Giuliana Di Nola

Reproductive prognosis after hysteroscopic metroplasty in 102 women: life-table analysis

OBJECTIVE To evaluate reproductive prognosis after hysteroscopic metroplasty. DESIGN The cumulative proportions of women who became pregnant and gave birth, subdivided according to previous obstetric history, were calculated by the product limit method and compared using the log rank test. SETTING Outpatient infertility clinic of Milan University. PATIENTS One hundred two consecutive patients with complete (n = 23) or partial septate uterus (n = 79) referred because of infertility or repeated abortion. INTERVENTION Hysteroscopic metroplasty performed by microscissors (n = 80), argon laser (n = 10), or electroresectoscope (n = 12). MAIN OUTCOME MEASURES Postoperative cumulative pregnancy and birth rates. RESULTS At 36 months the cumulative pregnancy and birth rates were 89% and 75%, respectively, in the septate uterus group and 80% and 67% in the subseptate uterus group. CONCLUSIONS Reproductive prognosis after hysteroscopic metroplasty was favorable and not influenced by the malformation subclass.

Presacral neurectomy for the treatment of pelvic pain associated with endometriosis: A controlled study

OBJECTIVE Our objective was to evaluate the efficacy of presacral neurectomy combined with conservative surgery for the treatment of pelvic pain associated with endometriosis. STUDY DESIGN In a randomized, controlled study performed in a tertiary institution 71 patients with moderate or severe endometriosis and midline dysmenorrhea were randomly assigned to conservative surgery alone (n = 36) or conservative surgery and presacral neurectomy (n = 35). Main outcome measures were relief of dysmenorrhea, pelvic pain, and deep dyspareunia after surgery according to a multidimensional and an analog pain scale. RESULTS Presacral neurectomy markedly reduced the midline component of menstrual pain, but no statistically significant differences were observed between the two groups in the frequency and severity of dysmenorrhea, pelvic pain, and dyspareunia in the long-term follow-up. After presacral neurectomy, constipation developed or worsened in 13 patients and urinary urgency occurred in three and a painless first stage of labor in two. CONCLUSION Presacral neurectomy should be combined with conservative surgery for endometriosis only in selected cases.

Buserelin acetate in the treatment of pelvic pain associated with minimal and mild endometriosis: a controlled study *

OBJECTIVE To evaluate the changes of pain symptoms induced by buserelin acetate, a gonadotropin-releasing hormone agonist, in a group of patients with endometriosis. DESIGN Thirty-five infertile patients with one or more of the following symptoms (dysmenorrhea, pelvic pain, deep dyspareunia, and endometriosis stage I or II) were allocated randomly to treatment with buserelin acetate 1,200 micrograms/d IN for 6 months (n = 19) or expectant management (n = 16). Pain symptoms were recorded by the women themselves using a questionnaire that included two scales for pain evaluation: one analogue and one multidimensional. The treated and untreated patients were followed for a minimum of 18 and 12 months from the time of randomization, respectively. RESULTS Buserelin acetate markedly reduced dysmenorrhea, pelvic pain, and dyspareunia during the treatment and also for the 12 subsequent months. During follow-up of the expectant management group, dysmenorrhea resolved in 19% (3/16) of the cases, and pelvic pain did not recur after diagnostic laparoscopy in one of the three women affected nor did deep dyspareunia in two of the five who reported the symptom before laparoscopy. CONCLUSION Buserelin acetate induced a significant improvement of pain symptoms that persisted in approximately half of the patients even after withdrawal of the drug. However, symptoms associated with endometriosis showed a spontaneous remission in approximately one fifth of the untreated patients.

The Recurrence of Endometriosis

The possibility of endometriosis recurrence after treatment is commonly considered a proof of the difficulty of eradicating the disease and its progressive nature. However, the natural history of endometriosis is unclear and the real rate of recurrence is uncertain. According to both the most accredited pathogenetic theories-implantation and coelomic metaplasia-there may be a state of equilibrium between factors that favor and those that limit the growth of implants with the consequence of static lesions, and an alteration of this equilibrium with the consequence of spread of the disease. Both theories are also compatible with the possibility that after complete elimination of the existing implants the factors that led to the original development of the disease may re-emerge, thus explaining the recurrence. Only a few of the studies investigating the course of endometriosis have done so prospectively. Repeat laparoscopy performed by Thomas and Cooke’ on 17 women with minimal and mild endometriosis after 6 months of placebo treatment revealed progression of the lesions in eight of them, improvement in five and total disappearance in four. Progression of nonpigmented lesions to typical pigmented ones was first observed by Janssen and Russel2 in six patients who underwent two laparoscopies at an interval of 6 to 24 months. The results of two different cross-sectional studies suggest that the nature of endometriosis, at least that of peritoneal disease, is substantially static. In 1987 Redwine3 reported that the number of pelvic areas involved in the disease does not increase with advancing age. More recently Koninckx et observed no increase of the total pelvic area involved in endometriosis with an advance in age although the depth of infiltration of the implants was greater and also the incidence of endometriomas. The finding5 that endometriotic foci are detectable by microscopy in apparently intact peritoneal areas has been confirmed many times. Such foci could progress to form visible and clinically relevant implants. The currently available data indicate that ex nouo formation of implants is a relatively infrequent phenomenon whereas lesions appear potentially progressive in about 50% of affected women. Many disease recurrences could represent the evolution of foci not visible at the time of diagnosis and treatment or be due to unrecognized subperitoneal lesions. Another not infrequent cause of recurrence is inadequate, not radical treatment.

Endometrial patterns during therapy with danazol or gestrinone for endometriosis: structural and ultrastructural study

We treated 36 women with laparoscopically proven endometriosis with danazol 600 mg/d (n = 17) or gestrinone 5.0 mg/wk (n = 19) for 6 months. Endometrial samples were obtained before and at 3 and 6 months of treatment and were studied by light, scanning, and transmission electron microscopy. At 3 months of treatment, the endometria of the danazol-treated patients were more atrophic than those of the women who received gestrinone. Some cell organelle involution was evident in patients of both treatment groups. After 6 months of treatment, marked endometrial atrophy was observed in all the patients, including those in whom spotting had occurred. The ultrastructural investigation demonstrated complete involution of the cytoplasmic organelles with cytoplasmic collapse in glandular cells of patients treated with danazol, whereas in the gestrinone group degeneration phenomena were observed in both nucleus and cytoplasm. Irregular secretory transformation was seen in the endometria of patients in both groups. Long-term treatment with danazol caused endometrial atrophy similar to that induced by gestrinone, but it appeared earlier; thus, the former drug seems preferable in short-term treatment.

Relief of dysmenorrhea associated with septate uteri after abdominal or hysteroscopic metroplasty

We analyzed the postoperative modifications of dysmenorrhea in 90 patients with septate or subseptate uterus, but no other genital or pelvic disorders, who underwent metroplasty according to Tompkins (n = 28) or hysteroscopic metroplasty (n = 62). The frequency of dysmenorrhea fell from 50% to 32.1% after the Tompkins procedure and from 54.8% to 17.7% after hysteroscopic metroplasty. The severity of dysmenorrhea evaluated with two scales, one linear and one multidimensional, showed a significant postoperative decrease in both the groups. In view of the limited cost and low risks of hysteroscopic metroplasty, primary dysmenorrhea associated with septate or subseptate uterus may be considered an indication for this intervention.

Endometrial patterns during danazol and cyproterone acetate treatment for endometriosis: structural and ultrastructural study

We studied the endometrial structure and ultrastructure in serial biopsies from 16 patients with endometriosis treated with danazol (n = 9) or the combination cyproterone acetate plus ethinyl estradiol (n = 7) for 6 months. Biopsies were performed before and at 3 and 6 months of treatment. The material obtained was studied by light (LM), scanning (SEM) and transmission electron microscopy (TEM). A morphometric analysis was performed evaluating three morphometric and three stereologic indices. The results indicate that danazol had a progestational effect on endometrial glands and stroma, associated with a marked hypotrophy of the mucosa. The cyproterone acetate/ethinyl estradiol combination induced progressive atrophy of the endometrium with an increase in the stromal component and a reduction of glandular tissue.

Ultrastructural aspects of endometrial surface in Kartagener’s syndrome

The endometrium of an infertile patient with Kartageners syndrome showed initial secretory phase characteristics at SEM, whereas TEM analysis demonstrated several alterations in the central and peripheral microtubular distribution in 87% of the cilia examined. Such aspects seemed appropriate for a normal implantation, but the ciliary immotility or dyskinesia could cause an altered flow of the endometrial secretions and compromise the upstream movement of the spermatozoa.