Luca Bruni

Surgical Hysteroscopic Treatment of Cesarean-Induced Isthmocele in Restoring Fertility: Prospective Study

The reproductive outcome in 41 consecutive patients with cesarean-induced isthmocele and secondary infertility was evaluated prospectively. Patients included menopausal women (mean [SD; 95% CI] age, 35 [4.1; 29-42] years), with fertility duration of 3 to 8 (4.6 [28]) years with isthmocele, postmenstrual abnormal uterine bleeding, and suprapubic pelvic pain. Transvaginal ultrasound and office hysteroscopy were used to diagnosis isthmocele. Complete fertility tests were performed to exclude other causes of infertility in both female and male participants. Operative hysteroscopy was performed to correct the cesarean scar defect, and histologic findings were evaluated. Correction of isthmocele via operative hysteroscopy was successful in all cases evaluated. Patients became pregnant spontaneously between 12 and 24 months after isthmoplasty. Thirty-seven of the 41 patients (90.2%) delivered via cesarean section, and 4 (9.8%) had a spontaneous abortion in the first trimester. Isthmoplasty resulted in resolution of postmenstrual abnormal uterine bleeding and suprapubic pelvic pain in all patients. Thus, it was concluded that surgical treatment of cesarean-induced isthmocele using a minimally-invasive approach (operative hysteroscopy) restores fertility and resolves symptoms in women with a cesarean section scar and secondary infertility.

A retrospective case-control study comparing hysteroscopic resection versus hormonal modulation in treating menstrual disorders due to isthmocele.

In a retrospective case–control study, we compared the effectiveness of hysteroscopic correction and hormonal treatment to improve symptoms [postmestrual abnormal uterine bleeding (PAUB), pelvic pain localized in suprapubic site] associated with isthmocele. Women (n = 39; mean age ± SD, 35 ± 4.1 years) were subdivided in Group A [patients (n = 19) subjected to hysteroscopic surgery (isthmoplasty)] and, Group B [women (n = 20) undergoing hormonal treatment consisting of one oral tablet containing 0.075 mg of Gestodene and 0.030 mg of Ethynylestradiol for 21 days, followed by 7 days of suspension]. Resolution and/or improvement of menstrual disorders; patients degree of satisfaction with the treatment were measured 3 months later, by office hysteroscopy (Grop A) or phone call. PAUB and pelvic pain resolution was achieved in all patients: Group A had significant lower numbers of days of menstrual bleeding (P < 0.001), prevalence of pelvic pain in the suprapubic area (P = 0.04) and, higher degree of satisfaction (P < 0.001) compared to Group B. In conclusion, resectoscopic surgery is a valid way to treat patients with symptoms of prolonged postmenstrual uterine bleeding caused by isthmocele. Data from this study also indicate that resectoscopy may be the first choice because it is minimally invasive and yields good therapeutic results.

Evaluation of endometrial activin A secretion for prediction of pregnancy after intrauterine insemination

OBJECTIVE To measure activin A concentrations in uterine washing fluid collected from women with couple infertility undergoing intrauterine insemination (IUI). DESIGN Retrospective case-control study. SETTING Tertiary university center for womens care. PATIENT(S) Fifty women, of whom 25 became pregnant after up to three IUI attempts and 25 did not. INTERVENTION(S) Endocrine and clinical evaluation, semen analyses and hypo-osmotic swelling test, ovarian stimulation, endometrial thickness measurement by ultrasound, uterine washing fluid collection by sonohysterography, and IUI. MAIN OUTCOME MEASURE(S) Activin A measurement by enzyme-linked immunosorbent assay, receiver operating characteristics curve analysis, and pregnancy rates after IUI; sensitivity, specificity, positive and negative likelihood ratios of activin A, and endometrial thickness for pregnancy prediction. RESULT(S) Activin A was measurable in all samples evaluated, and the levels (mean +/- SEM) were statistically significantly higher in the pregnant (0.08 +/- 0.01 ng/mL) than in the nonpregnant (0.022 +/- 0.001 ng/mL) group. Activin A at the cut off of 0.04 ng/mL achieved a sensitivity of 76.0 % (95% CI, 54.9%-90.6%) and a specificity of 100% (95% CI, 86.2%-100%) as a single marker for prediction of pregnancy. CONCLUSION(S) Activin A is secreted into uterine lumen; the levels in endometrial washing fluids were higher in women who subsequently became pregnant after IUI, so its measurement may be useful in predicting successful implantation.

Ultrasound and fetal stress: study of the fetal blink-startle reflex evoked by acoustic stimuli

The development of ultrasound techniques opened a window on the prenatal world. Since the early 1990s, bidimensional ultrasonography has played an important role in the study of certain fetal behaviours in attempts to understand fetal well-being. Certain fetal attitudes can be likened to those subsequently seen in newborns [1]. Study of fetal circulation by Doppler ultrasonography in parts of the fetal body such as the middle cerebral arteries has also clearly shown that certain pathophysiological and pathological conditions cause a redistribution of normal fetal circulation, indicating a change in fetal status.