Francesca Rizzello

Does Controlled Ovarian Hyperstimulation in Women with a History of Endometriosis Influence Recurrence Rate

BACKGROUND Endometriosis is a common estrogen-dependent disease. The aim of this study was to assess whether controlled ovarian hyperstimulation (COH) for assisted reproductive technology (ART) was associated with an increased incidence in endometriosis recurrence as documented by transvaginal ultrasound (TV-US). METHODS In a retrospective cohort study of 592 patients submitted to laparoscopy for endometriosis, 177 with infertility-related endometriosis who underwent a periodic ultrasound follow-up after laparoscopy were selected. Women who started ART after laparoscopy (n = 90) were compared with the control group, who did not undergo ART (n = 87). Recurrence of endometriosis was defined as the presence of endometriotic lesions observed through TV-US. RESULTS During a long-term TV-US follow-up (1-15 years), 40 (22.6%) recurrences were observed. Patients submitted to ART showed a cumulative recurrence rate similar to that of the control group (28.6% and 37.9% respectively, p = 0.471). Recurrent lesions were ovarian cysts (47.5%), ovarian nodules (37.5%), and rectovaginal disease (15%). The stratified analysis based on stages of endometriosis and pelvic pain did not show differences. CONCLUSIONS Gonadotropin treatments do not seem to affect the natural history of endometriotic lesions. The most important prognostic factors in recurrent disease observed by TV-US seem to be the stage of endometriosis and the presence of pelvic pain at the time of the first laparoscopic treatment.

Seven-liter ovarian cyst in an adolescent treated by minimal access surgery: laparoscopy and open cystectomy

Laparoscopic approaches to giant ovarian cysts, particularly in adolescents, have critical management concerns as follows: risk of malignancy, risk of cyst rupture, and limited working space. A 15-year-old girl presented with a giant (>25 cm) ovarian serous cyst adenoma containing 7 L of fluid. At open laparoscopy, a giant, entirely cystic, smooth mass originating from the right ovary and lying between the symphysis and the xiphoid was observed. After intraabdominal fluid aspiration, open conservative cystectomy was performed, avoiding spillage. The patient made an uneventful postoperative recovery and was discharged on the second postoperative day. To our knowledge, this is the largest ovarian cyst treated conservatively in an adolescent. Minimal access surgery, laparoscopy and open cystectomy, can be safely proposed in this group of patients. Conservative surgery should always be evaluated for preservation of ovarian function in cases of giant ovarian cysts in adolescents.

Comparison of five classification systems for interpreting electronic fetal monitoring in predicting neonatal status at birth.

Objective: To compare the accuracy of five different classification systems for interpreting electronic fetal monitoring (EFM) when predicting neonatal status at birth, as determined by the umbilical cord arterial pH. Methods: Ninety-seven cardiotocography traces were retrospectively interpreted according to five classification systems for EFM: Dublin Fetal Heart Rate Monitoring Trial (DFHRMT), Royal College of Obstetricians and Gynecologists (RCOG), Society of Obstetricians and Gynaecologists of Canada (SOGC), National Institute of Child Health and Human Development (NICHD) and Parer & Ikeda’s. For each classification system, sensitivity, specificity, positive and negative predictive values were calculated. The capacity of the classifications to predict neonatal pH was also evaluated by receiver-operating characteristic (ROC) curves. Agreement between the five systems was estimated using weighted kappa statistic. Results: Considering pH ≤7.15 as the cutoff for low pH, the sensitivity and specificity values were 100 and 18% (DFHRMT); 100 and 15% (RCOG); 88 and 37% (SOGC); 67 and 92% (NICHD); 55 and 67% (Parer & Ikeda). The ROC curves showed that all classifications analyzed had a low discriminative capacity when predicting umbilical artery pH ≤7.15. An excellent agreement was observed between DFHRMT and RCOG (weighted κ value: 0.860). Conclusions: Parer & Ikeda and NICHD classifications had the highest specificity in detecting umbilical cord arterial pH ≤7.15. The high specificity of the NICHD classification is hindered by a high percentage of “intermediate” traces (80%). Parer & Ikeda classification is the one that best classify as pathological only the traces of fetuses that are truly at risk of acidemia, thus avoiding unnecessary intervention. It also showed the best trade-off between sensitivity and specificity and the lowest rate of traces considered “intermediate.”

Adnexal masses: what is the role of ultrasonographic imaging?

PurposeAdnexal masses represent a common finding among both premenopausal and postmenopausal women. This article will concentrate on the importance of an accurate preoperative diagnosis of adnexal masses that may be encountered in the course of an assessment of the female pelvis. The ultrasonographic modalities including two-dimensional, Doppler, three-dimensional and real-time four-dimensional approach, the accuracy of the technique, and the role of second-level exam will be discussed.MethodsIn this review, we searched for the most relevant articles on the topic with a special focus on the importance of an accurate preoperative diagnosis of adnexal masses, the different ultrasonographic modalities, and the role of second-level exam.ResultsThe primary goal of diagnostic evaluation is to exclude malignancy. Furthermore, differentiation among pelvic masses with non-malignant features is relevant as well since suitable counseling and treatment depend on the suspected histology. Ultrasound represents the first-line modality for assessing adnexal masses and showed a very accurate examination. Ultrasound, performed by experienced operators, is effective in the morphologic evaluation of the adnexal masses and is useful in discriminating between benign and malignant lesions. Second-level exams may include assessment by an experienced ultrasound examiner, magnetic resonance imaging, and computed tomography.ConclusionUltrasound represents the first-line modality for assessing adnexal masses. Predicting the nature of an adnexal mass is essential regarding counseling, clinical management and surgical planning in such patients. Pattern recognition can accurately diagnose the majority of the benign masses and malignancies.

Enhanced Production of Bioactive Isoprenoid Compounds from Cell Suspension Cultures of Artemisia annua L. Using β-Cyclodextrins

Plant cell cultures as valuable tools for the production of specific metabolites can be greatly improved by the application of elicitors including cyclodextrins (CDs) for enhancing the yields of the desired plant compounds. Here the effects of 2,6-dimethyl-β-cyclodextrins (DIMEB) on the production of carotenoids and quinones from Artemisia annua L. cell suspension cultures were investigated. The addition of 50 mM DIMEB induced an early increase of intracellular carotenoid and quinone contents, which could be observed to a higher extent for lutein (10-fold), Q9 (3-fold) and Q10 (2.5-fold). Real Time PCR analysis revealed that the expression of 1-deoxy-d-xylulose-5-phosphate reductoisomerase (DXR) gene in DIMEB treated cell cultures after three days was 2.5-fold higher than in untreated samples, thus suggesting that the DIMEB induced increase of carotenoids and quinones could be due to the induction of the plastidial isoprenoid biosynthetic route. In addition, the DIMEB treatment induced an enhanced release of carotenoids and quinones into the culture medium of A. annua cell suspension cultures possibly due to the ability of CDs to form inclusion complexes with hydrophobic molecules.

Recurrent Pregnancy Losses and Gestational Age Are Closely Related An Observational Cohort Study on 759 Pregnancy Losses

To assess the accurate dating of the cessation of pregnancy in patients with recurrent pregnancy loss (RPL) and to evaluate the incidence and recurrence rate of pregnancy losses in similar gestational age. In a retrospective cohort study, couples with history of RPL and availability of precise documentation regarding previous pregnancy losses were included. The vast majority of losses occurred within the first trimester. In patients experiencing more than 2 miscarriages in the same gestational stage, a tendency for recurrent losses around the same period of gestation was observed. Overall, the probability of losses at different gestational stages goes down with increasing number of miscarriages at the same stage. The study supports the need to ascertain data regarding the timing of pregnancy loss as accurately as possible for prognosis of future pregnancies and management of couples. A classification for unexplained RPL based on gestational age of miscarriages could help researchers to better investigate RPL.

Ultrasound‐guided excision of rectus abdominis muscle endometriosis

We report a rare case of rectus abdominis muscle endometriosis excised under ultrasound guidance. A 36‐year‐old woman came to our observation presenting an abdominal nodule located in the right side of the umbilical area. Ultrasound of the abdominal wall showed two hypoechogenic nodules in the context of the right rectus abdominis muscle and a fine‐needle aspiration, performed under ultrasound guidance, confirmed the diagnosis of endometriosis. The patient underwent surgical excision of the lesions. Intraoperative localization was performed through ultrasonography. In our case, the diagnosis was essentially based on ultrasound scan. Computed tomography and magnetic resonance imaging were not performed. A high‐resolution ultrasound is a simple, inexpensive and safe method and is sufficient for indicating surgery. Furthermore, the use of intraoperative ultrasound allowed adequate margins of excision.

A Biochemical Approach to Detect Oxidative Stress in Infertile Women Undergoing Assisted Reproductive Technology Procedures

Oxidative stress plays a major role in critical biological processes in human reproduction. However, a reliable and biologically accurate indicator of this condition does not yet exist. On these bases, the aim of this study was to assess and compare the blood and follicular fluid (FF) redox status of 45 infertile subjects (and 45 age-matched controls) undergoing in vitro fertilization (IVF), and explore possible relationships between the assessed redox parameters and IVF outcomes. Reactive Oxygen Species (ROS) production, assessed by flow cytometry analysis in blood leukocytes and granulosa cells, significantly increased (p < 0.05) in infertile patients. Also, oxidative stress markers—ThioBarbituric Acid-Reactive Substances (TBARS) as an index of lipid peroxidation, and Oxygen Radical Absorbance Capacity (ORAC) to account for total antioxidant capacity, both assayed by fluorometric procedures—in blood and FF were significantly (p < 0.001) modified in infertile patients compared to the control group. Moreover, a significant correlation between blood redox markers and FF redox markers was evident. An ORAC/TBARS ratio, defined as the redox index (RI), was obtained in the plasma and FF of the patients and controls. In the patients, the plasma RI was about 3.4-fold (p < 0.0001) lower than the control, and the FF RI was about six-fold (p < 0.0001) lower than the control. Interestingly, both the plasma RI and FF RI results were significantly correlated (p < 0.05) to the considered outcome parameters (metaphase II, fertilization rate, and ongoing pregnancies). Given the reported findings, a strict monitoring of redox parameters in assisted reproductive techniques and infertility management is recommended.

Sonographic diagnosis of a large and deep endometrioma of the uterine cervix

We present a rare case of endometriosis of the cervix. Transvaginal sonography showed a 35‐mm cyst in the cervix with diffuse, low‐level internal echoes. Transvaginal sonography‐guided aspiration with a 17‐gauge needle was performed, yielding a very thick chocolate‐colored fluid. Cytological examination of the fluid revealed the presence of endometrial cells. Symptoms resolved after aspiration and no recurrence has developed.

Role of Infection in In Vitro Fertilization Treatment

Abstract: With the increasing demand for assisted reproductive techniques (ARTs), it is important to consider how to manage infection. Three main positive factors that contribute to successful in vitro fertilization (IVF) cycles are maternal age, the ovarian hyperstimulation protocol used, and the number and quality of transferred embryos. Negative factors include contamination and infection. This paper describes the issues relating to infection during IVF and proposes guidelines to control infection and to increase laboratory safety.