Bruno Ramalho de Carvalho

Ovarian reserve evaluation: state of the art

PurposeRevise role of hormonal basal and dynamic tests, as well as ultrasonographic measures as ovarian reserve markers, in order to provide better counseling to subfertile couples.MethodsReview of publications on the topic, with an emphasis on recent well designed articles.ResultsCurrently available ovarian reserve tests do not provide sufficient evidence to be solely considered ideal, even for premature ovarian senescence patients who do not present subfertility complaints. However, these markers occupy important place in initial approach to treatment of subfertile couples, predicting unsatisfactory results that could be improved by differentiated induction schemes and reducing excessive psychological and financial burdens, and adverse effects.ConclusionsIn order to remedy the limitations due to the scarcity of strong evidence about this topic, future studies should try to clarify predictive value of markers in groups of specific diseases-related subfertility and pay special attention to propaedeutic multivariate models including anti-Müllerian hormone and antral follicle count.

Sexuality during the climacteric period.

BACKGROUND Cultural, social, physiological and psychological factors may alter the course of sexual function in climacteric women. OBJECTIVE The objective of the present literature review is to survey the prevalence of sexual dysfunctions in the climacteric and to establish the association between the organic and psychic changes that occur during this phase and sexual dysfunction. We also discuss potential treatments. METHODS We evaluated the data available in PubMed (1982-2008). For each original article, two reviewers analyzed the data independently and considered a study to be of high quality if it had all three of the following characteristics: prospective design, valid data and adequate sample size. Both reviewers extracted data from each of the 99 studies selected: 34 cross-sectional studies, 25 cohort studies, 9 trials, 31 reviews related to sexuality in pre- and post-menopausal women. RESULTS Sexual dysfunction among climacteric women is widespread and is associated with bio-psychosocial factors. However, there is not enough evidence to correlate sexual dysfunction with a decrease in estrogen levels and biological aging. A strong association exists between climacteric genital symptoms and coital pain. There is, however, sufficient evidence demonstrating the benefits of local estrogen therapy for patients with genital symptoms. CONCLUSION A significant decline in sexual function occurs in climacteric women, although it is still unclear whether this is associated with the known decrease in estrogen levels or with aging, or both. Relational factors may interfere with sexual function during this phase. The climacteric genital symptoms improve with estrogen replacement therapy, and positively influence sexual function. Further studies are needed to establish the actual impact of the decrease in estrogen levels and of aging on the sex life of climacteric women.

Endometriosis in postmenopausal women without previous hormonal therapy: report of three cases

Introduction Endometriosis is a benign, estrogen-dependent, chronic gynecological disorder associated with pelvic pain and infertility. The disease most commonly affects women during the reproductive age, although postmenopausal patients do rarely present it. These rare occurrences are generally associated with hormonal use. Material and methods We present three cases of endometriosis in postmenopausal patients who have no history of hormone therapy and no previous history of endometriosis or infertility. Case reports In case 1, a 62-year-old woman presented with acyclic pelvic pain and a left ovarian homogeneous cystic mass. After laparoscopic salpingoophorectomy and histological analysis, an ovarian endometriotic cyst was confirmed. In case 2, a 78-year-old woman presented with a painful abdominal wall mass that was confirmed by ultrasound and tomography. Her past medical history included an abdominal hysterectomy 20 years prior to the discovery of this mass. The lesion was surgically excised and histological analysis showed areas of endometrial stroma and glands surrounded by fibrosis, compatible with endometriosis. In case 3, a 54-year-old woman presented with chronic pelvic pain and a nodule in the rectovaginal septum was noted during gynecological examination. Menopause occurred at 48 years of age. She had no previous dysmenorrhea. Ultrasound confirmed the nodule in the rectovaginal septum. The patient was submitted to a diagnostic colonoscopy that revealed a friable lesion, which was subsequently biopsied. The histological diagnosis was endometriosis. Conclusions These three cases of postmenopausal endometriosis support the celomic metaplasia theory for the genesis of this disease.

Cryopreservation time does not decrease follicular viability in ovarian tissue frozen for fertility preservation

OBJECTIVE: To determine the effect of storage duration on cryopreserved ovarian tissue using fresh and frozen-thawed samples. METHODS: Seventeen fertile patients underwent an ovarian biopsy during elective laparoscopic tubal ligation. The tissue sample was divided into three parts: one part was processed fresh (FG), and two were slowly frozen, cryopreserved for 30 (G30) or 180 days (G180), thawed and analyzed. Follicular density, follicular viability, and steroidogenic capacity were assessed. RESULTS: We observed no differences between the groups in follicular density, which was assessed in hematoxylin and eosin–stained tissue sections. A heterogeneous follicular distribution was observed in the parenchyma, with a mean density of 361.3±255.4, 454.9±676.3, and 296.8±269.0 follicles/mm3 for FG, G30 and G180, respectively (p = 0.46). Follicular viability was greater in FG (93.4%) when compared with the cryopreserved tissues (70.8% for G30 (p<0.001) and 78.4% for G180 (p<0.001)), with no difference in viability between the frozen samples (p>0.05). The steroidogenic capacity of the tissue was not significantly reduced following cryopreservation. CONCLUSION: The slow freezing procedures used for ovarian cryopreservation are capable of preserving follicular viability and maintaining the steroidogenic capacity of the tissue despite a roughly 30% decrease in follicular viability. Furthermore, short-term storage of ovarian tissue does not appear to compromise follicle integrity.

Increased basal FSH levels as predictors of low‐quality follicles in infertile women with endometriosis

To determine whether basal levels of follicle‐stimulating hormone (FSH) and anti‐müllerian hormone (AMH), antral follicle count (AFC), and the numbers of dominant follicles, oocytes, and mature oocytes retrieved after ovarian stimulation differed between infertile women with endometriosis and healthy women undergoing assisted reproduction techniques (ART).

Molde de látex natural (Hevea brasiliensis) para neovaginoplastia

PURPOSE: to evaluate the use of natural latex mold (Hevea brasiliensis) as a modification of McIndoe and Bannister neovaginoplasty in patients presenting Mayer-Rokitansky-Kuster-Hauser (MKRH) syndrome. METHODS: we retrospectively included nine patients presenting MKRH syndrome, who had been submitted to McIndoe and Bannister neovaginoplasty modified by the use of natural latex mold. Neovaginal epithelization and depth, coitus occurrence and satisfaction, and surgical complications were evaluated. RESULTS: five weeks after the procedure, eight patients presented an epithelized 7 to 12 cm deep neovagina. There was one case of complete neovaginal stenosis, because of incorrect use of the mold. After at least one year, the others maintained 4 to 8 cm deep neovaginas and capacity for intercourse, with 66.7% satisfaction. One woman presented precocious rectovaginal fistula and late episodes of uretrovaginal fistulae. Two patients presented distal neovaginal stenosis in long-term follow-up. One of these and the patient with fistulae were submitted to a new procedure. CONCLUSIONS: the use of natural latex mold as a modification of classic neovaginoplasty technique allows the creation of neovaginas morphologically and functionally similar to the normal vagina in patients with vaginal agenesis.

Endometriose umbilical sem cirurgia pélvica prévia

PURPOSE: to present a series of cases of umbilical endometriosis in patients in reproductive age, with no previous pelvic surgery. METHODS: four patients aged between 33 and 43 years were included in the study. They all presented umbilical bleeding associated or not with pelvic pain, and medical history varied from two months to four years. Abdominal wall ultrasound was performed for diagnosis support before surgical excision of the umbilical lesions, and histological examination was also performed. RESULTS: the ultrasonographic evaluation of the four patients showed hypoechogenic umbilical lesion suggestive of endometriosis. All patients were submitted to surgical excision and histological examination of the lesions. CA-125 serum levels were measured in three of the patients, but they were within normal ranges (from 6.8 to 10.1 U/mL). In addition to umbilical surgery, laparoscopy was performed in all patients, but only one presented concomitant pelvic endometriosis. In a one-year follow-up, patients maintained asymptomatic and there was no recurrence of the lesions. CONCLUSIONS: umbilical endometriosis is a rare entity, but it may be remembered as a possibility in cases of umbilical nodulations or bleeding, even if there is no previous history of pelvic surgery with endometrial manipulation. Its treatment is always surgical and, in general, it is enough to promote complete elimination of the lesion and of the symptoms.

Neovaginoplastia com membrana amniótica na síndrome de Mayer-Rokitansky-Küster-Hauser

PURPOSE: to evaluate the results of neovaginoplasty with the use of a human amniotic graft in patients with the Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome. METHODS: the study was a retrospective analysis of a series of 28 patients with the MRKH syndrome conducted from 1990 to 2003. The patients were attended and treated at the Ambulatorio de Ginecologia Infanto-Puberal (AGIP) of the Hospital Universitario of the Faculdade de Medicina de Ribeirao Preto of the Universidade de Sao Paulo (FMRP-USP), being submitted to neovaginoplasty by the technique of McIndoe and Bannister, modified by the use of a human amniotic membrane graft. Epithelization, amplitude and depth of the neovaginas were evaluated 7 and 40 days after the procedure. Patient satisfaction was determined during the late postoperative period in terms of the presence of discomfort and dyspareunia during sexual relations. RESULTS: postoperatively, seven patients (25%) presented vaginal stenosis and six of them were submitted to a new surgical intervention, one had shortening of the neovagina, corrected with the use of exercises with a vaginal mold, three (10.7%) developed a rectovaginal fistula, one (3.6%) a uterovesical fistula, and one (3.6%) excess skin in the vaginal introitus - all successfully corrected with surgery. Four patients (14.3%) presented urinary tract infection. Two months after surgery, 11/19 patients (57.8%) presented satisfactory sexual activity and 42% dyspareunia, and within a maximum period of four years, 20/21 patients (95.2%) had satisfactory sexual activity and 4.8% dyspareunia. CONCLUSIONS: an amniotic membrane graft is a good option for the treatment of vaginal agenesis. Perioperative follow-up involves educational guidance regarding the use of the mold and regarding patient sexuality in order to reduce the complaints of dysfunctional coitus in the presence of a favorable surgical evolution and a neovagina of adequate aspect.

Reproductive planning in times of Zika: getting pregnant or delaying plans? The opinion of the Brazilian Society of Assisted Reproduction Committee – a basis for a bioethical discussion

Although the causality between Zika virus, microcephaly, and other central nervous system disorders has been taken for granted by the scientific community, many uncertainties remain. The gap of knowledge at the moment is large enough to remove part of the confidence physicians have on the advice given to patients - and infertile women in particular - on their reproductive plans. Pretreatment serologic screening is a possible strategy to offer more confidence for individuals choosing to bear children regardless of the Zika virus, but the tests currently available do not seem to be sufficiently adequate. Until now, there is no formal recommendation to avoid pregnancy solely because of the Zika virus outbreak, and the choice of becoming pregnant has been regarded as a personal decision to be made by each woman and her family.

Corifollitropin alfa compared to daily rFSH or HP-HMG in GnRH antagonist controlled ovarian stimulation protocol for patients undergoing assisted reproduction

Objective This study aimed to compare the outcomes of controlled ovarian stimulation (COS) with corifollitropin alfa versus daily recombinant follicle-stimulating hormone (rRFSH) or highly purified human menopausal gonadotropin (HP-HMG) in patients undergoing in vitro fertilization (IVF) cycles based on gonadotropin-releasing hormone (GnRH) antagonist protocols. The primary endpoints were total number of oocytes and mature oocytes. Methods This retrospective study looked into 132 controlled ovarian stimulation cycles from IVF or oocyte cryopreservation performed in a private human reproduction center between January 1 and December 31, 2014. Enrollment criteria: women aged < 40 years submitted to COS with corifollitropin alfa 100µg or 150µg (n = 26) and rFSH or HP-HMG in the first seven days of treatment with daily doses of 150-225 IU (n = 106); all subjects were on GnRH antagonist protocols. Results The groups had similar mean ages and duration of stimulation. The mean number ± standard deviation of total aspirated oocytes and MII oocytes was 11.9±10 and 10.3±7.9 in the corifollitropin alfa group, and 10.9±7.2 and 8.6±5.7 in the group on rFSH or HMG (p>0.05). There were no significant differences in fertilization (76.9% vs. 76.8%, p=1.0), biochemical pregnancy (66.7% vs. 47.2%, p=0.1561) or embryo implantation rates (68.7% vs. 50%, p=0.2588) between the groups using corifollitropin alfa and rFSH or HMG, respectively. Conclusions Corifollitropin alfa seems to be as effective as rFSH or HP-HMG when used in the first seven days of ovulation induction for patients undergoing assisted reproduction in GnRH antagonist protocols.