Mauro Schimberni

Natural-cycle in vitro fertilization in poor responder patients: a survey of 500 consecutive cycles.

OBJECTIVE To determine the role of the natural cycle for in vitro fertilization (IVF) in poor responder patients. DESIGN Retrospective survey. SETTING Private center for assisted reproduction. PATIENT(S) 294 women who were poor responders in a previous IVF cycle. INTERVENTION(S) Analysis of 500 consecutive natural cycles IVF. MAIN OUTCOME MEASURE(S) Number of cycles with oocytes, pregnancy rate per cycle, per transfer, and implantation rate. RESULT(S) Oocytes were found in 391 cases (78.1%), and cleaving embryos suitable for transfer were obtained in 285 cycles (57.0%). Pregnancy was observed in 49 cases, with a pregnancy rate of 9.8% per cycle, 17.1% per transfer, and 16.7% per patient. The patients were subdivided arbitrarily by the womens age into three groups. Patients 35 years old or younger showed a pregnancy rate of 18.1% per cycle, 29.2% per transfer, and 31.7% per patient. Women aged between 36 and 39 years showed a pregnancy rate of 11.7% per cycle, 20.6% per transfer, and 20.3% per patient. Women 40 years old or older showed a pregnancy rate of 5.8% per cycle, 10.5% per transfer, and 9.7% per patient. No differences were found for any of the evaluated parameters, independent of which cycle was the first, the second, third, fourth, or fifth, or further consecutive cycle. CONCLUSION(S) In poor responder patients, natural-cycle IVF is an effective treatment, especially in younger women.

Cetrorelix protocol versus gonadotropin-releasing hormone analog suppression long protocol for superovulation in intracytoplasmic sperm injection patients older than 40

OBJECTIVE To determine which protocols work better between cetrorelix and long protocols in older patients in a randomized controlled study. DESIGN A controlled randomized study in a single private IVF center. SETTING Infertile women referred to a private IVF center. PATIENT(S) Five hundred sixty-four women 40 years or older undergoing IVF. INTERVENTION(S) At their first IVF cycle, the women were randomized into two study groups using a computer-generated number sequence: 281 cases were treated with the cetrorelix protocol, and 283 patients were treated with a long protocol for controlled ovarian hyperstimulation. MAIN OUTCOME MEASURE(S) Days of stimulation, E(2) on the day of hCG administration, amount of FSH administered, number of oocytes yielded, number of embryos obtained, pregnancy rate, and implantation rate. RESULT(S) Patients treated with the long protocol showed a significantly higher number of oocytes retrieved and a higher pregnancy rate for both the cycle and transfer with respect to the cetrorelix protocol patients. The other parameter evaluated did not show any statistically significant differences. CONCLUSION(S) Our study showed that the long protocol performed better in older women than the cetrorelix protocol and that the GnRH antagonist may be detrimental in older women.

Pregnancy outcome after loop electrosurgical excision procedure for cervical intraepithelial neoplasia

To determine pregnancy outcomes among women who underwent loop electrosurgical excision procedure (LEEP).

Follicular fluid adrenomedullin concentrations in spontaneous and stimulated cycles: relationship to ovarian function and endothelin-1 and nitric oxide

The objective of this study was to determine concentration of adrenomedullin (AM) in follicular fluid and whether a correlation exists between AM and nitric oxide (NO) or endothelin-1 (ET-1) levels in follicular fluid, serum 17beta-estradiol or other parameters of ovarian function in spontaneous and gonadotrophin stimulated ovarian cycles. Follicular fluid samples were obtained at oocyte retrieval from 50 women who underwent an in vitro fertilization (IVF) program: 40 undergoing ovarian hyperstimulation with recombinant FSH and 10 had spontaneous ovarian cycles. AM, ET-1, and NO were detected in all of the follicular fluid samples and their concentrations were similar in spontaneous and stimulated cycles. In patients undergoing ovarian stimulation, follicular fluid AM levels correlated with serum 17beta-estradiol concentration. No correlation was found between follicular AM concentration and parameters of ovarian function. Similarly, no relationship was observed between ET-1, NO, and AM follicular fluid concentrations in either spontaneous or stimulated cycles. This study suggests a possible regulatory effect of the sexual hormones on AM production by the ovary during the ovulatory process. The site of AM secretion and its function (if any), however, remain to be established.

Number of Embryos Transferred and Implantation

Abstract: Multiple pregnancies are considered the most frequent and serious complication of assisted reproduction technology. To reduce the frequency of multiple pregnancies, several centers have adopted a policy of reducing the number of embryos transferred in the uterus, suggesting single embryo transfer. Even though a significant number of papers have been published on this issue, no general consensus exists on how many embryos to replace in the uterus and at which cleavage stage. We conducted a retrospective study on cycles performed throughout 2003, analyzing the relation between the number of embryos transferred and the pregnancy and implantation rates, evaluating also the role of the womans age. No differences were found among the groups except in one‐embryo transferred women, which were mostly natural cycles, for estradiol levels, number of mature oocytes retrieved, number of top quality embryos, and pregnancy rate. The implantation rate was significantly higher in the two‐embryo transfers versus three‐embryo transfers. We found higher pregnancy and implantation rates with similar multiple pregnancy rates in patients where only two embryos were transferred versus three embryos transfer when women were less than 35 years old. In women aged less than 35 years, which in turn have the higher expectancy of successful pregnancy and also the higher risk of multiple pregnancy, the single embryo transfer is a suitable choice for these patients.

Clinical factors and malignancy in endometrial polyps. Analysis of 1027 cases

STUDY OBJECTIVE To assess the prevalence of polyps carrying a malignancy and match association between clinical factors and oncologic progression. STUDY DESIGN A retrospective study (Canadian Task Force classification II-3) at a university hospital in Rome, Italy. We retrospectively analyzed data from 1027 women consecutively treated for endometrial polyps at our center in the period 2002-2011. The association of malignancy with hormonal status, tamoxifen, hypertension, symptoms, diabetes mellitus, obesity, and hormonal replacement therapy in pre- and post-menopausal women was assessed. RESULTS Mean age was 45.8±10.8 years. Benign polyps accounted for 95.8% of the total, pre-malignant for 2.67%, malignant for 1.54%. Our data showed that post-menopausal and older women (>60y) with endometrial polyps have a higher risk of developing a related endometrial cancer (OR: 3.05, 95% CI [1.54, 6.19], p<0.001 and OR: 2.8, 95% CI [1.38, 5.56], p≤0.003. Also we observed that women with AUB in the post-menopausal period displayed a risk of malignancy (OR: 31.1, 95% CI [10.3,111], p value <0.001). CONCLUSION Special attention should be drawn to symptomatic post-menopausal patients that appear to be at higher risk of malignancy. Symptomatic pre-menopausal women and asymptomatic post-menopausal women with polyps may be a group with intermediate-risk. These patients should undergo an individualized management plan, balancing both risks and benefits of surgical intervention after discussion with the patient.

IVF pregnancies: Neonatal outcomes after the new Italian law on assisted reproduction technology (law 40/2004)

Objective. To compare maternal and neonatal outcome of pregnancies achieved by assisted reproduction technique (ART) according to the guidelines of the newly established Italian ART law 40/2004, with that of naturally conceived. Design. Three hundred and sixty‐four ART pregnancies and 304 naturally conceived pregnancies were analyzed in terms of the incidence of obstetric complications and perinatal outcome. Control group was enrolled prospectively after being matched for an extensive number of maternal characteristics. Results. Among singletons, ART pregnancies when compared to naturally conceived pregnancies showed a higher incidence of pregnancy loss (23.4% versus 10.5%) and a lower mean birth weight. A higher but not significant incidence of small for gestational age fetuses was observed in ART pregnancies, compared to those from normally conceived pregnancies (7.2% versus 2.7%). Moreover, the ART pregnancies showed a slightly, but nonetheless significantly shorter mean gestational age (38.6 versus 39.3 weeks) and more frequent preterm deliveries (11%) than the control group (2.7%). No difference was found in terms of other obstetric complications such as pregnancy‐induced hypertension, gestational diabetes and placental abruption. Neonatal outcome was similar in both groups. Conclusion. Although the obstetric outcome among singleton ART pregnancies was good, these patients should be considered obstetric risk cases. The different frequency of complications is not related to maternal age or parity and could be the consequence of infertility or the procedures by which these women conceived. The reasons are, however, unclear and further studies are necessary.

Life-threatening bleeding after pelvic lymphadenectomy for cervical cancer: endovascular management of ruptured false aneurysm of the external iliac artery.

Late rupture of external iliac artery pseudo-aneurysm is an uncommon complication in patients who undergo extensive gynecologic radical surgeries. A 28-year-old woman with stage IB cervical cancer underwent pelvic lymphadenectomy and extrafascial trachelectomy. Two months after surgery, massive bleeding from ruptured pseudo-aneurysm of the external iliac artery occurred. Endovascular management with covered stent placement was feasible and safe to stop bleeding.

A case of high-grade leiomyosarcoma of the bladder with delayed onset and very poor prognosis

Mesenchymal tumors represent a small number of bladder cancer cases. Leiomyosarcoma is the most common histology with over 100 cases reported in the whole literature. This tumor is been historically considered as highly aggressive and showing a poor prognosis. Despite very low survival rates showed in older reports, some authors indicate that some patients could have a better outcome. We report a review of the literature and a case of high-grade LMS of the bladder in a 68 years old woman. Diagnosis was delayed and disease was locally advanced. Symptoms and imaging of our case first oriented to a gynecologic condition with an adnexal or uterine origin of the mass, and, a genitourinary origin could be unveiled only intra-operatively.

Laparoscopic injury of the obturator nerve during fertility-sparing procedure for cervical cancer

BackgroundIntraoperative injury of the obturator nerve has rarely been reported in patients with gynecological malignancies undergoing extensive radical surgeries. Irreversible damage of this nerve causes thigh paresthesia and claudication. Intraoperative repair may be done by end-to-end anastomosis or grafting when achieving tension-free anastomosis is not possible.Case presentationA 28-year-old woman with stage IB cervical cancer underwent fertility–sparing surgery, including conization and bilateral pelvic lymphadenectomy. The left obturator nerve was damaged intraoperatively during pelvic dissection.ConclusionImmediate laparoscopic repair was successful and there was no functional deficit in the left thigh for six months postoperatively.