Daniela Marconi

Hysteroscopic Findings in 344 Women with Recurrent Spontaneous Abortion

STUDY OBJECTIVEnTo evaluate the prevalence of different anatomic factors in women with recurrent spontaneous abortion (RSA).nnnDESIGNnRetrospective analysis over 9 years (Canadian Task Force classification II-2).nnnSETTINGnUniversity hospital-affiliated endoscopic unit.nnnPATIENTSnThree hundred forty-four consecutive patients with RSA and 922 controls referred for abnormal uterine bleeding.nnnINTERVENTIONnDiagnostic hysteroscopy.nnnMEASUREMENTS AND MAIN RESULTSnMajor and minor uterine mullerian abnormalities (septate, unicornuate uteri) were found significantly more often in women with RSA than in controls (32% vs 6%, p <0.001). The frequency of acquired uterine anomalies (submucous myomas, polyps) was significantly higher in controls (32% vs 9%, p <0.001). No significant differences were observed between groups in frequency of adhesions (4% vs 2%).nnnCONCLUSIONnMajor mullerian uterine abnormalities are associated with RSA, and minor uterine anomalies may be correlated with an increased risk of recurrent miscarriage.

Hysteroscopic Metroplasty Improves Gestational Outcome in Women with Recurrent Spontaneous Abortion

STUDY OBJECTIVEnTo compare the reproductive outcome in women with recurrent spontaneous abortion (RSA) associated with septate uterus after hysteroscopic metroplasty compared with patients who did not undergo surgery.nnnDESIGNnLongitudinal evaluation (Canadian Task Force classification II-2).nnnSETTINGnUniversity of Rome, Tor Vergata-affiliated endoscopic unit.nnnPATIENTSnForty-eight consecutive women with septate uterus and RSA were enrolled in the study.nnnINTERVENTIONSnHysteroscopic metroplasty.nnnMEASUREMENTS AND MAIN RESULTSnReproductive outcome in terms of term pregnancy was significantly improved after hysteroscopic metroplasty compared with controls (76% vs. 20%). No differences were found in the prevalence of preterm delivery between groups (4% vs. 5%).nnnCONCLUSIONnOur data suggest that hysteroscopic septum incision can improve pregnancy outcome in patients with RSA associated with septate uterus.

Selective uterine artery embolization in the management of uterine myomas

OBJECTIVEnTo evaluate the effectiveness of uterine artery embolization in women with uterine myomas in terms of the clinical results for the relief of related symptoms.nnnDESIGNnA pilot study on 26 women affected by uterine single myoma.nnnSETTINGnTertiary level care in an university hospital.nnnPATIENT(S)nTwenty-six patients, aged 32 to 54 years, suffering of menorrhagia, pelvic pain, and abdominal mass for single myoma, intramural localization.nnnINTERVENTION(S)nSelective uterine artery embolization performed under peridural anesthesia.nnnMAIN OUTCOME MEASURE(S)nWe measured the x-ray dose to which patients were exposed. Color power Doppler ultrasound examinations were performed during the follow-up evaluations at 1 to 6 months and 1 year after the procedure.nnnRESULT(S)nUterine artery embolization was successfully performed in 100% of cases. The mean fluoroscopy time was of 20 minutes during the procedure. The mean dose of x-ray absorbed by the ovary was estimated at 18.7 cGy and the mean dose of x-ray absorbed by the skin was 126.7 cGy. A reduction of myoma volume of 55% was found at 6 months ultrasound examination and 75% at the 1-year examination.nnnCONCLUSION(S)nPatients are well satisfied and have short recovery times with this procedure. Uterine artery embolization may be a valid alternative to traditional surgery.

Differential Expression of IGF-I and IGF-II in Eutopic and Ectopic Endometria of Women With Endometriosis and in Women Without Endometriosis

PROBLEM: Factors regulating the development, growth, and differentiation of endometrial cells of endometriotic lesions are poorly understood. To investigate the paracrine‐autocrine regulation of ectopic endometrial cell growth, the expression of IGF‐I and IGF‐II were studied.

Transvaginal sonographic and hysteroscopic findings in postmenopausal women receiving tamoxifen

STUDY OBJECTIVEnTo evaluate the effect of tamoxifen on the endometrium.nnnDESIGNnProspective study.nnnSETTINGnDepartment of Obstetrics and Gynecology of the University of Rome.nnnPATIENTSnOne hundred one postmenopausal women with breast cancer receiving tamoxifen 20 to 30 mg/day for at least 1 year; of these 78 were asymptomatic and 23 had vaginal bleeding.nnnINTERVENTIONSnAll patients underwent transvaginal color Doppler sonography. Those with endometrial thickness greater than 5 mm were advised to undergo hysteroscopy and if necessary endometrial biopsy. For women with endometrial thickness less than 5 mm, hysteroscopy was recommended only if irregular endometrial echotexture was observed.nnnMEASUREMENTS AND MAIN RESULTSnEleven (14%) asymptomatic patients and 1 (4.3%) with vaginal bleeding had endometrial thickness less than 5 mm (p = 0.4, NS). Women with vaginal bleeding had a significantly thicker endometrium than asymptomatic patients (15.8 +/- 7.5 vs 11.1 +/- 5.7 mm, p = 0.003). In the asymptomatic group 31 polyps, 15 atrophic endometria, and 6 hyperplasias were observed. Two endometrial cancers, 13 polyps, and 3 hyperplasias were detected in patients with vaginal bleeding. Hysteroscopy did not always allow endometrial biopsy, even in the presence of increased endometrial thickness with or without irregular surface. No statistical differences were found for mean pulsatility and resistance indexes of uterine and endometrial arteries between symptomatic and asymptomatic women, but these indexes were significantly lower compared with normal postmenopausal values.nnnCONCLUSIONnWomen receiving tamoxifen, especially those who are asymptomatic, should be closely monitored by transvaginal sonography and hysteroscopy to detect endometrial pathologies.

Myolysis of uterine fibroids: is there a role?

Myolysis is among the new procedures under development for the treatment of symptoms related to uterine leiomyoma. The procedure targets the destruction of fibroids using one of a number of focused energy delivery systems including those based upon radiofrequency electricity, supercooled cryoprobes, and, most recently, focused ultrasound monitored by real time magnetic resonance imaging. For thermomyolysis and cryomyolysis, delivery of the energy requires access to the tissue by laparoscopy, and, in some instances, hysteroscopy. For focused ultrasound, the patient is detached from the energy source, which is delivered by an array of external beams. Clinical evaluation has been confined to case series, but it is evident that the approach results in a variable degree of reduction of the total uterine mass, and, usually, a reduction in uterine bleeding. Clearly, longer term appropriately designed comparative trials are required that evaluate and compare myolysis with myomectomy, uterine artery embolization, and hysterectomy, to name a few.

TNFα Expression in Hyperplastic Endometrium

PROBLEM: Tumor necrosis factor‐alpha (TNFα) is produced by the endometrium, and it has been shown that this cytokine has cyclic variations through the menstrual cycle.u2028 METHOD OF STUDY: In this study we assessed TNFα, estradiol and progesterone levels in the endometrium and serum of 21 patients with recent abnormal uterine bleeding (AUB). Eleven women showed histological diagnosis of endometrial hyperplasia, and ten women showed normal endometrium.u2028 RESULTS: The TNFα value in the serum of patients with hyperplasia and in normal endometrium did not show significant differences (64.8±21.4 vs 77.6±14.8 pg). The amounts of TNFα released by hyperplastic endometrial tissue were significantly higher than in control patients (258.8±78.0 vs 140.6±79.8 pg/g; P<0.001). Immunohistochemistry of hyperplastic endometria showed a stronger staining than normal ones. Serum E2 levels in patients with hyperplastic endometrium were 49.5±31.6 ng/mL, and in controls were 107.3±66.0 ng/mL. The levels of estradiol released by hyperplastic endometria were significantly lower than in normal endometria (152.7±60.0 vs 279.9±178.7 ng/g; P<0.003).u2028 CONCLUSIONS: Hyperplastic endometria produce higher amounts of TNFα with respect to controls. These findings may explain the frequent bleeding observed in the patients with endometrial hyperplasia, since TNFα promotes apoptosis and endometrial shedding.

The use of topical anesthesia in diagnostic hysteroscopy and endometrial biopsy

STUDY OBJECTIVEnTo determine whether the pain and discomfort of routine hysteroscopy with endometrial biopsy to diagnose infertility and endometrial pathology can be minimized by topical application of mepivacaine.nnnDESIGNnProspective, randomized, double-blind study.nnnSETTINGnThe Department of Obstetrics and Gynecology at a teaching hospital in Rome, Italy.nnnPATIENTSnEighteen women undergoing diagnostic hysteroscopy.nnnINTERVENTIONSnHysteroscopy and endometrial biopsy were performed after transcervical injection of 5 ml 2% mepivacaine or 5 ml saline solution into the uterine cavity.nnnMEASUREMENTS AND MAIN RESULTSnDifficulty introducing the hysteroscope was rated by the operator on a scale of 1 to 3. An observer scored visible signs of each womans distress using a three-point scale. The patients reported their pain 15, 30, 60, 120 minutes after the procedure on a visual analog scale. Mepivacaine was more effective than placebo according to all measurements.nnnCONCLUSIONSnTopical mepivacaine reduced the pain experienced during and after hysteroscopy and endometrial biopsy.

New tool (Laparotenser) for gasless laparoscopic myomectomy: a multicenter-controlled study

OBJECTIVEnTo assess feasibility and safety of a new surgical instrument-Laparotenser-in the procedure of gasless laparoscopic myomectomy.nnnDESIGNnMulticenter controlled study.nnnSETTINGnAcademic departments of obstetrics and gynecology, Italy.nnnPATIENT(S)nThirty patients scheduled for gasless laparoscopic myomectomy (experimental group) and another group of 30 patients from our historical records that have undergone traditional laparoscopic myomectomy, matched with the cases for number of fibroids and for size of the main fibroid (control group).nnnINTERVENTION(S)nGasless laparoscopic myomectomy using Laparotenser.nnnMAIN OUTCOME MEASURE(S)nSurgical data.nnnRESULT(S)nNo significant differences in total operative time, postoperative ileus, hospitalization, time to return to full activity/work, and complication rates were observed between groups. Intraoperative blood loss, hemoglobin level, and surgical difficulty were significantly higher in the experimental than in the control group. Postoperative pain and number of analgesic vials used were significantly lower in the experimental group than in the control group.nnnCONCLUSION(S)nAlthough performed during the learning curve period, the use of the Laparotenser instrument in gasless laparoscopic myomectomy is a safe procedure.

PreImplantation Factor in endometriosis: A potential role in inducing immune privilege for ectopic endometrium.

Endometriosis is a chronic inflammatory condition characterised by the growth of endometrial epithelial and stromal cells outside the uterine cavity. In addition to Sampson’s theory of retrograde menstruation, endometriosis pathogenesis is facilitated by a privileged inflammatory microenvironment, with T regulatory FoxP3+ expressing T cells (Tregs) being a significant factor. PreImplantation Factor (PIF) is a peptide essential for pregnancy recognition and development. An immune modulatory function of the synthetic PIF analog (sPIF) has been successfully confirmed in multiple animal models. We report that PIF is expressed in the epithelial ectopic cells in close proximity to FoxP3+ stromal cells. We provide evidence that PIF interacts with FoxP3+ cells and modulates cell viability, dependent on cell source and presence of inflammatory mediators. Our finding represent a novel PIF-based mechanism in endometriosis that has potential for novel therapeutics.