Short- and long-term outcomes of intraoperative spillage during laparoscopic removal of benign ovarian cysts.

BACKGROUND: To compare the short- and long-term outcomes in patients with and without intraoperative spillage from benign adnexal masses during laparoscopic removal. METHODS: We conducted a retrospective analysis of all cases of laparoscopic removal of ovarian cysts (cystectomy or adnexectomy) in our institution between the years 2013 and 2017, excluding malignant lesions. RESULTS: During the study period, 186 cases of ovarian cyst removal were identified. Intraoperative ovarian cyst spillage (IOCS) occurred in 104 cases (study group), while in the remaining 82 cases no spillage was reported (control group). Baseline clinical characteristics were comparable between groups. Large cyst diameter and intraperitoneal adhesions were significantly associated with the occurrence of IOCS (P  = 0.008 and < 0.001, respectively). The use of an endoscopic retrieval bag was significantly inversely associated with IOCS. Postoperative complications (pain score, hospital stay, febrile illness and recurrence of ovarian cyst) were comparable between groups. CONCLUSIONS: IOCS during laparoscopic cystectomy is associated with larger cyst diameter and intraperitoneal adhesions, but not with adverse short- or long-term outcomes nor with recurrence rates.

Does the empty follicle syndrome occur in cases of low number of maturing follicles in assisted reproduction?

The pathophysiology of the genuine empty follicle syndrome (EFS) is still debated. Ovarian aging has been contested as a cause of this condition. Our aim was to investigate the occurrence of the genuine EFS in cases of a low number of mature follicles in a prospective manner. Ninety-five infertile women were recruited and evaluated following conventional controlled ovarian stimulation (COS) with ≤ six follicles of ≥14 mm diameter on the day of hCG administration. Enrolled women were 37.5 ± 5.2 years of age with basal FSH level of 9.1 ± 3.7 mIU/L, antral follicle count (AFC) of 6.9 ± 4.6, and number of ≥14 mm follicles (on the day of hCG) of 3.4 ± 1.5. Among the 95 women, four were complicated by the genuine EFS (4.2%) with features of the depleted ovarian reserve. Comparison between these four cases and the 91 controls revealed significant differences between age, AFC, number of ≥14 mm follicles, and serum E2 level corresponding to 41.8 ± 1.7 versus 37.4 ± 5.2 years, 1.7 ± 0.6 versus 7.1 ± 4.5, 2.0 ± 0.8 versus 3.4 ± 1.5 follicles, and 356 ± 200 versus 975 ± 557 pg/mL, respectively. Post hoc analysis revealed that 56 among the 95 women fulfilled the Bologna criteria for poor ovarian response and all four cases matched the definition of the genuine EFS raising its incidence to 7.1% in this group. A logistic regression analysis showed that AFC was a significant factor in the development of the genuine EFS. We conclude that the genuine EFS complicates infertile women characterized by a low number of mature follicles. Our findings suggest that the mechanism behind this occurrence is associated with a more exhausted ovarian reserve.

Proof of concept use of progesterone/estradiol ratio to investigate late follicular progesterone in women with low number of pre-ovulatory follicles.

BACKGROUND: To investigate late follicular progesterone (P) serum level in women with low number of pre-ovulatory follicles in the assisted reproductive technologies (ART) setting. METHODS: Fifty-five consecutive women having four or less pre-ovulatory follicles of >14 mm on the day of human chorionic gonadotropin (hCG) administration were prospectively evaluated. Spearman correlation tests between serum estradiol (E2) level, serum P level, P/E2 ratio, number of pre-ovulatory follicles, oocytes and embryos were performed. Women enrolled were further divided into two groups in accordance with the P/E2 ratio on the day of hCG administration and compared. RESULTS: Serum E2 level correlated positively with P serum level (rs = 0.36, P < 0.01), number of mature follicles (rs = 0.50, P < 0.01) and number of oocytes retrieved (rs = 0.36, P < 0.05), whereas negatively with P/E2 ratio (rs = - 0.68, P < 0.01). Likewise, number of pre-ovulatory follicles correlated positively with E2 level (rs = 0.50, P < 0.01), P level (rs = 0.27, P < 0.05) and number of oocytes retrieved (rs = 0.33, P < 0.05), while it correlated negatively with P/E2 ratio (rs = - 0.33, P < 0.05). Furthermore, women with P/E2 ratio > 1 on the day of hCG administration received considerably higher total follicular stimulating hormone (FSH) dosage and achieved significantly lower number of oocytes and embryos as compared to controls. CONCLUSIONS: The reverse relationship between number of pre-ovulatory follicles and P/E2 ratio implies that P rise is not only the result of increased steroidogenic activity but other oocytefollicle disrupted mechanisms seems to be involved. An exaggerated FSH stimulation appears to disrupt further these mechanisms.

The "vanishing follicle" in women with low number of developing follicles during assisted reproduction.

OBJECTIVE: To investigate the occurrence of the "vanishing follicle" phenomenon in women with low number of developing follicles in assisted reproduction. STUDY DESIGN: Women with ≤ 6 follicles on the day of hCG administration with ≥ 14mm diameter were prospectively studied. Primary outcome measures were disappearance of ≥14mm and all-diameter follicles on the day of oocyte pick-up compared to the day of hCG administration. RESULTS: Among the 120 women recruited, 95 were found eligible and completed the study. The "vanishing follicle" phenomenon occurred in 3.1% (95% confidence level: 0.7%-9.0%) and 18.9% (95% confidence level: 11.6%-28.3%) of cases affecting ≥14mm and all-diameter follicles, respectively. In all cases, mid-late follicular serum LH and P levels remained within normal follicular phase range and trans-vaginal scan did not show signs of ovulation. Markedly, the main significant difference between the study and control groups in the ≥14mm follicle group was serum E2 level on the day of hCG administration; median (Interquartile range), corresponding to 395 (382.0-405.5) versus 823.0 (544.5-1291.0) pg/mL, respectively (P=0.04). The same trend was encountered in all-diameter vanishing follicles group but it did not reach significance. Interestingly, in all-diameter vanishing group, chronic smoking and the P/E2 ratio on the hCG day were significantly higher than controls. Post hoc multiple logistic regression analysis of data in accordance with the Bologna criteria reveled that antral follicle count was found to significantly affect the development of the "vanishing follicle" phenomenon. CONCLUSIONS: The "vanishing follicle" phenomenon occasionally occurs in women with low number of developing follicles during assisted reproduction with no signs of ovulation. Our preliminary findings suggest that this phenomenon may be related to exhausted ovarian reserve however, an early-unrecognized LH elevation could not be ruled out.