Clinical relevance of diagnostic hysteroscopy with concurrent endometrial biopsy in the accurate assessment of intrauterine alterations.

PURPOSE: The aim of this retrospective observational study was to evaluate the reliability of diagnostic hysteroscopy, routinely performed along with endometrial biopsy, by analyzing and comparing both hysteroscopic and histopathological outcomes in asymptomatic infertile patients, previously to their IVF cycle. METHODS: The study included 84 consecutive infertile patients who underwent diagnostic hysteroscopy followed by endometrial biopsy. Four-micrometer sections were stained with hematoxylin and eosin and examined microscopically. The data evaluated the frequency and characteristics of endometrial abnormalities found in the biopsies of patients with normal hysteroscopy outcome. Descriptive data are presented as percentages, and the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of hysteroscopy for diagnosis of endometrial alterations were calculated on the basis of pathologic reports. RESULTS: The hysteroscopy evaluation showed 50.0 % of patients with a normal uterine cavity, 40.5 % with endometrial polyps, 6.0 % with endometrial hyperemia, and 3.5 % with other endometrial abnormalities. Among the 42 patients with a normal uterine cavity at hysteroscopic examination, 60.0 % also had a normal biopsy outcome, but in other 40.0 % of patients at least one histopathological abnormal aspect was diagnosed at biopsy. The sensitivity (67.3 %), specificity (80.6 %), PPV (85.4 %) and NPV (59.5 %) of diagnostic hysteroscopy were calculated on the basis of histopathological findings. CONCLUSIONS: Our results show that diagnostic hysteroscopy demonstrated intrauterine alterations in half of infertile patients; histopathological endometrial alterations suggest high rate of false-negative outcomes. Therefore, diagnostic hysteroscopy and concurrent endometrial biopsy should be used as complementary diagnostic and therapeutic approach, especially for patients with previous IVF failures.

Prophylactic low-molecular-weight heparin in women with thrombophilia undergoing in vitro fertilization.

OBJECTIVE: To verify whether low-molecular-weight heparin (LMWH) could increase pregnancy rates and/or decrease abortion rates in women with thrombophilia undergoing assisted reproduction cycles. METHODS: Cross-sectional study with patients undergoing in vitro fertilization (IVF) (N = 104). Women without thrombophilia (control group, n = 20), women with thrombophilia who did not receive LMWH (untreated group, n = 30), and women with thrombophilia, treated with daily enoxaparin from the day of embryo transfer until week 36 of gestation (treated group, n = 54). All women underwent controlled ovarian hyperstimulation. IVF was performed by intracytoplasmic sperm injection, and embryos were transferred on day 3. Pregnancy was detected by ß-human chorionic gonadotropin (biochemical pregnancy) and fetal heartbeat at week 5 to 6. Ongoing pregnancy was determined by ultrasound on week 12. RESULTS: Patients in the untreated thrombophilia group presented with significantly lower ongoing pregnancy rates and live birth rates and significantly higher early pregnancy loss and abortion rates when compared with the control and the treated thrombophilia groups. CONCLUSIONS: In women with diagnosed coagulation disorders, use of LMWH is important to avoid miscarriages.

Melatonin improves fertilization rate in assisted reproduction: Systematic review and meta-analysis.

BACKGROUND: Melatonin is a hormone produced by the pineal gland and it has antioxidant properties. AIM: This study aimed to evaluate the effects of melatonin on assisted reproductive technologies through a systematic review and a meta-analysis. MATERIALS AND METHODS: Search strategies were used in PubMed and in other databases covering the last 15 years. After screening for eligibility, 17 articles were selected for the systematic review. For the meta-analysis statistics, two groups were formed, the treatment group (with melatonin) and the control group (without melatonin) for various assisted reproduction outcomes. RESULTS: The main results were that no statistical differences were found concerning the clinical pregnancy outcome (p = 0.64), but there was a statistical difference with respect to Mature Oocytes (MII) (p = 0.001), antral follicle count (p = 0.0002), and the fertilization rate (p ≤ 0.0001). CONCLUSIONS: Melatonin had beneficial effects such as the improvement in the fertilization rate, although the authors did not obtain significance in the clinical pregnancy rate.

Is the length of time between endometrial scratching and embryo transfer important for pregnancy success? An observational study.

OBJECTIVE: This study sought to evaluate the influence of time (early <90 days and late >90 days) and endometrial injury on pregnancy success. METHODS: This is a retrospective study in which all infertile women who underwent at least one in vitro fertilization cycle at Clinica Gera between 2010 and 2015 were considered for inclusion. We included patients with a normal ovarian reserve and regular menses at intervals of up to 30 days. A total of 315 patient files were reviewed, and the study group was composed of patients who faced fertility issues and had male-caused infertility or idiopathic infertility. Also, women with male or unknown cause of infertility who have performed endometrial biopsy and have undergone embryo transfer up to 180 days after this procedure between 2010 and 2015 were included. The patients were divided into two groups according to the interval between biopsy and embryo transfer: group 1 (early-an interval of <90 days) and group 2 (late-an interval of >90 days and up to 180 days). RESULTS: The results were superior for the group with an interval of less than 90 days relative to the group with an interval of more than 90 days (p<0.04). The pregnancy rates for group 1 and group 2 were 58.5% and 43.4%, respectively. The odds ratio for pregnancy success was 1.63 (95% confidence interval: 1.04 to 2.55). CONCLUSION: The early transfer of embryos (<90 days) may produce better results with a high rate of pregnancy. Further studies are necessary to identify the mechanism involved in this phenomenon.

Increased prevalence of endocervical Mycoplasma and Ureaplasma colonization in infertile women with tubal factor.

OBJECTIVE: Most women suffering from tubal factor infertility do not have a history of pelvic inflammatory disease, but rather have asymptomatic upper genital tract infection. Investigating the impacts of such infections, even in the absence of clinically confirmed pelvic inflammatory disease, is critical to understanding the tubal factor of infertility. The aim of this study was to investigate whether the presence of endocervical bacteria is associated with tubal factors in women screened for infertility. METHODS: This retrospective cross-sectional study involved 245 women undergoing hysterosalpingography (HSG), screened for endocervical colonization by Chlamydia trachomatis, Neisseria gonorrhea, Ureaplasma urealyticum and Mycoplasma hominis, as part of a routine female infertility investigation between 2016 and 2017. RESULTS: endocervical bacterial colonization by Chlamydia trachomatis, Ureaplasma urealiticum, Mycoplasma hominis and other bacteria corresponded to 3.7%, 9.0%; 5.7% and 9.8%, respectively. There was no colonization by Neisseria gonorrhea. The prevalence of tubal factor was significantly higher in patients with positive endocervical bacteria colonization, regardless of bacterial species. When evaluating bacteria species individually, the women who were positive for endocervical Mycoplasma hominis had significantly higher rates of tubal factor. Associations between endocervical bacterial colonization and tubal factor infertility were confirmed by multiple regression analysis adjusted for age and duration of infertility. CONCLUSION: Besides the higher prevalence of Mycoplasma and Ureaplasma infectious agents, the findings of this study suggest the possible association of endocervical bacterial colonization - not only Chlamydia trachomatis and Neisseria gonorrhea, but also Mycoplasma species with tubal performance.

Is the length of time between endometrial scratching and embryo transfer important for pregnancy success? An observational study

SUMMARY OBJECTIVE: This study sought to evaluate the influence of time (early <90 days and late >90 days) and endometrial injury on pregnancy success. METHODS: This is a retrospective study in which all infertile women who underwent at least one in vitro fertilization cycle at Clinica Gera between 2010 and 2015 were considered for inclusion. We included patients with a normal ovarian reserve and regular menses at intervals of up to 30 days. A total of 315 patient files were reviewed, and the study group was composed of patients who faced fertility issues and had male-caused infertility or idiopathic infertility. Also, women with male or unknown cause of infertility who have performed endometrial biopsy and have undergone embryo transfer up to 180 days after this procedure between 2010 and 2015 were included. The patients were divided into two groups according to the interval between biopsy and embryo transfer: group 1 (early—an interval of <90 days) and group 2 (late—an interval of >90 days and up to 180 days). RESULTS: The results were superior for the group with an interval of less than 90 days relative to the group with an interval of more than 90 days (p<0.04). The pregnancy rates for group 1 and group 2 were 58.5% and 43.4%, respectively. The odds ratio for pregnancy success was 1.63 (95% confidence interval: 1.04 to 2.55). CONCLUSION: The early transfer of embryos (<90 days) may produce better results with a high rate of pregnancy. Further studies are necessary to identify the mechanism involved in this phenomenon.

Estimulação ovariana em usuárias do sistema intrauterino liberador de levonorgestrel para preservação de fertilidade / Ovarian stimulation in users of the levonorgestrel releasing intrauterine system for fertility preservation

O objetivo deste estudo foi buscar evidências sobre a interferência do uso do SIU-LNG em mulheres submetidas a ciclos de hiperestimulação ovariana para preservação de fertilidade. Através de uma revisão integrativa, com busca nas bases de dados Lilacs, Pubmed e Cochrane, utilizamos algumas palavras-chaves, relacionando inicialmente 43 artigos, totalizando após aplicação dos critérios de inclusão e exclusão em 30 estudos. Os artigos abordados foram selecionados baseados nos itens: autor principal, ano de publicação, desenho do estudo, nível de evidência científica e assunto principal. Os estudos foram separados conforme os seguintes temas de abrangência: preservação de fertilidade, preservação de fertilidade e métodos contraceptivos, SIU-LNG e preservação de fertilidade, SIU-LNG e farmacocinética e SIU-LNG e gestação. Existem poucos estudos na literatura avaliando mulheres usuárias do SIU-LNG submetidas à estimulação ovariana em ciclos de reprodução assistida. Em dois estudos disponíveis, ambos com doadoras de oócitos, não foram observadas diferenças estatisticamente significantes entre as doadoras usuárias do SIU-LNG em relação aos controles, quando comparados os parâmetros descritos: número de ampolas de gonadotrofinas utilizadas na estimulação, número de folículos recrutados, número de oócitos, taxas de fertilização, taxas de clivagem e número de embriões por receptora. O impacto do uso do SIU-LNG em mulheres submetidas à estimulação ovariana em ciclos de preservação oocitária ainda não está claro, assim como o protocolo ideal. As evidências atuais são insuficientes para definir o real efeito do uso do SIU-LNG durante os ciclos de estimulação ovariana. Entretanto, o SIU-LNG não parece ter efeito negativo sobre o crescimento folicular, sobre a qualidade oocitária e a qualidade embrionária, podendo ser utilizado durante este processo. Há a necessidade de estudos randomizados controlados avaliando uma nova opção terapêutica nos ciclos de reprodução assistida.(AU)

The objective of this study was to search for evidence on the interference of the use of LNG-SIU in women submitted to cycles of ovarian hyperstimulation for preservation of fertility, through an integrative review, with search in the databases Lilacs, Pubmed and Cochrane. Using related keywords 43 articles were examined, totaling, after inclusion and exclusion criteria, in 30 studies. The articles were classified according to a synoptic table organized in topics: main author, year of publication, study design, level of scientific evidence and main subject. The studies were separated according to the topics covered: preservation of fertility, preservation of fertility, and contraceptive methods, SIU-LNG and preservation of fertility, SIU-LNG and pharmacokinetics and SIU-LNG and gestation. It was observed that there are few studies in the literature evaluating women users of LNG-IUS who undergo ovarian stimulation in cycles of assisted reproduction. In two of them, both induding oocyte donors, no statistically significant differences were observed among donors using the LNG-IUS as compared to controls regarding the described parameters: number of gonadotrophin ampules used in stimulation, number of recruited follicles, number of oocytes, fertilization rates, cleavage rates and number of embryos per recipient. The impact of the use of IUS-LNG in women submitted to ovarian stimulation in oocyte preservation cycles is still unclear, as it is the ideal protocol. Current evidence is insufficient to define the real effect of the use of LNG-SIU during cycles of ovarian hyperstimulation in assisted reproduction. However, although there is little research available, the LNGSIU does not seem to have a negative effect on follicular growth, on oocyte quality and on embryo quality, and it can be used during this process. There is a need for randomized controlled trials and other research in this context to evaluate a new therapeutic option in the cycles of assisted reproduction.(AU)

Functional endometrial polyps in infertile asymptomatic patients: a possible evolution of vascular changes secondary to endometritis.

OBJECTIVE: Functional polyps and chronic endometritis are among the most common abnormalities seen in the endometrium of patients with implantation failures and recurrent miscarriages. In this study we describe morphological vascular changes in endometrial samples from asymptomatic infertile patients and their association with chronic endometritis and polyp. STUDY DESIGN: We selected 435 asymptomatic infertility patients submitted to office-based diagnostic hysteroscopy and endometrial biopsy. We described vascular changes and searched for histologic signs of endometritis and functional polyps in the endometrial samples. We explored the associations between these conditions. RESULTS: Signs of endometritis, vascular changes and polyps were identified in 176 (40.5%), 168 (38.6%) and 102 (23.4%) cases, respectively. There was a significant association between endometritis and vascular changes. The more frequent vascular alteration (70%) was the hyaline thickening of vessels, a morphological pattern very similar to the thick-walled vessels of polyps. Polyps were associated with endometritis in 28 (27.4%) cases and with other vascular changes besides the vascular stalk in 14 (13.7%). All the polyps with vascular changes had histologic evidence of endometritis. There was a significant association between inflammatory phenomena and vascular changes, even among cases of polyps. CONCLUSIONS: Endometrial samples from infertile patients present a broad spectrum of vascular changes, most of them associated with endometritis. This association is also identified in functional polyps. Our results suggest that these alterations may be etiologically related. It is possible that the vessel axis of functional polyps actually may originate from the evolution of the vascular changes associated with endometritis. This would place functional polyps among the spectrum of inflammatory endometrial diseases.

Hormônio do crescimento como adjuvante à estimulação ovariana de pacientes más respondedoras candidatas à fertilização in vitro / Growth hormone as an adjuvant to ovarian stimulation of poor responder IVF candidates

A má resposta ovariana em fertilização in vitro apresenta uma prevalência de 2 a 30% dos ciclos de estimulação ovariana. Diversos tratamentos adjuvantes são encontrados na literatura, no entanto, a utilização de hormônio de crescimento (GH) adjuvante foi o que apresentou os resultados mais promissores, com elevação da taxa de gravidez em até 17% nestas pacientes. O objetivo deste estudo foi realizar uma revisão da literatura para esclarecer como o GH atua na estimulação ovariana e para investigar as formas de utilização em más respondedoras. Foram encontrados estudos que relacionam a utilização de GH com o aumento no número de oócitos, na sua qualidade, na redução do tempo de êxito na concepção, na taxa de nascimentos, no estímulo de secreção de progesterona e de gonadotrofina coriônica humana (hCG). Foram discutidas as limitações dos estudos anteriores e de que forma limitam ou condicionam os resultados encontrados. Apesar dos estudos revisados terem diferido na dosagem e na forma de utilização do GH, seus resultados suportaram a proposta de utilização de GH no protocolo de estimulação de pacientes más respondedoras.(AU)

Between 2 and 30% of the patients submitted to ovarian stimulation present poor ovarian response. Several adjuvant treatments were found in the literature, however, the use of growth hormone (GH) as adjuvant presented the most promising results, increasing pregnancy rates in up to 17% in these patients. The objective of this study was to review the literature in order to clarify how GH acts on ovarian stimulation and to investigate ways to use it in poor responders. Studies that relate the use of GH with increase in the number of oocytes, on its quality, in the reduction of time to conception, life birth rate, in the stimulus of progesterone and human corionic gonadotropin (hCG) secretion were found.. The limitations found on previous studies and the way in which they limit or condition the founded results were discussed. Although the dosage and ways of use of GH have differed on the reviewed studies, their results supported the proposal of GH use on the stimulation protocols for poor responder patients.(AU)

O que influencia doação de óvulos quando não há compensação financeira? / What influences oocyte donation when there is no financial compensation?

Aim: To evaluate the influence of factors such as age, education level and previous treatment for infertility in the decision to donate or receive eggs. Methods: Patients visting our service for the first time answered the question: “Would you donate or receive eggs?”. We assessed whether the inclination to donate or receive was related to age, level of education and the previous unsuccessful treatment for infertility.Results: 313 patients were included and most (56.9%) said they would donate eggs while only 34.5% would receive a donation. When giving and receiving were evaluated jointly we observed a positive correlation between them (Pearson correlation: r = 0.537, p < 0.01). Patients that underwent previous treatments for infertility were significantly more prone to egg donation (63.4% yes vs. 36.6% no, p < 0.05 vs no previous treatment group), but not toreceive (41.8% yes vs. 58, 2% no). In high and low levels of education most patients were in favor of donation (55.4% and 61.3%, respectively), but against the idea of receiving (33.9%and 37.5%, respectively). There was no significant differences between groups. The age of the patients (< 35 years old or > 35 years old) did not influence the will do donate (58.2% and56.4% respectively) or receive eggs (36.9% and 33.0%, respectively).Conclusions: Our results help understand the factors that may influence the decision to participate in an egg-sharing scheme. We could speculate that patients who have previously undergone unsuccessful treatments are more open to egg-sharing, despite their age or educational background. It would also be relevant to investigate the psychosocial reasons that make couples more willing to donate eggs than receiving.

Objetivo: Avaliar a influência da idade, grau de escolaridade e tratamento anterior na decisão de doar ou receber óvulos. Pacientes e métodos: Mulheres atendidas em nosso serviço responderam à pergunta: “Vocêdoaria ou receberia óvulos?”. Avaliou-se a concordância de aceitação de ovodoação ou ovorecepção com a idade, o grau de escolaridade e tratamento anterior para infertilidade. Resultados: Foram incluídas 313 pacientes e a maioria (56,9%) respondeu que doaria óvulos enquanto apenas 34,5% receberiam. Houve correlação positiva entre doação e recepção (r = 0,537, p < 0,01). Pacientes submetidas a tratamento anterior de infertilidade se mostraram significativamente mais propensas à doação (63,4% sim vs 36,6% não, p < 0.05 vs sem tratamento anterior), mas não a receber (41,8% sim vs 58,2% não). Em níveis altos e baixos de escolaridade a maioria dos pacientes se mostrou a favor da doação (55,4% e 61,3%, respectivamente), mas contra a ideia de receber (37,5% e 33,9%, respectivamente), não houvediferenças significativas entre os grupos. A maioria das pacientes com menos ou mais de 35 anos de idade doaria (58,2% e 56,4%, respectivamente), mas não receberia (36,9% e 33,0%, respectivamente).Conclusões: Nossos resultados são relevantes para entender os fatores que podem influenciar na decisão de participar em um esquema de partilha de óvulos. Poderíamos especular que pacientes previamente submetidas a tratamentos mal sucedidos são mais aberta à ovodoação, apesar de sua idade ou formação educacional.

A influência da endometrite crônica nas pacientes com falhas de implantação recorrentes após fertilização in vitro / The influence of chronic endometritis in patients with recurrent implantation failure after in vitro fertilizatio

A endometrite crônica é um processo inflamatório persistente na camada endometrial, geralmente causada por invasão bacteriana. É uma afecção mal definida quanto a critérios de diagnósticos e tratamento. Devido à sua discreta sintomatologia, a real prevalência da endometrite crônica na população em geral não é conhecida, mas estima-se que esteja entre 0,8 e 19%. A aplicação de protocolos para rastreamento da endometrite crônica em mulheres com falha de implantação de embriões de boa qualidade após fertilização in vitro FIV é controversa. Alguns serviços utilizam a histeroscopia em todas as pacientes antes de iniciar o tratamento de reprodução assistida; entretanto, não há consenso de que a efetividade da histeroscopia melhore o prognóstico das mulheres inférteis. Os achados sugerem que o impacto da endometrite crônica na fertilidade e nos resultados da FIV precisam de futuras investigações em estudos prospectivos randomizados.

Chronic endometritis is a persistent inflammation of the endometrial lining usually caused by bacteria invasion. It is a non-well defined pathology difficult to both diagnosis and treatment. Because of its subtle nature, the real prevalence of chronic endometritis in the general population is ill defined, but is estimated between 0.8 and 19%. The implementation of protocols for screening of women, who have recurrent implantation failure after IVF with good quality embryo, is controversial, but some services have been using hysteroscopy in every patient immediately prior to FIV. However, there is no consensus on the effectiveness of hysteroscopy in improving the prognosis of infertile women. The findings suggest that the impact of chronic endometritis on fertility and outcomes should be further investigated in prospective randomized studies.

Alterações no cariótipo que podem gerar infertilidade ou abortamento de repetição / Karyotype alterations that may lead to infertility or repetitive abortion

A infertilidade pode ser definida como a incapacidade de se conseguir uma gravidez dentro de um determinado período ou a falha repetida em levar uma gravidez a termo. Os fatores mais comuns associados com o abortamento habitual são de ordem genética, hormonal ou anatômica. O aumento da heterocromatina encontrado nos cromossomos humanos autossomos 1, 9, 16 e no cromossomo sexual Y tem sido comumente definido como sendo uma variação da normalidade. Todavia, têm-se alguns relatos da frequência aumentada dessas alterações em pais de crianças com anomalias cromossômicas, casais com abortos recorrentes e em conceptos cromossomicamente anormais. Sabe-se que os genes responsáveis pela fertilidade e viabilidade são encontrados presentes na heterocromatina, sugerindo que tais variantes não podem ser ignoradas.(AU)

Infertility can be defined as the inability to achieve pregnancy within certain time frame, or the repetitive failure to carry pregnancy through completion. The most common factors associated with habitual abortion have a genetic, hormonal, or anatomical cause. The increase found in heterochromatin at chromosomes 1, 9 and 16 as well as in the sex chromosome Y has been implicated as a variation of normality. However, some reports have highlighted cases of children having chromosomal abnormalities from parents carrying a higher alteration frequency, cases of repetitive abortions, and also some chromosomal abnormal conceptions. It is known that genes for fertility and viability are now thought to reside in heterochromatin, which suggests that variants should not be ignored.(AU)

Tratamento da endometriose associada à infertilidade - revisão da literatura / Treatment of endometriosis associated with infertility - a literature review

A endometriose é uma desordem estrogênio-dependente definida pela presença de tecido endometrial fora da cavidade uterina, e é uma das principais causas de infertilidade feminina. A melhor escolha para seu tratamento, associado à infertilidade, ainda permanece obscura. As evidências científicas disponíveis indicam que a supressão da função ovariana, apenas com o tratamento hormonal, não melhora as taxas de gravidez. O tratamento cirúrgico é, entretanto, provavelmente eficaz em todos os estágios da doença. Nos casos de endometriose mínima e leve, corrigida cirurgicamente e com anatomia pélvica normal, a inseminação intrauterina (IIU), acompanhada de hiperestímulo ovariano controlado, é recomendada. Em casos de endometriose avançada, especialmente se estiver associada a alterações tubárias, fatores masculinos ou falha de tratamento prévio, após laparoscopia, a melhor opção é a Fertilização in vitro (FIV). O sucesso pode ser maior com o tratamento de análogos de gonadotropina (GnRH) de três a seis meses antes da FIV. Finalmente, é importante ressaltar que as recomendações acima deverão ser revistas à medida que estudos clínicos randomizados e controlados mostrarem evidências mais concretas e confiáveis dessa enigmática doença.

Endometriosis is an estrogen-dependent disorder defined as the presence of endometrial tissue outside of the uterine cavity, and is a leading cause of female infertility. The optimal choice for its treatment associated with infertility remains obscure. The available scientific evidence indicates that suppression of ovarian function with hormonal treatment is not effective and should not be offered for this indication alone, and it does not get better pregnancy rates. Surgery treatment is probably efficacious for all stages of the disease. Intrauterine insemination (IUI) with controlled ovarian stimulation is effective in endometriosis minimal-mild and surgically corrected when the pelvic anatomy is normal. In advanced endometriosis cases, especially if tubal function is compromised, if there is also male factor infertility, and other treatments have failed, in vitro fertilization (IVF) is the appropriate treatment. The success may increase with gonadotropin-releasing hormone analog treatment (GnRH) for three to six months before IVF. Finally, it is important to emphasize that the recommendation above should be revised as randomized controlled clinical trials with more concrete and reliable evidence of this enigmatic disease.

Diagnóstico genético pré-implantacional: uma ferramenta importante para a rotina de fertilização in vitro? / Preimplantation genetic diagnosis: an important tool for the in vitro fertilization routine?

Erros cromossômicos numéricos são comuns durante as primeiras etapas do desenvolvimento embrionário humano, contribuem significativamente com processos de falta de implantação e são causadores da perda gestacional recorrente em pelo menos 50 por cento dos abortos ocorridos no primeiro trimestre. Tradicionalmente, a prevenção das anomalias genéticas cromossômicas em pacientes de alto risco é realizada por exames pré-natais, como a biópsia do vilo coriônico, aminiocentese e a cordocentese. Uma vez diagnosticada a anomalia, não existe tratamento eficaz para portadores de aberrações genéticas e a interrupção da gestação nestes casos ainda é ética e legalmente questionável. O diagnóstico genético pré-implantacional (DGPI) representa uma ferramenta valiosa aos casais de alto risco, por permitir a seleção de embriões saudáveis obtidos através de programas de fertilização in vitro antes de estes serem transferidos para um útero materno. Os primeiros relatos da utilização do DGPI datam da década de 90, quando eram utilizadas metodologias da reação em cadeia da polimerase para determinação do sexo do embrião, permitindo desta maneira transferir embriões que não fossem portadores de doenças ligadas ao cromossomo X. O DGPI é uma técnica extremamente eficaz, que analisa uma única célula do embrião que é biopsiado a partir do terceiro dia de desenvolvimento. Esta metodologia tem como finalidade identificar embriões gerados por processos de reprodução assistida, os quais sejam portadores de aberrações cromossômicas numéricas que envolvam os cromossomos X, Y, 13, 16, 18, 21 e 22. A metodologia mais utilizada para a realização do DGPI é a técnica de hibridização in situ, utilizando-se sondas fluorescentes para os cromossomos citados. Este é um método eficiente e que deve ser discutido com casais cuja idade da mulher seja acima dos 39 anos, casais com cariótipo alterado ou ainda casais com histórico familiar de presença de portadores de cromossomopatias. A eficiência...

The potential transmission of genetic disorders to the offspring has been a major problem for many couples when contemplating pregnancy. Numerical chromosomes errors are common during the first stages of the human embryonic development and contribute significantly with processes of implantation failure and it is also related to recurrent miscarriage, in at least 50 percent of the abortions occurred in the first trimester. Traditionally, the prevention of genetic chromosomal abnormalities in high risk patients is achieved by pre-natal examinations such as biopsy of the chorionic villi, aminiocentese of cordocentesis. Once diagnosed the genetic error, there is no effective treatment for patients with genetic aberrations and the interruption of pregnancy in these cases are ethically and legally questionable. The risk has been greatly decreases by the evaluation of the family history of the age of the mother, and the implementation of prenatal diagnosis in those couples in which the risk was increased compared to the general population. An alternative approach that is available with assisted reproductive technologies is the preimplantation genetic diagnosis (PGD), which it is possible to observe X, Y, 13, 16, 18, 21 and 22 chromosomes or to perform gene screen by PCR for knowing genetic diseases before the corresponding embryo is transferred to the uterus of the mother. PGD was first clinically applied in the early nineties, and was initially used in sexing cases for couples who were at risk of transmitting an X-linked recessive disorder. PGD involves the analysis of either polar bodies, extruded from oocytes during meiosis, or single cells (blastomeres) biopsied from embryos after fertilization. PGD tests have largely focused on two methodologies: fluorescent in situ hybridization and polymerase chain reaction. The efficiency of the method is about 98 percent and its extremely invasive technique demands high level professional.

Tratamento cirúrgico com técnica minimamente invasiva de tumor ovariano localizado na pelve: Relato de caso / Minimally invasive surgical treatment for early-stage ovarian cancer: a case report

Relato de caso de uma paciente de 54 anos, sem queixas e sem alterações ao exame físico, realizou ultra-sonografia pélvica rotineira que mostrou cisto complexo em ovário direito, confirmado àtomografia. A dosagem sérica de CA125 estava elevada, enquanto os outros marcadores tumorais-antígeno carcinoembriogênico,alfa-fetoproteína, e a fração beta da gonadotropina coriônica estavam normais. A abordagem diagnóstica e terapêutica foi feita por meio de videolaparoscopia, com observação de lesões vegetantes em ambos os ovários, sem outras alterações. As massas tumorais foram biopsiadas e analisadas por técnica de congelação intraoperatória, sendo constatada neoplasia serosa de baixo potencial de malignidade - “borderline”. A seguir, foi realizado estadiamento para carcinoma ovariano, segundo norma preconizada pela Federação Internacional de Ginecologistas e Obstetras: salpingo oforectomia bilateral, histerectomia total, linfadenectomia pélvica bilateral e paraaórtica. Para completar o estadiamento, foi realizada a omentectomia por meio de corte transversal de 4 cm no epigástrio, dilatado com um afastador especial - Protractor®, a incisão também possibilitou a remoção das peças cirúrgicas. A paciente teve alta hospitalar no dia seguinte à cirurgia, evoluindo sem complicações. A análise histológica confirmou o tumor tipo “borderline” e não encontrou células malignas nas outras peças cirúrgicas removidas. A videolaparoscopia, uma minilaparotomia, e a utilização de um afastador especial permitiram o adequado diagnóstico, estadiamento e remoção de tumor ovariano localizado.

Endoscopia e mama / The endoscopy and breast

O uso da endoscopia na mama e para muitos um tema ainda muito recente, algumas vezes ate desconhecido. Procuramos mostrar nesse artigo as recentes aquisicoes, e os varios aspectos relacionados a...

Valor preditivo da dopplervelocimetria no crescimento intra-uterino retardado (CIUR) / Dopplervelocimetry predictive value in intrauterine growth retardation (IGUR)

O CIUR e uma entidade morbida que continua a contribuir para a morbimortalidade perinatal. Este trabalho procura demonstrar que o exame Dopplervelocimetrico e capaz de estudar com maior detalhe a circulacao utero-placentaria e fetal, permitindo melhor compreensao das alteracoes fisiopatologicas nos fetos portadores de CIUR. As alteracoes dos indices (sistole/diastole, Indice de Pulsatilidade e Indice de Resistencia) dos vasos placentarios, arteriais e circulacao venosa fetais sao descritos tentando sempre correlacionar com a progressiva deteriorizacao do bem-estar fetal

Fertilizaçäo in vitro: idade limite / In vitro fertilization: age limit

Com o propósito de orientar melhor as mulheres com idade mais avançadas em um programa de fertilizaçäo assistida, os autores fizeram uma revisäo do assunto. Expöem as possíveis razöes para a diminuiçäo da fertilidade, bem como tentam quantificá-la. Analizam a importância das dosagens hormonais no 3§ dia do ciclo menstrual, principalmente FSH, na seleçäo destas pacientes