P.H.M. Bianchi

Extensive Excision of Deep Infiltrative Endometriosis before In Vitro Fertilization Significantly Improves Pregnancy Rates

STUDY OBJECTIVE We sought to compare the outcomes of in vitro fertilization (IVF) treatments in women with infertility-associated deep infiltrative endometriosis (DIE) who underwent extensive laparoscopic excision of endometriosis before IVF with those who underwent IVF only. DESIGN Prospective cohort study. SETTING Infertility clinic and private hospital in São Paulo, Brazil. PATIENTS A total of 179 infertile patients younger than 38 years had symptoms and/or signs of endometriosis and sonographic images suggestive of DIE. INTERVENTIONS After thorough counseling, 179 women were invited to participate in a prospective cohort study with 2 treatment options: IVF without undergoing laparoscopic surgery (group A, n = 105) and extensive laparoscopic excision of DIE before IVF (group B, n = 64). Ten women were lost to follow-up. The IVF outcomes were compared between the 2 groups. MEASUREMENTS AND MAIN RESULTS In group B, patients had 5 +/- 2 (mean +/- SD) DIE lesions excised during laparoscopy. Patient characteristics in groups A and B, respectively, were: age (32 +/- 3 vs 32 +/- 3 years, p = .94), infertility duration (29 +/- 20 vs 27 +/- 17 months, p = .45), day-3 serum follicle-stimulating hormone levels (5.6 +/- 2.5 vs 5.9 +/- 2.5 IU/L, p = .50), and previous IVF attempts (1 +/- 1 vs 2 +/- 1, p = .01). The IVF outcomes differed between groups A and B, respectively, with regard to total dose of recombinant follicle-stimulating hormone required to accomplish ovulation induction (2380 +/- 911 vs 2542 +/- 1012 IU, p = .01), number of oocytes retrieved (10 +/- 5 vs 9 +/- 5, p = .04), and pregnancy rates (24% vs 41%, p = .004), but not number of embryos transferred (3 +/- 1 vs 3 +/- 1, p = 1). The odds ratio of achieving a pregnancy were 2.45 times greater in group B than in group A. CONCLUSION Extensive laparoscopic excision of DIE significantly improved IVF pregnancy rates of women with infertility-associated DIE.

Review: Follicular Waves in the Human Ovary: A New Physiological Paradigm for Novel Ovarian Stimulation Protocols

Ovulation induction (OI) is a cornerstone of human assisted reproduction treatments (ART). Current OI protocols are based on the human follicular dynamics model known as propitious moment theory (PMT), by which follicles continuously grow from the primordial pool without any pattern, and follicular fate depend on the occurrence of a gonadotropin surge. Recently, a new paradigm of human follicular dynamics called follicular waves was revealed using sequential ultrasound examination of 1 interovulatory interval. Instead of random growth, follicles develop in coordinated groups or waves, occurring 2 to 3 times during an interovulatory interval. Follicular waves are common in several other mono-ovulatory species, like equines and bovines. In fact, this model was applied to the development of several OI protocols in veterinary medicine, especially in cows. It has been shown that synchronization of OI with the emergence of a follicular wave increases substantially success rates in animals, even with single embryo transfer. Veterinarians have already developed mechanisms to control wave emergence through mechanical or chemical ablation of the dominant follicle or corpus luteum. Considering the follicular dynamics similarities between humans and bovines regarding the follicular wave phenomenon, we hypothesize that synchronization of follicular wave emergence with ovarian stimulation produces more competent oocytes and embryos and will enhance ART efficiency in humans. At the end of this article, we propose 2 theoretical approaches to induce the emergence of a follicular wave in women: (1) a mechanical strategy by aspiration of the dominant follicle and (2) a pharmacological strategy by administering estradiol and progesterone.

Successful Live Birth in a Woman With 17α-Hydroxylase Deficiency Through IVF Frozen-Thawed Embryo Transfer

CONTEXT Congenital adrenal hyperplasia (CAH) due to 17α-hydroxylase deficiency in 46,XX patients is characterized by primary amenorrhea, absent or incomplete sexual maturation, infertility, low serum levels of estradiol, and elevated progesterone (P). There were no previous reports of singleton live births from such women. OBJECTIVE To describe the first successful singleton live birth in a female with CAH due to 17α-hydroxylase deficiency. CASE DESCRIPTION A 26-year-old Brazilian woman with CAH associated with 17α-hydroxylase deficiency due to the compound heterozygote mutation (p.W406R/P428L) in the CYP17A1 gene expressed the desire to conceive. In vitro fertilization (IVF) was recommended due to the complexity of the disorder. The first attempt of treatment failed despite the production of viable embryos. At the second IVF attempt, all viable embryos were frozen due to inadequate endometrial development associated with prematurely elevated serum P during ovarian stimulation. Subsequently, a long-acting GnRH agonist and oral dexamethasone were used to lower ovarian and adrenal P overproduction. Once serum levels of P were < 1 ng/mL, endometrial preparation with estradiol valerate and frozen-thawed embryo transfer were performed, resulting in a singleton pregnancy. Estradiol supplementation was completely suspended by 14 weeks of gestation. She delivered at 30 weeks and 4 days due to acute fetal distress. The puerperium was uneventful; the newborn was discharged in good conditions 5 weeks after birth. CONCLUSION A successful live birth was achieved in a woman with 17-hydroxylase deficiency through IVF, cryopreservation of all embryos, and frozen-thawed embryo transfer after adequate endometrial preparation.

Transvaginal ultrasound after bowel preparation to assist surgical planning for bowel endometriosis resection

up 3 as those more than The rectosigmoid colon (RSC) is involved in up to 93% of all endometriotic lesions of the bowel [1]. Preoperative diagnosis of bowel endometriosis is very important for surgical planning and patient counseling. In this context, estimation of the distance from endometriotic lesions to the anal border hasmajor surgical implications because the risk of complications is greater for gastrointestinal anastomosis performed below the peritoneal reflection, in the lower rectum (less than 5 cm from the anal border) [2]. From the authors’ personal experience (MOCG and LPC), transvaginal ultrasound after bowel preparation (TVS-BP) improves the detection and characterization of intestinal lesions, permitting identification of the affected layers and the distance between the lower margin of the lesions and the anal border. Fifty-one patients who presented with endometriosis-associated infertility at the Huntington Medicina Reprodutiva Sao Paulo, Brazil, from October 2005 to October 2006 underwent TVS-BP measurement of the distance between RSC lesions to the anal border, and laparoscopic excision of endometriosis. Eighteen bowel lesions were resected in 16 women. During surgery, the actual distances between the endometriotic lesions and the anal border were recorded as the distance from the insertion of an endoscopic stapler at the anal border up to where the tip of the stapler touched the lesion. Lesions were divided into 3 groups based on their distance from the anal border, with group 1 categorized as those from1–5 cm (1/18; 5.6%); group 2 as those 6–10 cm (9/18; 50%); and gro

Successful Interval Laparoscopic Transabdominal Cervicoisthmic Cerclage Preceding Twin Gestation: A Case Report

Laparoscopic transabdominal cervicoisthmic cerclage (LTCC) is an alternative, less-morbid option to the traditional transabdominal cerclage, indicated for patients with cervical incompetence. Experience with the technique is based on case reports and a few case series. Considering LTCC for twin gestations, reports are very scarce and are derived from LTCC performed during pregnancy. We report the case of a 36-year-old patient, gravida 1, para 0, aborta 1, who underwent interval LTCC after a previous failed transvaginal emergency cerclage performed in the second trimester. Hysteroscopic metroplasty was concomitantly performed for an incomplete septate uterus. The procedure lasted 100 minutes, with an estimated blood loss of 50 mL. The patient was discharged home on the second postoperative day. The patient became pregnant with twins 3 months after the procedure after undergoing in vitro fertilization. The gestational course was uneventful, and the patient delivered 2 healthy neonates at 38 weeks gestation by elective cesarean section. The cerclage tape was left in situ. Minor modifications of the previously reported techniques included use of a laparoscopic Deschamps needle for placing the cotton cardiac tape used as suture material. Vessels in the cervical transverse cervical ligament were exposed before cerclage tape application. To our knowledge, this is the first report of interval LTCC preceding a twin gestation.

Successful Pregnancies After Adequate Hormonal Replacement in Patients With Combined Pituitary Hormone Deficiencies

Context: Women with hypopituitarism have lower pregnancy rates after ovulation induction. Associated pituitary hormone deficiencies might play a role in this poorer outcome. Objective: We evaluated fertility treatment and pregnancy outcomes in five women with childhood-onset combined pituitary hormone deficiencies (CPHD). Patients and Methods: Five women with CPHD were referred for fertility treatment after adequacy of hormone replacement was determined. Patients were subjected to controlled ovarian stimulation (COS) for timed intercourse, intrauterine insemination, or in vitro fertilization, according to the presence or absence of other infertility factors (male or tubal). Results: All women became pregnant. The number of COS attempts until pregnancy was achieved varied between 1 and 5. The duration of COS resulting in at least one dominant follicle varied between 9 and 28 days, and total gonadotropin consumed varied between 1200 and 3450 IU. Two patients with severely suppressed basal gonadotropin levels since an early age had a cancelled COS cycle. All pregnancies were singleton except one (monochorionic twin gestation). The gestational ages at birth ranged from 35 weeks to 39 weeks and 4 days; three patients underwent cesarean section, and two had vaginal deliveries. Only one newborn was small for gestational age (delivered at 35 weeks). Conclusion: Adequate hormonal replacement prior to ovarian stimulation resulted in successful pregnancies in patients with childhood-onset CPHD, indicating that hormone replacement, including growth hormone, is an important step prior to fertility treatments in these patients.