for hormone therapy and a follow-up period lasting at least 5 years. We selected a control group. Patients attended annual or 6-monthly visits for the duration of the 5-year follow-up period. For each patient, total-cholesterol, HDL-cholesterol, LDL-cholesterol and triglyceride values were considered at the first visit and after 5 years. We compared these values of the above parameters in relation to time and EPT and the repercussions that the presence/absence of replacement therapy had in terms of lipid profile alteration between the groups studied. RESULTS: Of the 223 patients eligible for enrolment, 178 made up the study group (EPT Group) and 45 made up the control cohort (N-EPT-Group). At the first visit, median value was (EPT-Group vs. N-EPT-Group): cholesterol was 240 versus 226 mg/dL, LDL-cholesterol 169 versus 174 mg/dL, HDL-cholesterol 60 mg/dL in both groups, triglyceride 125 versus 92 mg/dL (p:n.s). Five years later, median value was (EPT-Group versus N-EPT-Group): cholesterol 225 versus 236 mg/dL (p < 0.001), LDL-cholesterol 125 versus 184 mg/dL (p < 0.001), HDL-cholesterol 64 versus 68 mg/dL (p:n.s.), triglyceride 72 versus 94 mg/dL (p:n.s.). No adverse effects of EPT were observed. CONCLUSIONS: Thorough risk/benefit assessment, associated with initially low doses and without rigid cutoffs, particularly when started early, EPT can be made a valid means of cardiovascular prevention, specifically because it positively alters the lipid profile of menopausal women.

An update on diabetic women obstetrical outcomes linked to preconception and pregnancy glycemic profile: a systematic literature review.

Women with type 2 diabetes were less likely to have diabetes related complications than women with type 1. Women with type 1 diabetes had a high prepregnancy care and showed a worse glycemic control than women with type 2 both in the preconception period and during pregnancy. Obstetrical outcomes showed that preeclampsia and stillbirth rate is almost doubled in type 1 patients while perinatal deaths and SGA importantly increased in type 2 diabetes. In modern obstetrical care it is mandatory to maintain glucose levels as close to normal as possible particularly in diabetic population. HbA1C no higher than 6% before pregnancy and during the first trimester seems to decrease the risk of adverse obstetrical outcomes. Both the preconceptional counseling and glycemic profile optimization represent a fundamental step to improve pregnancy outcomes in women with preexisting diabetes. A systematic approach to family planning and the availability of preconception care for all diabetic women who desire pregnancy could be an essential step for diabetic management program.

Bakri balloon in vaginal-perineal hematomas complicating vaginal delivery: a new therapeutic approach.

OBJECTIVE: The study aimed to evaluate the effectiveness of Bakri balloon as a hemostatic device in severe postpartum hemorrhage due to complicated vaginal-perineal hematoma not responsive to standard surgical treatments. MATERIALS AND METHODS: The article discusses an effective and minimally invasive technique for resolving a case of massive vaginal-perineal bleeding after vaginal delivery complicated by ischiorectal fossa hematoma. A 36-year-old primipara white woman, 41 weeks 1 day pregnant, was admitted to our unit for beginning of labor. She experienced a precipitous delivery of a healthy male baby (3.72 kg, 51 cm in length), and spontaneous complete afterbirth of placenta and membranes. The intervention involved positioning of an hemostatic Bakri balloon device in the vagina, to compress the vaginal wall, ensuring that the draining apex was well positioned into the uterine cervix. RESULTS: The patient was discharged after having a puerperal course without further complications. CONCLUSIONS: Vaginal hemostatic Bakri balloon device shows hemostatic efficacy immediately assessable, is promptly removable, not interfering with subsequent surgical or radiological procedures, does not increase the risk of infections as other compressive procedures, allows flow of lochia, does not cause pain or discomfort in women, and permits adjustable compression when a drainage is placed during surgery. Despite the high cost, it does not show disadvantages.

Nowadays which emergency contraception? Comparison between past and present: latest news in terms of clinical efficacy, side effects and contraindications.

Despite many highly effective methods of contraception are available nowadays, many pregnancies are unintended. Emergency contraception (EC) is the use of drug or device after unprotected intercourse to prevent an unwanted pregnancy. It is a woman's last chance to prevent unintended pregnancy. Nevertheless the confusion about mechanisms of action, side effects, clinical efficacy and controindications makes the intervention underused in every setting investigated. So far levonorgestrel (LNG) has been considered the gold standard for oral EC. Today, a new type of second generation progesterone receptor modulator, ulipristal acetate (UPA) has been proposed as a more effective drug than LNG in prevention of unwanted pregnancies by delaying or inhibiting ovulation; even if many other devices are disposable in commerce. We revised the literature to concern most of the data available on the role of EC and moreover clarifying the available methods, the action windows of the accessible devices, the adverse events and the controindications.

Maternal hydration therapy improves the quantity of amniotic fluid and the pregnancy outcome in third-trimester isolated oligohydramnios: a controlled randomized institutional trial.

OBJECTIVES: Amniotic fluid is important for the maintenance of fetal well-being; therefore, an amniotic fluid deficiency, ie, oligohydramnios, can have multiple impacts on the prognosis of the pregnancy. In some cases, there are no evident fetal or maternal causes, and the condition is called isolated oligohydramnios. The aim of our study was to validate maternal intravenous and oral hydration therapy as a means for improvement of isolated oligohydramnios in the third trimester of pregnancy. METHODS: We conducted a prospective randomized controlled study on pregnancies complicated by idiopathic oligohydramnios (group A, 66 women) with a control group of women with normal pregnancies without oligohydramnios (group B, 71 women). Oligohydramnios was diagnosed using the amniotic fluid index (AFI; <5 cm). Sonographic examinations were performed with a convex 3.5-MHz probe. Group A underwent 6 days of intravenous infusion of 1500 mL of an isotonic solution per day. An AFI measurement, a nonstress test, and a fetal biophysical profile were performed at 0 and 7 days. Group A was randomized into subgroups A1 and A2. Subgroup A1 was prescribed home oral hydration therapy of 1500 mL/d and subgroup A2 2500 mL/d. We considered the AFI to compare the effectiveness of the therapy. RESULTS: General features did not reveal any significant differences between the two groups. In group A, the mean AFI ± SD at recruitment was 39.68 ± 11.11 mm; in group B, it was 126.92 ± 10.59 mm (P < .001). In group A, the mean AFI at 7 days was 77.70 ± 15.03 mm; in group B, it was unchanged. In subgroup A1, the mean AFI at birth was 86.21 ± 16.89 mm; in subgroup A2, it was 112.45 ± 14.92 mm (P < .001). CONCLUSIONS: Our data show that in pregnancies complicated by isolated oligohydramnios, hydration therapy significantly improves the quantity of amniotic fluid.

Placental mesenchymal dysplasia: can early diagnosis ensure a good materno-foetal outcome? A case report.

Placental mesenchymal dysplasia is a rare disorder characterized by an increased size placenta with cystic villi and ectasic vessels. The correct diagnosis is very important, because placental mesenchymal dysplasia is usually compatible with a normal foetal morphology and a good materno-foetal outcome. An accurate ultrasound evaluation can help in the identification of characteristic patterns associated to this trophoblastic disease, particularly to distinguish it from its main differential diagnosis, i.e. hydatidiform mole. We report an early second-trimester ultrasound diagnosis of placental mesenchymal dysplasia complicated by foetal growth restriction, but with normal female karyotype and good healthy baby.

[Rhabdomyoma of the vagina. Case report and short literature review]. / Rhabdomyome du vagin. Revue de la littérature à partir d'un cas clinique.

The differential diagnosis of vaginal polypoid masses should take rhabdomyoma into consideration even it is an extremely rare tumor. The present report describes a vaginal cystic mass located in the anterior wall of an asymptomatic, 38-year-old, Caucasian, nulliparous woman. Local excision and subsequent pathological examination were performed. The final diagnosis was vaginal rhabdomyoma. The literature is reviewed and differential diagnosis are discussed.

Cervical Mullerian adenosarcoma with heterologous sarcomatous overgrowth: a fourth case and review of literature.

BACKGROUND: Uterine sarcomas are relatively rare tumors that account for approximately 1-3% of female genital tract malignancies and between 4-9% of uterine cancers. Less than 8% of all cases are Mullerian adenosarcoma, a distinctive uterine neoplasm characterized by a benign, but occasionally atypical, epithelial and a malignant, usually low-grade, stromal component, both of which should be integral and neoplastic constituents of the tumor. Mullerian adenosarcoma with sarcomatous overgrowth (MASO) is a very aggressive variant, associated with post-operative recurrence, metastases, even when diagnosed in early stage. CASE PRESENTATION: We present a fourth MASO case derived from uterine cervix in a 72-year-old woman with metrorrhagia and a polypoid mass protruding through the cervical ostium. Total abdominal hysterectomy, bilateral salpingo-oophorectomy, systematic pelvic lymph node dissection, omental biopsy and appendectomy were performed. Surgery treatment was associated with adjuvant whole-pelvis radiation (45 Gy) and adjuvant chemotherapy (cisplatin/ifosfamide). After nine months of follow up, the patient was free of tumor. CONCLUSIONS: The rarity of MASO of the cervix involves a management difficult. Most authors recommend total abdominal hysterectomy, usually accompanied by bilateral salpingo-oophorectomy. There is no common agreement on staging by lymphadenectomy during primary surgery and adjuvant chemo-radio therapy.

Randomised prospective study of abdominal wall closure in patients with gynaecological cancer.

BACKGROUND: Median laparotomy is the most common approach to the abdominopelvic cavity in patients with gynaecological tumours. AIMS: The primary endpoint of the study was to evaluate the onset of incisional hernia. The secondary endpoint was to evaluate the onset of infection, wound dehiscence, wound infection, and scar pain during the post-operative period. METHODS: A total of 191 patients were eligible for the study. They were divided into three groups. Group A underwent en bloc closure of the peritoneum and fascia with Premilene suture, Group B en bloc closure of the peritoneum and fascia with Polydioxanone suture, and Group C separate closure of the peritoneum and fascia with single stitches of Ethibond suture. Statistical analysis was performed using the Statistical Software Package for Social Sciences 12.0. RESULTS: Group A and Group B comprised 63 patients, and Group C included 65 patients. The three groups proved homogeneous on statistical analysis (P > 0.05). The statistical analysis did not reveal significant differences between the different suture types and techniques with respect to the incidence of incisional hernia (P > 0.05). CONCLUSION: In our study, the incidence of incisional hernia was 8%. Randomised patients were homogeneous for sample size and risk factors. No significant differences were found between suture types or techniques. Currently, there is no suture material or technique that can be considered superior to others. When possible, we believe that the best way to prevent incisional hernia is to preserve the integrity of the abdominal wall using minimally invasive techniques.

A case report of Sheehan's syndrome with acute onset, hyponatremia and severe anemia.

Sheehan's syndrome is a well-known cause of panhypopituitarism secondary to pituitary apoplexy, that generally occurs after an intra- or postpartum bleeding episode characterized by severe hypertension or hemorrhagic shock. The diagnosis can be difficult and is often formulated after some years from the syndrome occurrence. We report the case of a woman with an early diagnosis of early-onset Sheehan's syndrome associated with severe hyponatremia following dystocic childbirth complicated by postpartum hemorrhage.