Charalampos Grigoriadis

Changes in hormonal profile and seminal parameters with use of aromatase inhibitors in management of infertile men with low testosterone to estradiol ratios

OBJECTIVE To compare the effects of 2.5 mg letrozole with those of 1 mg anastrazole daily on the hormonal and semen profiles of a subset of infertile men with low T/E(2) ratios. DESIGN Prospective, nonrandomized study. SETTING Reproductive medicine clinic. PATIENT(S) The study group consisted of 29 infertile men with a low serum T/E(2) ratio (<10). INTERVENTION(S) Patients were divided into two groups. Group A included 15 patients treated with 2.5 mg letrozole orally once daily for 6 months, and Group B consisted of 14 patients treated with 1 mg anastrazole orally every day for 6 months. MAIN OUTCOME MEASURE(S) Hormonal evaluation included measurement of serum FSH, LH, PRL, T, and E(2). In all sperm analyses pretreatment and posttreatment total motile sperm counts (ejaculate volume × concentration × motile fraction) were evaluated. RESULT(S) The use of aromatase inhibitors (either letrozole or anastrazole) in cases of infertile men with low T/E(2) ratios improved both hormonal and semen parameters. CONCLUSION(S) This study suggests that some men with severe oligospermia, low T levels, and normal gonadotropin concentration may have a treatable endocrinopathy.

Bakri balloon tamponade for the management of postpartum hemorrhage.

Maternal mortality –0.46 (0.004) –0.36 (0.063) West: –0.63 (0.008) West: –0.69 (0.013) East: –0.24 (0.478) East: 0.04 (0.919) Central: 0.75 (0.246) Central: 0.99 (0.037) Southern: –0.80 (0.101) Southern: –0.67 (0.327) Neonatal mortality –0.39 (0.019) –0.30 (0.119) West: –0.55 (0.027) West: –0.53 (0.079) East: –0.04 (0.912) East: –0.24 (0.539) Central: –0.92 (0.080) Central: –0.98 (0.116) Southern: –0.52 (0.369) Southern: –0.23 (0.773) Early neonatal mortality –0.31 (0.062) –0.22 (0.254) West: –0.47 (0.064) West: –0.44 (0.156) East: –0.08 (0.803) East: –0.26 (0.496) Central: –0.96 (0.034) Central: –0.97 (0.154) Southern: –0.49 (0.401) Southern: –0.18 (0.820) Late neonatal mortality b –0.47 (0.004) –0.39 (0.043) West: –0.59 (0.014) West: –0.55 (0.063) East: 0.05 (0.877) East: –0.11 (0.787) Central: –0.84 (0.156) Central: –0.99 (0.056) Southern: –0.59 (0.295) Southern: –0.37 (0.627)

Antibiotic prophylaxis in diagnostic hysteroscopy: is it necessary or not?

OBJECTIVE Surgical site infection remains the most common complication of surgery. Up to 5% of patients undergoing operative procedures will develop an infection leading to a prolonged hospital stay with increased cost. On the other hand the indiscriminate use of antibiotics has been associated with the development of antibiotic-resistant bacteria. The aim of this study was to examine the effect of antibiotic prophylaxis in cases of diagnostic hysteroscopy. STUDY DESIGN This was an eight-year randomized controlled clinical trial. The study group consisted of 364 women who underwent diagnostic hysteroscopy because of menometrorrhagia, post-menopausal vaginal bleeding, ultrasound findings of increased thickness of the endometrium, or as a routine examination prior to a first in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) treatment. RESULTS Of the 364 women who underwent diagnostic hysteroscopy during this eight-year study period, 176 received antibiotic prophylaxis whereas 188 did not. There were no significant differences in the prevalence of postoperative infections observed between women who received antibiotic prophylaxis (0.57%) and those who underwent the procedure without prophylaxis (0.53%). CONCLUSION Given the very low risk of infection after diagnostic hysteroscopy and lack of evidence of efficacy, routine antibiotic prophylaxis is not recommended.

Role of Hysteroscopy Prior to Assisted Reproduction Techniques

STUDY OBJECTIVE To determine whether diagnostic hysteroscopy before assisted reproduction techniques (ΑRT) in women without known disease of the uterine cavity is necessary. DESIGN Prospective cohort clinical study. SETTING Reproductive medicine clinic. PATIENTS The study group consisted of 217 infertile women attending the Reproductive Clinic for examination before undergoing ART, either in vitro fertilization or intracytoplasmic sperm injection. INTERVENTIONS Patients underwent transvaginal sonography (TVS) and hysterosalpingography (HSG) for initial evaluation. If there were no abnormal intrauterine findings, diagnostic hysteroscopy was additionally performed. MEASUREMENTS AND MAIN RESULTS The safety and diagnostic value of hysteroscopy before ART was examined. Diagnostic hysteroscopy was performed successfully, without complications, in all 217 women. Ninety-five (43.7%) had a history of ART failures (group 1), and 122 (56.3%) had undergone no previous ART attempts (group 2). In 148 women (68.2%), findings at hysteroscopy were normal, whereas in 69 (31.8%), hysteroscopy revealed intrauterine lesions (polyps, septa, submucosal leiomyomas, or synechiae) that led to operative hysteroscopy. The most common intrauterine abnormality was the presence of endometrial polyps in 26 patients (12%). The total percentage of abnormal intrauterine findings was higher in women with a history of repeated ART failures in comparison with those with no history of ART attempts. No statistically significant difference in the outcome of in vitro fertilization or intracytoplasmic sperm injection was observed between women with normal hysteroscopic findings and patients with hysteroscopically corrected endometrial disease. CONCLUSION Sensitivity of diagnostic hysteroscopy is significantly higher than TVS and HSG in the diagnosis of intrauterine lesions. Diagnostic hysteroscopy should be performed before ART in all patients, including women with normal TVS and/or HSG findings, because a significant percentage of them have undiagnosed uterine disease that may impair the success of fertility treatment.

The Janus face of maternal serum relaxin: a facilitator of birth, might it also induce preterm birth?

Abstract Objective: Preterm birth is a major cause of neonatal morbidity and mortality in the developed world. In order to better understand the pathophysiological pathway of this condition, the role of genetic factors and/or inflammation-associated molecules, as well as of socioeconomic parameters, is therefore under intense investigation. The purpose of this review study was to examine the potential role of maternal serum relaxin levels in the etiology of preterm birth. Methods: Electronic databases (Pubmed, Embase, Cochrane Library) were searched for previously published research studies that investigated the biological role of relaxin and the mechanisms in which this hormone is involved during pregnancy and labor. Results: It is evident that while relaxin is an essential endometrial/decidual angiogentic factor playing a vital role in maternal accommodation of pregnancy, elevated levels of this hormone could well be associated with preterm birth. Conclusions: There are strong indications that maternal serum hyperrelaxinemia correlates with an increased risk of preterm birth.

Hofbauer cells morphology and density in placentas from normal and pathological gestations

PURPOSE In placentas from uncomplicated pregnancies, Hofbauer cells either disappear or become scanty after the fourth to fifth month of gestation. Immunohistochemistry though, reveals that a high percentage of stromal cells belong to Hofbauer cells. The aim of this study was to investigate the changes in morphology and density of Hofbauer cells in placentas from normal and pathological pregnancies. METHODS Seventy placentas were examined: 16 specimens from normal term pregnancies, 10 from first trimesters miscarriages, 26 from cases diagnosed with chromosomal abnormality of the fetus, and placental tissue specimens complicated with intrauterine growth restriction (eight) or gestational diabetes mellitus (10). A histological study of hematoxylin-eosin (HE) sections was performed and immunohistochemical study was performed using the markers: CD 68, Lysozyme, A1 Antichymotrypsine, CK-7, vimentin, and Ki-67. RESULTS In normal term pregnancies, HE study revealed Hofbauer cells in 37.5% of cases while immunohistochemistry revealed in 87.5% of cases. In first trimesters miscarriages and in cases with prenatal diagnosis of fetal chromosomal abnormalities, both basic and immunohistochemical study were positive for Hofbauer cells. In pregnancies complicated with intrauterine growth restriction or gestational diabetes mellitus, a positive immunoreaction was observed in 100 and 70% of cases, respectively. CONCLUSIONS Hofbauer cells are present in placental villi during pregnancy, but with progressively reducing density. The most specific marker for their detection seems to be A1 Antichymotrypsine. It is remarkable that no mitotic activity of Hofbauer cells was noticed in our study, as the marker of cellular multiplication Ki-67 was negative in all examined specimens.

Horner syndrome following bolus low dose epidural analgesia for labor

To the Editor: We report herein a case of Horner syndrome following bolus low dose epidural analgesia for labor and vaginal delivery. Although benign and transient, Horner syndrome may be distressing for the patient and confusing on diagnostic approach. A 27-year-old, 68-kg, 161-cm, ASA I primagravida presented in labor at 39 weeks of gestation. Epidural analgesia was provided upon request when the cervix was dilated to 4 cm. With the patient positioned in the left lateral decubitus position, a 18-gauge Tuohy needle was inserted at the L3–L4 intervertebral space; the epidural space was found using the loss-of-resistance technique. A polyamide catheter was easily introduced and placed at the 11-cm catheter mark. A test dose of 2.5 ml 2 % lidocaine was injected. After catheter placement the patient was turned supine with left uterine displacement and was given 8 ml ropivacaine 0.2 % and 50 lg fentanyl. A sensory block to T9 was established a few minutes later. Thirty minutes from the epidural bolus, the patient complained of numbness over the right side of her face and heaviness in her right eyelid. On physical examination, the patient was awake and alert. No signs of hypotension, bradycardia, or desaturation were observed. Right-sided ptosis and miosis were noted; there were no other sensory or motor deficits, and further neurological examination was unremarkable. During this period, fetal monitoring showed no decelerations or bradycardia. Forty minutes after the initial epidural injection, the patient’s symptoms were completely resolved and labor progressed. The same initial bolus dose was repeated and was given in small increments over a 10-min period under close monitoring. Right-sided Horner syndrome developed once again and resolved after approximately 40 min. During the same time, labor progressed uneventfully with vaginal delivery of a healthy male infant. As the patient requested further pain control for perineotomy repair, she was repositioned and then given 5 ml lidocaine 2 %. This dose was effective and was not associated with the development of Horner syndrome. In this case there was no evidence of excessive blockade. Pregnancy venous congestion resulting in decreased epidural compliance and Valsalva maneuver during labor is not always the cause of Horner syndrome, as the same symptoms following low dose epidural infusions have been described in male adults [1] and the pediatric population [2], as well as in trauma patients [3]. An autonomic-like explanation would seem more logical. The true mechanism of this complication may not yet have been discovered. Anesthesiologists, gynecologists, and personnel attending labor should be aware of this rare and confusing complication to reassure the patient and guide their practice according to the patient’s safety and satisfaction.

Effect of a low dose combined oral contraceptive pill on the hormonal profile and cycle outcome following COS with a GnRH antagonist protocol in women over 35 years old

Abstract This prospective study examines if pre-treatment with two different doses of an oral contraceptive pill (OCP) modifies significantly the hormonal profile and/or the IVF/ICSI outcome following COS with a GnRH antagonist protocol. Infertile patients were allocated to receive either OCP containing 0.03 mg of ethinylestradiol and 3 mg of drospirenone, or OCP containing 0.02 mg of ethinylestradiol and 3 mg of drospirenone prior to initiation of controlled ovarian stimulation (COS) with recombinant gonadotropins on a variable multi-dose antagonist protocol (Ganirelix), while the control group underwent COS without OCP pretreatment. Lower dose OCP was associated with recovery of FSH on day 3 instead of day 5, but the synchronization of the follicular cohort, the number of retrieved oocytes and the clinical pregnancy rate were similar to higher dose OCP. Chinese abstract 这个前瞻性的研究是为了检测联合用GnRHa超促排卵方案治疗前用2种不同剂量的口服避孕药是否可以明显改善激素水平和/或IVF/ICSI的结果。不孕患者被分为接受口服避孕药含EE 0.03mg和屈螺酮3mg，或者口服避孕药含EE 0.02mg和屈螺酮3mg，在多剂量变化的GnRHa加重组促性腺激素超促排卵（(Ganirelix)）启动前开始应用，而对照组只用超促排卵治疗不用口服避孕药。低剂量口服避孕药在第3天而不是第5天与FSH的恢复相关，但卵泡同步化及卵母细胞回收及妊娠率方面与口服避孕药较高剂量组相似。

Alpha-Methyldopa-Induced Autoimmune Hemolytic Anemia in the Third Trimester of Pregnancy

Alpha-methyldopa has been demonstrated to be safe for use during pregnancy and is now used to treat gestational hypertension. In pregnancy, alpha-methyldopa-induced autoimmune hemolytic anemia does not have typical features and the severity of symptoms ranges from mild fatigue to dyspnea, respiratory failure, and death if left untreated. A case of alpha-methyldopa-induced autoimmune hemolytic anemia in a 36-year-old gravida 2, para 1 woman at 37+6 weeks of gestation is reported herein along with the differential diagnostic procedure and the potential risks to the mother and the fetus.

Association of Meconium Stained Amniotic Fluid with Fetal and Neonatal Brain Injury

Zoe Iliodromiti1, Charalampos Grigoriadis2, Nikolaos Vrachnis2, Charalampos Siristatidis3, Michail Varras4 and Georgios Creatsas2 1Neonatal Unit, 2nd Department of Obstetrics and Gynecology, University of Athens Medical School, Aretaieio Hospital, Athens, 22nd Department of Obstetrics and Gynecology, University of Athens Medical School, Aretaieio Hospital, Athens, 33nd Department of Obstetrics and Gynecology, University of Athens Medical School, Attiko Hospital, Athens, 4 Department of Obstetrics and Gynecology, Elena Hospital, Athens, Greece