Operative transvaginal hydrolaparoscopy improve ovulation rate after clomiphene failure in polycystic ovary syndrome.

Aim of our study was to assess the ovulation rate, with mid-luteal progesterone level and ultrasound follicles monitoring, in PCOS CC-resistant patients undergone transvaginal hydrolaparoscopy ovarian drilling. A prospective observational study was carried out in 123 PCOS, infertile, CC-resistant patients who undergone THL ovarian drilling. Each woman was evaluated by hormonal measurement, and ultrasound evaluation during 6 months follow-up. Progesterone serum levels were assessed on days 20-24 of the cycle after surgical treatment. Pg levels >3 ng/mL were considered as ovulation. Ovulation frequency and the highest mean follicular diameters during the monitoring were recorded. 117 patients complete the study, since six patients were lost to follow-up. Mean follicular diameter during ovulation monitoring was 16.37 mm. Ovulation rate at the follow up was 64.1% one month after treatment, 79.5% after three months and 82.9% after six months. 28 patients conceived during follow-up period. Pregnancy rate was 70.1%. Our study has shown that THL ovarian drilling improves ovulation and pregnancy rate in women with CC-resistant PCOS. We believe that this approach should be offered as second-line therapy at all PCOS CC-resistant women who fail the medical methods of ovulation induction.

Serum anti-Mullerian hormone levels after ovarian drilling for the second-line treatment of polycystic ovary syndrome: a pilot-randomized study comparing laparoscopy and transvaginal hydrolaparoscopy.

Aim of the study was to asses and compare serum anti-Mullerian harmone (AMH) levels after laparoscopic ovarian drilling (LOD) and transvaginal hydrolaparoscopy (THL) ovarian drilling in clomifene citrate (CC)-resistant polycystic ovary syndrome (PCOS) patients; secondary outcome was to evaluate postoperative pain to estimate the acceptability of procedures. A total of 246 patients with CC-resistant PCOS were randomized into two groups: 123 underwent LOD and 123 underwent THL ovarian drilling. AMH serum levels were evaluated before and after the procedure; moreover, women were asked to rate pain on a visual analog scale (VAS) from 0 (no pain, perfectly acceptable) to 10 (unbearable pain, completely unacceptable). In both groups, postoperative serum AMH levels were significantly reduced compared to preoperative levels (6.06 ± 1.18 and 5.84 ± 1.16 versus 5.00 ± 1.29 and 4.83 ± 1.10; p < 0.0001). Comparing postoperative serum AMH levels, no statistically significant difference was observed between the two surgical technique. After the procedure, mean pain VAS score was significantly higher for women who underwent LOD ovarian drilling in comparison to THL (3.26 ± 1.1 versus 1.11 ± 0.5; p < 0.0001). In conclusion, THL ovarian drilling is comparable to the LOD in terms of reduction in AMH, but it is preferred by patients in terms of acceptability. These results could support to use of THL ovarian drilling in the treatment of patients with CC- resistant PCOS.

Impact of transvaginal hydrolaparoscopy ovarian drilling on ovarian stromal blood flow and ovarian volume in clomiphene citrate-resistant PCOS patients: a case-control study.

Polycystic ovarian syndrome (PCOS) is the most common endocrine disorder in gynecology. In PCOS patients vascularization parameters are altered. Transvaginal hydrolaparoscopy (THL) is a mini-invasive approach for ovarian drilling in PCOS patients. In this study, we assessed the effect of ovarian drilling using THL on ovarian volume (OV) and vascularization index (VI) using 3D power Doppler ultrasonography in CC-resistant PCOS patients. A case-control study on 123 CC-resistant PCOS women who underwent THL ovarian drilling was performed. Patients underwent 3D ultrasound and power Doppler to measure VI, flow index (FI), vascularization flow index (VFI) and to evaluate OV before and after the procedure, at six months, and on the early follicular phase of the menstrual cycle. After THL ovarian drilling, OV and power Doppler flow indices were significantly reduced compared to pre-operative values (OV: 7.85 versus 11.72 cm3, p < 0.01; VI: 2.50 versus 4.81, p < 0.01; VFI: 1.10 versus 2.16, p < 0.01; FI: 32.05 versus 35.37, p < 0.01). In conclusion, THL ovarian drilling seems to reduce OV and 3D power Doppler indices, and could therefore be a viable alternative to LOD in PCOS patients resistant to medical therapy.

"In patient" medical abortion versus surgical abortion: patient's satisfaction.

OBJECTIVE: To compare patients' satisfaction with medical and surgical abortion, implementing the Italian guidelines on medical abortion entailing an "in patient" procedure. METHODS: A total of 1832 pregnant chose between surgical (vacuum aspiration) or medical abortion (mifepristone p.o. followed after 3 days by sublingual misoprostol) and expressed their expected satisfaction on a visual analog scale (VAS). A total of 885 women chose surgical and 947 medical abortion. The primary end-point was satisfaction VAS score 20 days after the procedure. Secondary end-points were: difference between pre- and post-abortion VAS score; difference in satisfaction VAS scores according to parity and previous abortion; incidence of side effects. RESULTS: VAS score was high in each group but significantly higher for the 1-day surgical than for the 3-day medical abortion procedure (7.9 ± 1.0 versus 7.2 ± 1.2; p < 0.0001). In the surgical group the VAS score increased after the treatment (6.9 ± 1.6 versus 7.9 ± 1.0, p < 0.0001), while it decreased in the medical group (7.5 ± 1.0 versus 7.2 ± 1.2; p < 0.0001). Multiparous women reported higher satisfaction with medical abortion; women with a previous abortion preferred surgical abortion. CONCLUSIONS: Both procedures are considered satisfactory by the patients. Performing medical abortion as a 3-day "in patient" procedure, decreased women's satisfaction scores from their baseline expectations.

The Challenging Intrauterine Contraceptive: In-office Hysteroscopic Approach.

STUDY OBJECT: To describe 3 cases of misplaced or retained Intrauterine Contraceptive (IUC) that were successfully resolved by hysteroscopy performed in an ambulatory setting using miniaturized electrosurgical and mechanical operative instruments. DESIGN: Step-by-step description of the technique using slides, pictures, and video (educative video) (Canadian Task Force classification III). SETTING: Misplaced or retained IUC may be related to several causes; incorrect insertion is the leading cause. In these cases, patients may complain of abnormal bleeding, pelvic pain, or pregnancy or they may remain asymptomatic. When a displaced IUC is suspected, transvaginal ultrasonography is the primary investigation followed by radiography in cases in which the IUC is not seen within the uterus. Additional imaging such as computed tomographic scanning or magnetic resonance imaging may be needed. Hysteroscopy represents the gold standard for diagnostic clarification and management of a dislocated or embedded IUC. INTERVENTIONS: The hysteroscopic approach of the 3 cases was the following: removal of a partially perforating IUD in the cesarean scar pouch, repositioning of a dislocated IUS in the isthmocele, and removal of an embedded IUS in the cornual area. The procedures were performed in an ambulatory setting using a 5-mm continuous flow hysteroscope and vaginoscopic approach without any analgesia and/or anesthesia. The alternate use of mechanical and electrosurgical 5F instruments allowed us to separate the IUC from the myometrial uterine wall, respecting the healthy myometrium and without causing significant patient discomfort or complications. CONCLUSION: The possibility of using miniaturized electrosurgical and mechanical instruments with small-diameter hysteroscopes offers the possibility of an effective, safe, cost-efficient, and well-tolerated removal or repositioning of a misplaced or retained IUC. This minimally invasive approach can be performed in an office setting to avoid more invasive and traumatic approaches.

An Exceptional Case of Complete Septate Uterus With Unilateral Cervical Aplasia (Class U2bC3V0/ESHRE/ESGE Classification) and Isolated Mullerian Remnants: Combined Hysteroscopic and Laparoscopic Treatment.

STUDY OBJECTIVE: To report the combined hysteroscopic and laparoscopic treatment of a complete septate uterus with unilateral cervical aplasia (class U2bC3V0/ESHRE/ESGE classification) and isolated mullerian remnants. DESIGN: Step-by-step presentation of the surgical treatment (Canadian Task Force classification 4). SETTING: Complete septate uterus with unilateral cervical aplasia (formally Robert's uterus) is characterized by the presence of a uterine septum completely dividing the endometrial cavity into an obstructed hemicavity and a contralateral nonobstructing hemicavity connected normally to the existing cervix. It has always been described as isolated without any associated anomaly. PATIENT: A 30-year-old woman was referred to our department for dysmenorrhea and primary infertility. Hysterosalpingography showed the presence of a right (RT) hemiuterus with a patent fallopian tube; further evaluation with 2- and 3-dimensional ultrasound and magnetic resonance imaging showed an externally normal-appearing uterus, a right normal hemicavity connected normally with the existed cervix and, a left hemicavity fully divided from the right one by a complete septum and not connected with the cervix. Interestingly, a peculiar complex mass with cystic areas, attached posterolaterally from the left side to the uterine wall at the level of the isthmus and the upper cervix, was also diagnosed. INTERVENTIONS: The study protocol was approved by our local institutional review board. During outpatient hysteroscopy, a right uterine hemicavity with a single ostium was identified without any communication with the left hemicavity. The patient was then scheduled for combined laparoscopic and hysteroscopic treatment. During laparoscopy, a normal uterine body with multiple myomas and a pseudocystic lesion attached posteriorly and left laterally to the uterus at the level of the isthmus and the upper cervix were shown; no communication between the cystic part of that lesion and the isthmus or the cervicovaginal canal was observed. During hysteroscopy, a longitudinal incision of the septum with a 5F bipolar electrode was performed; the left hemicavity was opened, and the corresponding tubal ostium was identified. The pseudocystic lesion was then excised after opening and sent for pathological analysis; the defect was closed with interrupted intracorporeal knots. MEASUREMENTS AND MAIN RESULTS: A single normal endometrial cavity with both tubal ostia was obtained, thus restoring obstruction by unification of the uterine cavity. A histologic report of the removed pseudocystic lesion was compatible with the diagnosis of mullerian remnants. A follow-up hysteroscopy 3 months after showed a normal uterine cavity without postsurgical adhesions. CONCLUSION: The use of 3-dimensional ultrasound and magnetic resonance imaging in combination with the new ESHRE/ESGE classification system gives the opportunity to obtain a precise representation of the female genital anatomy even in the presence of complex anomalies. Although a septate uterus with unilateral cervical aplasia has been already described, the presence of mullerian remnants is a rare entity associated with cyclic pelvic pain, thus needing adequate recognition and treatment. The combined hysteroscopic and laparoscopic approach offers a unique opportunity for the treatment of complex anomalies.

Accuracy of Hysteroscopic Metroplasty With the Combination of Presurgical 3-Dimensional Ultrasonography and a Novel Graduated Intrauterine Palpator: A Randomized Controlled Trial.

UNLABELLED: STUDY OBJECTIVE: To assess whether the use of a novel graduated intrauterine palpator can improve the accuracy of hysteroscopic metroplasty, introducing objective intraoperative criteria. DESIGN: A prospective randomized study (Canadian Task Force I, evidence obtained from a properly design, randomized, controlled trial). SETTING: University Federico II hysteroscopic clinic. PATIENTS: Ninety women with a uterine septum diagnosed during office hysteroscopy and 3-dimesional transvaginal ultrasound (3D-TVS) were randomized into 2 groups: group T (metroplasty with intrauterine palpator) (n = 45) and group C (metroplasty without intrauterine palpator) (n = 45). INTERVENTIONS: Outpatient hysteroscopic metroplasty under conscious sedation using a 5-mm hysteroscope and miniaturized 5F instruments including a bipolar electrode for the removal of three quarters of the septum, blunt scissors to refine the base of the septum, and an intrauterine palpator to measure the portion of the removed septum (only group T). 3D-TVS and second-look hysteroscopy were used to identify the number of optimal (residual septum <5 mm), suboptimal (residual septum 5-10 mm), and incomplete resections (residual septum >10 mm). In group T, metroplasty was stopped when the intrauterine palpator showed that the resected septum corresponded to presurgical ultrasonographic measurements in order to obtain a fundal notch of 1.0 cm. In group C, metroplasty was interrupted once the tubal ostia were clearly visible on the same line and/or hemorrhage from small myometrial vessels of the fundus was observed. MEASUREMENTS AND MAIN RESULTS: No differences were observed in baseline characteristics between the 2 groups. The proportion of patients with complete septum resection was significantly higher in group T (71.5% vs 41%, χ(2): p = .006; relative risk: 1.684; 95% confidence interval, 1.116-2.506). Suboptimal resection was achieved in 13 cases (28.5%) in group T and 14 cases (20%) in group C, whereas incomplete resection was observed in only 12 patients in group C (27%). CONCLUSION: Presurgical evaluation with 3D-TVS together with the use of a graduate intrauterine palpator improves the accuracy of hysteroscopic metroplasty, allowing complete removal of a uterine septum in 1 surgical step.

Post-operative ovarian adhesion formation after ovarian drilling: a randomized study comparing conventional laparoscopy and transvaginal hydrolaparoscopy.

PURPOSE: To compare conventional laparoscopic ovarian drilling (LOD) with transvaginal hydrolaparoscopy (THL) ovarian drilling in terms of ovarian adhesion formation, evaluated using office THL during follow-up in CC-resistant anovulatory patients affected by PCOS. METHODS: Prospective randomized study on 246 CC-resistant women with PCOS. The patients enrolled were divided into two groups, 123 were scheduled to undergo LOD and 123 to undergo THL ovarian drilling. Six months after the procedure all patients were offered office transvaginal hydrolaparoscopy (THL) follow-up, under local anesthesia to evaluate adhesion formation. RESULTS: Duration of the procedure was significantly shorter in the THL group in comparison with LOD group (p < 0.0001). No intra- or post-operative complication was observed in any of the patients in both groups. Post-operative THL follow-up after 6 months showed that 15 (15.5 %) patients in the THL group and 73 (70.2 %) in the LOD group showed the presence of ovarian adhesion. This difference was highly significant with a p value <0.0001 and a relative risk of 0.22 [95 % IC 0.133-0.350]. CONCLUSION: This study seems to indicate that THL ovarian drilling may reduce the risk of ovarian adhesion formation and could be used as a safe and effective option to reduce ovarian adhesion formation in patients undergoing ovarian drilling.

Medium-term and long-term outcomes following placement of midurethral slings for stress urinary incontinence: a systematic review and metaanalysis.

INTRODUCTION AND HYPOTHESIS: Questions regarding the long-term efficacy and safety of midurethral slings (MUS) are still unresolved, notwithstanding the widespread use of these procedures. The objective of this review was to evaluate the long-term outcomes of retropubic MUS (RP-MUS) procedures and the medium-term outcomes of transobturator MUS (TO-MUS) procedures. METHODS: MEDLINE, EMBASE, NLH, ClinicalTrials.gov, and Google Scholar databases were searched up to June 2014 with restriction to English language and using the search terms: "stress urinary incontinence", "midurethral sling", "tension-free tape", "transobturator tape", and "follow-up". Studies with a follow-up of 36 months for TO-MUS and 60 months for RP-MUS were searched. Only studies comparing a RP-MUS or TO-MUS with another synthetic sling were included. Data from 49 studies were included. Data were expressed as odds ratios (OR) with 95 % confidence intervals (CI) and combined using the Mantel-Haenszel fixed effects model. Differences in the proportions were evaluated using the chi-squared test. RESULTS: RP-MUS had similar objective cure rates (OR 1.15, 95 % CI 0.75 - 1.76) but higher subjective cure rates than TO-MUS (OR 1.76, 95 % CI 1.08 - 2.86). No differences were observed between outside-in (TOT) and inside-out (TVT-O) and between TO-MUS and minisling. Bladder injuries were more frequent (OR 7.01, 95 % CI 2.94 - 17.90) and vaginal erosions were less frequent for RP-MUS (OR 0.24, 95 % CI 0.07 - 0.84). Vaginal injuries were more common with TOT than with TVT-O (OR 7.96, 95 % CI 1.15 - 157.9). Pain-related complications were more common with TO-MUS than with minimally invasive tapes (OR 8.75; 95 % CI 9.02 - 57.90). CONCLUSIONS: MUS have similar objective cure rates in the long term and medium term. TO-MUS is associated with a lower subjective cure rate than RP-MUS.

Bleeding profile in users of an etonogestrel sub-dermal implant: effects of anthropometric variables. An observational uncontrolled preliminary study in Italian population.

PURPOSE: The purpose of this study is to evaluate the menstrual profile in users of the etonogestrel (ENG)-releasing implant (Nexplanon®) and the possible correlation with anthropometric variables. METHODS: Ninety-two healthy women, desiring long-term contraception with the ENG implant were enrolled in a prospective observational study. Anthropometric variables were measured at baseline and after 3, 6, 9, and 12 months. Patients recorded daily the occurrence of any bleeding or spotting. The bleeding/spotting pattern was evaluated over consecutive 90-day intervals ("Reference Periods" - RPs). Patients who showed a favourable bleeding profile (amenorrhoea, infrequent, or normal bleeding) for 50% or more of the RPs were assigned to group A, while patients with a favourable bleeding profile for less than 50% of the RPs were assigned to group B. RESULTS: Sixty-eight women (79%) were assigned to group A; 18 (21%) to group B. Group B had a lower baseline body mass index (BMI) than group A (24.84 ± 4.95 kg/m(2) versus 20.75 ± 4.41 kg/m(2); p < 0.005). CONCLUSIONS: The ENG sub-dermal implant is a well-tolerated contraceptive method, with a high proportion of women experiencing a favourable bleeding profile. The lower basal BMI in Group B in comparison with Group A may account for the higher percentage of irregular bleeding.

Ultrasound assessment of the Essure contraceptive devices: is three-dimensional ultrasound really needed?

STUDY OBJECTIVE: To evaluate the feasibility of 3-dimensional ultrasound (3DUS) for sonographic localization of Essure microinserts, comparing it with 2-dimensional ultrasound (2DUS) insofar as time to visualize the inserts and accuracy in determining their localization. DESIGN: Prospective study (Canadian Task Force classification II-2). SETTING: University clinic. PATIENTS: Twenty-seven consecutive women undergoing hysteroscopic Essure device placement. INTERVENTIONS: Essure microinserts were inserted in the outpatient hysteroscopy clinic following the manufacturer's recommendations, leaving from 3 to 8 loops of the inserts in the uterine cavity. In all patients, 2DUS and 3DUS were performed 3 months after the procedure. 2DUS was performed first; the device(s) were located, and their position was recorded. Then 3DUS scans were acquired, trying when possible to have both devices at least at a 45-degree angle with the insonation beam for optimal rendering on 3DUS. The OmniView method with volume contrast imaging was used to show the relationships of the microinserts within the uterine cavity when possible. To define the position of the Essure device in relation to the uterus and the salpinges, we used the classification developed by Legendre and colleagues. After sonographic evaluation all women underwent hysterosalpingography to assess the success of sterilization. MEASUREMENTS AND MAIN RESULTS: Hysteroscopic insertion was successful in all patients, with 2 Essure devices placed in 25 patients and 1 device in 2 patients (due to previous salpingectomy performed because of ectopic pregnancy), for a total of 52 devices. One spontaneous late (within 3 months) expulsion of the device occurred; the device had migrated almost completely into the uterine cavity. At 3-month follow-up, all 51 correctly placed devices were easily observed at 2DUS (mean [SD] duration of the procedure, 2.25 [0.8] minutes). At 3DUS in 51 cases, the device was in perfect position (1+2+3) in 21 (41.2%), in position 2+3 in 14 (27.4%), and in position +3 in 16 (31.4%). Both microinserts were observed on 3DUS reconstructed images in 31 of 35 (88.6%) 1+2+3 and 2+3 cases. However, in the 16 cases in which the devices were in position +3 (salpinx only), a single 3D sweep failed to demonstrate both devices in 10 of 16 cases (62.5%), due to substantially different angles of orientation of the inserts. This was because if 1 of the 2 devices was placed at a <30-degree angle with the insonation beam, its identification along the uterine wall was questionable because of concurrent hyperechogenicity of the bowel loops and poor visualization. Time for performance of 3DUS was 14.4 [4.8] minutes. Hysterosalpingography was performed in all patients, and confirmed tubal occlusion in all but 1 case. CONCLUSIONS: On the basis of a limited number of patients, 2DUS is more time-efficient and equivalent to 3DUS in locating Essure contraceptive microinserts. These results should be considered when planning sonographic follow-up of patients with Essure devices.

Cold loops applied to bipolar resectoscope: A safe "one-step" myomectomy for treatment of submucosal myomas with intramural development.

AIM: To assess the safety and efficacy of cold loop myomectomy applied to bipolar resectoscope to perform "one-step" myomectomy of submucosal myomas with intramural involvement. METHODS: Seventy-two patients with at least one symptomatic G1 or G2 myoma (Wamsteker's classification) underwent cold loop myomectomy from January 2011 to January 2013. All surgical procedures were performed using a 26Fr resectoscope and bipolar energy source. At one month after the procedure, all patients underwent an office hysteroscopy check-up. A subgroup of seven infertile patients underwent an office hysteroscopy every two-weeks to evaluate recovery time of the myometrial fovea. RESULTS: Resectoscopic myomectomies were successfully performed in one surgical step in 70 out of 72 patients without any significant complications. Overall, the mean diameter of resected myomas was 32.2 ± 9 mm. Median operative time was 34.2 ± 24.1 min. Median fluid deficit was 761.22 ± 480.34 ml. The fovea was almost completely restored (>80%) six weeks after surgery in six of the seven infertile patients who underwent repeated follow-up office hysteroscopies every two weeks. CONCLUSIONS: Data from the present study show that the use of cold loops applied to bipolar resectoscope represent an effective, safe technique for "one-step" myomectomy of G1-G2 myomas, allowing rapid recovery of the myometrial fovea.

In-office transvaginal hydrolaparoscopy: a step-by-step, intraoperative pain evaluation.

PURPOSE: Transvaginal hydrolaparoscopy (THL) is a mini-invasive technique, which allows exploration of the posterior pelvis. THL can be carried out as an office procedure and may replace hysterosalpingography and laparoscopy for the diagnosis of infertility. The aim of this study was to assess pain level during each step of THL. METHODS: Forty infertile women underwent office THL with local anesthesia and had to score pain on a Likert scale (0-no pain, 5-maximum pain) during five stages of THL: stage 1, introduction of the intrauterine catheter; stage 2, introduction of the Veress needle in the Douglas pouch; stage 3, introduction of the trocar in the pelvis; stage 4, exploration of pelvic organs; stage 5, chromosalpingoscopy. At the end of the study, patients scored their overall satisfaction on a VAS scale (0-not satisfied at all; 10-completely satisfied). RESULTS: Stage 5 was associated with the highest pain score in comparison with stages 1-4 (p < 0.001), while pain score during stage 4 was significantly higher in comparison with stages 1-3 (p = 0.001). CONCLUSIONS: Office THL seems to be well tolerated by patients. Chromosalpingoscopy was the least tolerated stage but it does not adversely impact on the procedure, which can be adequately accomplished by performing proper counseling.

Effects of estradiol valerate and dienogest on quality of life and sexual function according to age.

This is an observational study on 102 women aged 25-45 years to evaluate if the E2V/DNG pill has any impact on quality of life (QoL) and sexual function (FSF). Thirty-nine women were younger than 35 years (group A), and 63 women were 35 years old or older (group B). At baseline and after 6 months, patients received the Italian validated version of the Short Form-36 questionnaire and the Italian validated version of the Female Sexual Function Index questionnaire. Group A showed an overall higher perception in all QoL scores at baseline and after 6-months (p < 0.05). E2V/DNG treatment did not exert any significant effect on QoL perception in group A apart from an increase in the GH domain (general health). In group B we observed a significant improvement both in GH and in VT (vitality) scores. We found a significant reduction in "lubrication" after 6 months both in group A and B (p < 0.01) and a significant improvement in "satisfaction" and "pain" scores in group A and in "desire", "satisfaction" and "total" score in group B (p < 0.01). The E2V/DNG pill is associated with a significant improvement of GH and VT and with an improvement in FSF with no difference between age groups.

Effects of a prolonged, 72 hours, interval between mifepristone and gemeprost in second trimester termination of pregnancy: a retrospective analysis.

OBJECTIVE: To evaluate if the 72 hours interval between mifepristone and gemeprost has a similar efficacy compared to the 48 hours interval for second trimester termination of pregnancy STUDY DESIGN: Two-hundred and fifteen consecutive pregnant women, admitted to our hospital, for second trimester TOP, were included in this retrospective analysis. Standard protocol was followed for all patients. On the first day of the procedure oral mifepristone 200 mg was administered. After 72 (group A, n = 78) or 48 hours (group B, n = 113) women were admitted for administration of gemeprost 1 mg pessary as per protocol. The induction to abortion time was defined as the interval between the insertion of the first gemeprost pessary and the expulsion of the fetus. RESULTS: There are no significant differences in the number of pessaries in the two groups. The induction to abortion interval was longer in group A than in group B. Twenty-one women required surgical evacuation of the uterus for retained placenta or incomplete abortion without difference between groups. CONCLUSION: A 48-hours interval between mifepristone and gemeprost leads to better results than a 72-hours interval, with a shorter abortion length and represents the elective method for second trimester TOP.

Impact of an implantable steroid contraceptive (etonogestrel-releasing implant) on quality of life and sexual function: a preliminary study.

The aim of the study was to determine the impact of etonogestrel (ENG)-implant used for contraceptive purpose on Quality of life (QoL) and on sexual function (FSF) of healthy Italian women. The Female Sexual Function Index (FSFI) questionnaire and the Short Form-36 (SF-36) validated questionnaire were administered at baseline, 3 and 6 months after insertion of Nexplanon. The implant seems to have a positive impact on QoL after the first three months of therapy. Users showed an improved general health status and physical role status. The implant did not show negative effects on libido and on sexual function. In the first three months of treatment, users experienced a temporary reduction of vitality, mental health, social functioning and emotional role functioning, which seem to disappear after six months of therapy.

Effect of local infiltration analgesia on post-operative pain following TVT-O: a double-blind, placebo-controlled randomized study.

PURPOSE: To evaluate the effect of a protocol of local anesthesia and epinephrine associated with sedo-analgesia on post-TVT-O pain in comparison with infiltration of saline and epinephrine. METHODS: Forty-two patients undergoing TVT-O were randomized into two groups to receive periurethral infiltration with epinephrine only (group A, n = 21) or with epinephrine plus 1 % lidocaine hydrochloride (group B, n = 21). Post-operative pain was assessed using a visual analog scale (VAS) from 0 (absence of pain) to 10 (maximum pain possible), 1, 6, 12 and 24 h after the procedure. The total amount of analgesia was recorded and the proportion of women reporting a pain VAS score ≥4, 1 h after the procedure was calculated. ANOVA for repeated measures and Bonferroni correction, the Student's t test for independent samples, the Mann-Whitney U test, the Fisher exact test, or the χ (2) test for parametric was used. RESULTS: Pain level was significantly lower in group B 1 (p = 0.01) and 6 h (p = 0.05) after surgery, but not 12 and 24 h after the procedure. No significant difference was observed in the proportion of women requesting analgesia and in the total dosage of analgesics between the two groups. A significant higher proportion of women in group A reported a pain VAS score higher than four 1 h after surgery in comparison with patients in group B. CONCLUSIONS: This randomized study seems to indicate that systematic infiltration before TVT-O positioning with local anesthetic may reduce immediate post-operative pain.

The role of a personalized dietary intervention in managing gestational weight gain: a prospective, controlled study in a low-risk antenatal population.

PURPOSE: To compare the efficacy of a personal dietary intervention on gestational weight gain control with a general intervention promoting healthy eating. METHODS: Prospective, controlled study including 154 low-risk pregnant women randomly allocated to two groups: 77 receiving a personalized diet plan and a close follow-up by a dietician (intervention group), 77 receiving standard dietary care by means of a brochure on healthy eating during pregnancy (control group). Pre-pregnancy weight, gestational age, height, weight and BMI at baseline, weight at term, gestational age at delivery and newborn weight were recorded for all participants. The primary end-point was the difference in body weight between baseline and term. Secondary end-points were the difference in body weight between pre-pregnancy and term and in newborn weights. RESULTS: Maternal weight gain at term was significantly lower both as compared to pre-pregnancy weight (8.2 ± 4.0 vs. 13.4 ± 4.2 kg; p < 0.001) and to weight at baseline (7.7 ± 3.8 vs. 13.7 ± 4.3 kg; p < 0.001) in the intervention group as compared to controls. A positive, significant correlation between the delta weight between baseline and term and newborn weight was observed in both groups, but stronger in patients from the intervention group (intervention group R = 0.76, p < 0.001; control group R = 0.35, p = 0.01). CONCLUSIONS: This study suggests that a personalized nutritional intervention, in which the dietician plays an active role within the obstetric team, may represent a successful approach in limiting weight gain in pregnant women.

Cervico-isthmic pregnancy successfully treated with bipolar resection following methotrexate administration: case report and literature review.

Cervico-isthmic pregnancy is a rare form of ectopic pregnancy associated with a high morbidity and mortality rate. Recent advances in high-resolution ultrasound have made the diagnosis of early cervico-isthmic pregnancies easier. Early diagnosis allows a more conservative therapeutic approach that avoids hysterectomy and preserves fertility. Here is reported a case of viable cervico-isthmic pregnancy successfully treated with resectoscopy after failed systemic and local (hysteroscopic) methotrexate administration. The resectoscopic excision of the cervico-isthmic pregnancy was carried out with the technique of slicing, using a 27 bipolar resectoscope with a 4-mm loop. The procedure was successful with the complete removal of the ectopic pregnancy, while maintaining satisfactory haemostasis. A literature review shows that no consensus exists for the treatment of cervico-isthmic pregnancies. We report a case of viable cervico-isthmic pregnancy successfully treated with resectoscopy after failed systemic and local (hysteroscopical) methotrexate administration. The resectoscopic excision of cervico-isthmic pregnancy was carried out with the technique of slicing, using a 27 bipolar resectoscope with a 4-mm loop. The procedure was successful with the complete removal of the ectopic pregnancy, while maintaining satisfactory haemostasis.

Effects of an oral contraceptive containing estradiol valerate and dienogest on circulating androgen levels and acne in young patients with PCOS: an observational preliminary study.

This study shows the effect of a 1 year treatment with an estradiol valerate/dienogest pill in 36 women suffering from polycystic ovaries and mild or moderate acne. At beginning of the study, 24 patients (66.7%) had grade 1-2 (mild) acne and 12 patients (33.3%) had grade 3 (moderate) acne. After 12 cycles of therapy, we found an improvement of acne in 19 (52.8%) patients and a worsening of acne in 3 (8.4%) patients. The percentage of patients recovered was statistically significant (p < 0.01). SHBG levels were significantly higher after 6 and 12 months of therapy (p < 0.001), while total testosterone levels were lower in all patients at 6 and 12 months although this trend did not reach statistical significance. In conclusion, the present study suggests that the E2V/DNG pill could exert a positive influence on acne and hyperandrogenism. Since this is an observational study on a very limited population number, additional randomized controlled studies on larger populations are needed also to determine the effects of this contraceptive over longer periods of use.