Guido Ambrosini

Genital tract infections and infertility.

Infectious agents can impair various important human functions, including reproduction. Bacteria, fungi, viruses and parasites are able to interfere with the reproductive function in both sexes. Infections of male genito-urinary tract account for about 15% of the case of male infertility. Infections can affect different sites of the male reproductive tract, such as the testis, epididymis and male accessory sex glands. Spermatozoa themselves subsequently can be affected by urogenital infections at different levels of their development, maturation and transport. Among the most common microorganisms involved in sexually transmitted infections, interfering with male fertility, there are the Chlamydia trachomatis and Neisseria gonorrhoeae. Less frequently male infertility is due to non-sexually transmitted epididymo-orchitis, mostly caused by Escherichia coli. In female, the first two microorganisms are certainly involved in cervical, tubal, and peritoneal damage, while Herpes simplex cervicitis is less dangerous. The overall importance of cervical involvement is still under discussion. Tubo-peritoneal damage seems to be the foremost manner in which microorganisms interfere with human fertility. C. trachomatis is considered the most important cause of tubal lacerations and obstruction, pelvic inflammatory disease (PID) and adhesions. N. gonorrhoeae, even though its overall incidence seems to decline, is still to be considered in the same sense, while bacterial vaginosis should not be ignored, as causative agents can produce ascending infections of the female genital tract. The role of infections, particularly co-infections, as causes of the impairment of sperm quality, motility and function needs further investigation. Tropical diseases necessitate monitoring as for their diffusion or re-diffusion in the western world.

Doppler, cardiotocography, and biophysical profile changes in growth-restricted fetuses.

OBJECTIVE: To assess from diagnosis to delivery the Doppler studies of the umbilical artery, middle cerebral artery, umbilical vein, ductus venosus, and amniotic fluid index of fetuses with idiopathic growth restriction. METHODS: A total of 145 singleton growth-restricted fetuses with abnormal umbilical artery pulsatility indexes were studied. Cesarean delivery was performed because of abnormal biophysical profile or nonreassuring fetal heart rate pattern. RESULTS: There were 4 fetal and 50 neonatal deaths. Two growth-restricted groups were identified: Group A (n = 44) included fetuses in whom all measures became abnormal preceding an abnormal biophysical profile or nonreassuring nonstress test. Group B (n = 101) included fetuses in whom 1 or more measures were normal at the time of cesarean delivery. There was no statistically significant difference in perinatal morbidity and mortality between the 2 groups. Neonatal death was increased in fetuses with umbilical artery reversed flow (odds ratio 2.34, 95% confidence interval 1.16–4.73; P < .05) and ductus venosus reversed flow (odds ratio 4.18, 95% confidence interval 2.01–8.69; P < .05). A significant correlation was also found between low birth weight and adverse perinatal outcome. CONCLUSION: In fetuses with idiopathic growth restriction, 1) low birth weight, 2) umbilical artery reversed flow, and 3) ductus venosus absent or reversed flow are associated with an increased perinatal morbidity and mortality. LEVEL OF EVIDENCE: II-2

Sonovaginography is a new technique for assessing rectovaginal endometriosis

OBJECTIVE To evaluate the efficacy of a new technique, the sonovaginography, for the assessment of rectovaginal endometriosis. DESIGN Prospective study. SETTING University hospital. PATIENT(S) Forty-six women were scheduled for laparotomic or laparoscopic surgery because of rectovaginal endometriosis suspected on the basis of patient history and/or clinical examination. INTERVENTION(S) Before surgery, all the women underwent transvaginal ultrasonography and then sonovaginography. The latter is based on transvaginal ultrasonography combined with the introduction of saline solution to the vagina that creates an acoustic window between the transvaginal probe and the surrounding structures of the vagina. Ultrasound findings were compared with the results of surgical exploration and histological examination. MAIN OUTCOME MEASURE(S) We assessed the accuracy of transvaginal ultrasonography and of sonovaginography for the detection and the location and extension assessment of rectovaginal endometriotic lesions, as well as compared patient compliance between the procedures. RESULT(S) Sonovaginography diagnosed rectovaginal endometriosis more accurately than did transvaginal ultrasonography, with a sensitivity and specificity of 90.6% and 85.7%, respectively, whereas the transvaginal ultrasonography has shown a sensitivity and specificity of 43.7% and 50%, respectively. Patient discomfort did not differ significantly between the procedures. CONCLUSION(S) Sonovaginography is a reliable and simple method for the assessment of rectovaginal endometriosis and provides information on location, extension, and infiltration of the lesions, which are important factors in selecting the kind of surgery.

Efficacy of low-dose intravaginal estriol on urogenital aging in postmenopausal women

Objective To assess the efficacy and safety of intravaginal estriol administration on urinary incontinence, urogenital atrophy, and recurrent urinary tract infections in postmenopausal women. Design Eighty-eight postmenopausal women with urogenital aging symptoms were enrolled in this prospective, randomized, placebo-controlled study. Participants were randomly divided into two groups, with each group consisting of 44 women. Women in the treatment group received intravaginal estriol ovules: 1 ovule (1 mg) once daily for 2 weeks and then 2 ovules once weekly for a total of 6 months as maintenance therapy. Women in the control group received inert placebo vaginal suppositories in a similar regimen. We evaluated urogenital symptomatology, urine cultures, colposcopic findings, urethral cytologic findings, urethral pressure profiles, and urethrocystometry before as well as after 6 months of treatment. Results After therapy, the symptoms and signs of urogenital atrophy significantly improved in the treatment group in comparison with the control group. Thirty (68%) of the treated participants, and only seven (16%) of the control participants registered a subjective improvement of their incontinence. In the treated participants, we observed significant improvements of colposcopic findings, and there were statistically significant increases in mean maximum urethral pressure, in mean urethral closure pressure as well as in the abdominal pressure transmission ratio to the proximal urethra. Urethrocystometry showed positive but not statistically significant modifications. Conclusions Our results show that intravaginal administration of estriol may represent a satisfactory therapeutic choice for those postmenopausal women with urogenital tract disturbances who have contraindications or refuse to undergo standard hormone therapy.

Healthy twins delivered after oocyte cryopreservation and bilateral ovariectomy for ovarian cancer

Anti-neoplastic treatments have significantly increased the survival of cancer patients, but female patients risk premature menopause. Oocyte cryopreservation has been proposed as a fertility-saving option. This report describes the first live birth achieved with autologous cryopreserved oocytes in an ovariectomized borderline cancer patient. A patient with a borderline ovarian tumour asked for oocyte cryopreservation after a right adnexectomy. Ovulation induction resulted in the retrieval and cryopreservation of seven mature oocytes. Thirty-nine months after a left ovariectomy, the patient asked for oocyte thawing and embryo transfer. Endometrial growth was induced using hormone replacement treatment. Three of the seven cryopreserved oocytes were thawed; they survived and, after insemination, normal fertilization took place. Three embryos were transferred into the patients uterus. A twin pregnancy was achieved with the birth of two healthy females. Oocyte cryopreservation may be a reliable option for preserving fertility in young cancer patients who risk premature menopause due to surgery, chemotherapy or radiotherapy.

Outpatient operative polypectomy using a 5 mm-hysteroscope without anaesthesia and/or analgesia: Advantages and limits

OBJECTIVE To assess the predictors of office-based operative hysteroscopic polypectomy using a 5.2mm continuous flow office hysteroscope without anaesthesia and/or analgesia for the treatment of endometrial and/or isthmic polyps and to define procedure limits. STUDY DESIGN Women with hysteroscopic diagnosis of endometrial or isthmic polyps were offered to proceed in the same session with operative hysteroscopy after 15 min without anaesthesia and/or analgesia. All procedures were performed using a 5.2 mm continuous flow office hysteroscope. Patient procedure compliance was assessed by means of a visual analogue scale (VAS) using a rating scale with 11 categories. A VAS < or = 4 was considered as patient procedure compliance. Regression analysis was performed to correlate the following variables: time required, size and number of polyps with VAS. A ROC analysis was performed to assess the cut-off of the strongest predictors. The influence of previous vaginal delivery and menopausal status was correlated with the VAS. RESULTS A total of 217 women underwent the office-based hysteroscopic procedure and 253 polyps were removed, among them 170 were endometrial and 83 isthmic polyps. There were 181 women with single polyps and 36 women presented multiple polyps. The size of polyps ranged from 0.5 to 5 cm. Median time of the procedure was 10 min (range 3-30 min). Regression analysis showed a statistical significative correlation between VAS and size of polyps and between VAS and operating time independent to the number of polyps. Using the ROC analysis a VAS < or = 4 was obtained when polyps were < or = 2 cm and/or time of the procedure lasted < or = 15 min. Menopausal status and previous vaginal deliveries were not significantly correlated to the VAS. CONCLUSIONS Office-based hysteroscopic polypectomy is a safe and feasible procedure and should be addressed in patients with endometrial or isthmic polyps < or = 2 cm in diameter, and the procedure limits in terms of patient procedure compliance are size of polyps and operating time, independent from menopausal status and previous vaginal delivery.

Postpartum ovarian vein thrombosis: an unpredictable event: two case reports and review of the literature

Abstract. Ovarian vein thrombosis (OVT) is a rare but serious postpartum complication that, in most cases, occurs in the right ovarian vein. Certain diagnosis, following clinical suspect because of lower quadrant tenderness and fever that alone does not respond to adequate broad-spectrum antibiotics, is now based on computed tomography (CT), although other imaging techniques, such as color Doppler ultrasonography and magnetic resonance (MR) imaging, are useful. Heparin and intravenous antibiotics are the mainstay of treatment so as to avoid laparotomy. We report on the management of two cases of postpartum OVT.

Placental Corticotropin‐Releasing Factor An Update

Abstract: Corticotropin‐releasing factor (CRF) produced in placenta has paracrine effects within placenta, decidua, and myometrium and endocrine effects on mother and fetus. CRF is a potent local regulator of myometrial contractility and of prostaglandin release, Recently, urocortin, a new member of the CRF family, has been localized in human placenta and membranes. Urocortin mimics some of the local effects of CRF in intrauterine tissues, that is, increase of adrenocorticotrophic hormone (ACTH) and prostagiandin release and myometrial contractility. A local CRF‐BP modulates the paracrine effects of CRF and urocortin. The various CRF receptor subtypes are well distributed in placenta and membranes. CRH also acts on placental blood vasculature and has an action on fetal adrenal gland to stimulate the productlon of the steroid DHEA‐S. In nonpregnant women, plasma CRF levels are low; they become higher during the first and second trimesters of pregnancy. A clear increase is evident at term and when CRF‐BP levels decrease. Women with preterm labor show high CRF and low CRF‐BP levels, supporting an involvement of this pathway in mechanism of parturition.

Evidence for local production of inhibin A and activin A in patients with ovarian endometriosis.

OBJECTIVE To evaluate the expression of inhibin A and activin A in ovarian endometriosis. DESIGN Uncontrolled cross-sectional study and controlled prospective in vitro study. SETTING Academic health centers in Siena, Udine, Sassari, and Milan, Italy. PATIENT(S) A group of women (n = 19) who underwent laparoscopic excision of ovarian endometriotic cysts. INTERVENTION(S) Specimens of serum, peritoneal fluid, and cystic fluid, ovarian tissue for immunohistochemistry, and endometriotic cells for primary culture were collected. Cell cultures were also prepared from proliferative endometrium of women without endometriosis. MAIN OUTCOME MEASURES Dimeric inhibin A and activin A concentrations in biological fluids; immunostaining of alpha and betaA subunits in ovarian endometrioma; alpha and betaA gene expression in cultured endometriotic cells compared with normal endometrium. RESULT(S) Inhibin A and activin A concentrations in the cystic fluid were slightly higher than in peritoneal fluid and significantly higher than in serum (P<.05). Immunoreactive alpha and betaA subunits were strongly expressed both in the epithelial and stromal components of ovarian endometrioma. The relative abundance of betaA mRNA was significantly decreased in endometriotic cells compared with eutopic stromal cells. CONCLUSION(S) The results of the present study provide evidence for a local production and secretion of inhibin A and activin A in ovarian endometriotic cysts.

Side effects and complications of sonohysterosalpingography

OBJECTIVE To evaluate the side effects and complications of, difficulties with, and possible solutions to the problems associated with sonohysterosalpingography. DESIGN Prospective study. SETTING University hospital. PATIENT(S) One thousand, one hundred fifty-three patients who underwent sonohysterosalpingography to investigate abnormal uterine bleeding, infertility, thick endometrium at transvaginal ultrasonography, müllerian abnormalities, or the Asherman syndrome. MAIN OUTCOME MEASURE(S) Side effects and complications of and difficulties related to the procedure. Tolerance was assessed by using a pain-rating scale. RESULT(S) Ninety-three percent (1,074 of 1,153) procedures were performed correctly. Investigation was not completed in 79 (7%) women; a second attempt was successful in 60 of these patients. Side effects, such as moderate or severe pelvic pain, vasovagal symptoms, nausea, and vomiting, occurred in 102 (8.8%) women. Such complications as fever and peritonitis occurred in 0.95% of patients. CONCLUSION(S) Sonohysterosalpingography is a simple, safe, and well-tolerated technique that has a low rate of side effects and rare complications.