Petros Drakakis

Adhesions: Laparoscopic Surgery versus Laparotomy

Abstract: This study was undertaken to assess the effectiveness in pregnancy rates of microsurgery and operative laparoscopy in adhesiolysis. Adhesions were found to be the sole infertility factor in 15% of our patients. One hundred and ninety infertile patients with periadnexal adhesions as the only cause of their infertility were treated by microsurgery (86) or operative laparoscopy (104) and were followed up for 24 months. Our results indicate that advanced laparoscopic surgery in general is as effective as microsurgery in healthy infertile patients with adhesions but offers some advantages in comparison to laparotomy. Factors that adversely affect the postoperative success rates are the age of the women, the duration of infertility, and the severity of the adhesions.

Novel trends in follicular development, atresia and corpus luteum regression : a role for apoptosis

During ovarian follicular development in humans, only a limited number of follicles mature and ovulate. The vast majority of follicles stop developing after the formation of an antrum and then undergo atresia. The few that are selected to become ovulatory follicles are transformed into corpora lutea following ovulation. The lifespan of the corpus luteum is also limited. In each oestrus/menstrual cycle, corpora lutea regress and are eliminated by a progress called luteolysis. During atresia and luteolysis, granulosa and lutein cells undergo apoptosis. It is believed that there are many signal transduction pathways that control apoptosis in order to suppress full maturation of too many follicles and to protect the dominant follicle from the apoptotic process prior the ovulation. Such interplay between different factors, some of them produced in the ovary, may modulate apoptosis of corpus luteum cells, in order to preserve the function of the corpus luteum during pregnancy or to eliminate the old corpora lutea of the previous cycle. The present review reports a number of factors that regulate follicular atresia and corpus luteum regression, via apoptotic pathways. Elucidation of apoptotic mechanisms may lead to prevention of female infertility or other pathological conditions.

Laparoscopic Treatment of Ovarian Dermoid Cysts: Eleven Years' Experience

STUDY OBJECTIVE To compare laparoscopic and open approaches in the management of benign ovarian teratomas (dermoid cysts) with regard to operative outcome, complications, and postoperative follow-up. Factors that predispose to rupture of dermoid cysts during laparoscopic removal and rates of adhesion formation in women with and without cyst rupture during laparoscopic surgery also were considered. DESIGN Review of cases of women with dermoid cysts who underwent cystectomy either by laparoscopy or laparotomy in our department from 1992 through 2002 (Canadian Task Force classification III). SETTING The Infertility and Operative Laparoscopy units of the First Department of Obstetrics and Gynecology of the University of Athens, Alexandra Maternity Hospital, Athens, Greece. PATIENTS Two hundred twenty-two women with an ovarian mass requiring surgical management. Of these, 187 women with benign cystic teratomas underwent laparoscopic cystectomy, and 35 underwent cystectomy by laparotomy. INTERVENTIONS Cystectomy either by laparoscopy or laparotomy. MEASUREMENTS AND MAIN RESULTS Potential benefits of operative laparoscopy include reduced blood loss, less postoperative pain, shorter hospital stay, fast recovery, and an excellent cosmetic result. CONCLUSION Laparoscopy should be considered the method of choice for the removal of benign ovarian cystic teratomas as it offers the advantages of fewer postoperative adhesions, reduced pain, shorter hospital stay, and better cosmetic result. It should be performed by surgeons with considerable experience in advanced laparoscopic surgery.

Endometriosis in patients with chronic pelvic pain : Is staging predictive of the efficacy of laparoscopic surgery in pain relief?

Background/Aims: Endometriosis is considered an important cause of chronic pelvic pain. Despite its high prevalence, controversy still exists regarding the true association between the extent of endometriosis and the severity of symptoms. We conducted this prospective study to investigate the association between the stage of endometriosis and type and severity of pain, and to evaluate the efficacy of laparoscopic surgery in pain relief. Methods: Ninety-five patients complaining of chronic pain were diagnosed with endometriosis and were treated with laparoscopic surgery. The severity of pain was assessed in patients with an endometriosis AFS (American Fertility Society) score less than 16 (group 1) and those with an AFS score greater than or equal to 16 (group 2), preoperatively and 6 months after surgery, using a visual pain scale. Any reduction in pain scores by 2 points or more was considered to be an improvement. Results: Dysmenorrhea and deep dyspareunia, were significantly more frequent in patients of group 2. Preoperative pain scores were significantly higher for dysmenorrhea (p = 0.0022) and deep dyspareunia (p < 0.0001) but not for non-menstrual pain in group 2. Deep dyspareunia was correlated with the presence of dense pelvic adhesions. After surgery, dysmenorrhea improved in 43% of cases in group 1, vs. 66% of cases in group 2 (p = 0.0037). For deep dyspareunia, improvement was reported by 33% in group 1, vs. 67% in group 2 (p = 0.074). Improvement in non-menstrual pain was not significantly different between the two groups (67% vs. 56%). Conclusions: Advanced endometriosis is more frequently related to dysmenorrhea and deep dypareunia in comparison to early disease. Laparoscopic surgery may offer relief or improvement in the majority of patients with endometriosis and chronic pelvic pain. Cases with advanced disease seem to benefit the most.

LAPAROSCOPIC EVALUATION OF INFERTILE PATIENTS WITH CHRONIC PELVIC PAIN

In this study over a 10-year period, 1584 patients complaining of infertility of more than 1 year duration were evaluated for their laparoscopic findings in relation to the presence or not of chronic pelvic pain (CPP). Infertility was the only complaint in 1215 cases (group 1), whereas 369 patients complained of infertility and CPP (group 2). All cases underwent routine infertility investigation and pelvic ultrasonography, followed by diagnostic laparoscopy, with infertility-only cases acting as a control group. At laparoscopy 76.7% of patients with CPP were found with pelvic pathology, compared with only 42.6% of cases without CPP (P < or = 0.0001). Omental-abdominal wall adhesions, advanced endometriosis, endometriomas with adhesions, pelvic venous congestion, and hydrosalpinges with pelvic adhesions were significantly more frequent in cases with CPP. Dysmenorrhoea was the most frequent type of CPP. Cases with CPP and a negative laparoscopy were further investigated using a multidisciplinary approach. In conclusion, chronic pelvic pain can be the result of several pelvic pathologies. Infertile patients with CPP are much more frequently found with an abnormal pelvis in comparison with cases without CPP. Laparoscopy is an invaluable diagnostic tool especially for symptomatic patients and should be used early in their diagnostic infertility work-up.

HBV viremia in newborns of HBsAg(+) predominantly Caucasian HBeAg(―) mothers

BACKGROUND Hepatitis B virus infection is an important public health problem worldwide and eliminating mother-to-infant transmission is important to decrease the prevalence of chronic HBV-infection. Although, immunoprophylaxis given at birth largely prevents mother-to-infant transmission, perinatal HBV viremia has been reported in HBsAg(-) newborns born mainly to HBeAg(+) women in endemic areas. OBJECTIVES To examine the incidence of perinatal HBV viremia in newborns of HBsAg(+) predominantly HBeAg(-) mothers. STUDY DESIGN Peripheral blood was obtained at birth from 109 HBsAg(+) mothers and their newborns before the administration of active-passive immunoprophylaxis. Infants were prospectively followed and appropriately vaccinated. RESULTS Although most (92.7%) of the HBsAg(+) mothers were HBeAg(-), 73.4% had detectable HBV viremia. Neonatal viremia was detected in 3/8 (37.5%) and 24/101 (23.8%) newborns of HBeAg(+) and HBeAg(-) mothers, respectively (p=0.386). However, HBV-DNA levels were significantly higher in newborns of HBeAg(+) mothers (p=0.025). No child developed chronic HBV infection, but one child had evidence of subclinical hepatitis. CONCLUSIONS Although the clinical significance of low viremia levels in almost one in four newborns of HBsAg(+) mothers in a low endemicity area is unclear, it may enhance our understanding of HBV mother-to-infant transmission.

Follicular fluid inhibin levels in relation to age in patients in an in vitro fertilization and embryo transfer programme.

Inhibin (INH), oestradiol (E2) and progesterone (P) were measured in the follicular fluid (FF) of 22 patients 28-38 years old (Group A) and 11 patients 43-47 years old (Group B) who had received gonadotrophin stimulation in an in vitro fertilization and embryo transfer (IVF-ET) programme. The results indicated that INH, E2 and P levels were significantly lower and the E2/P ratio was higher in FF of Group B patients (older women) compared to those of Group A. There were six single pregnancies among patients of Group A. No difference was observed in follicular fluid INH, E2 and P levels as well as in E2/P ratio between pregnant and non-pregnant patients of Group A (Group A1 and Group A2, respectively). A positive correlation was found between FF concentrations of E2 and P, E2 and INH and P and INH in the three Groups and a negative one between INH and the E2/P ratio in Group B. It seems likely that ovarian INH and E2 production are controlled by different mechanisms and that INH response to ovarian hyperstimulation is altered by advancing age.

Selective feticide of an affected fetus in the second trimester has comparable risks to those in the first trimester

The broad acceptance of prenatal diagnosis of various genetic diseases leads to an ever‐increasing number of parturients with twin gestations undergoing selective feticide of an affected fetus. In most of the cases, delayed diagnosis leads to second trimester reduction. The aim of the present study was to investigate whether this procedure can be performed in the second trimester with results comparable to those obtained when it is performed in the first trimester. There was a 5.6% miscarriage rate in the group reduced in the first trimester (n=18, Group A) and an 8.3% miscarriage rate in the group reduced in the second trimester (n=48, Group B). The mean weight of neonates in the first group was 2780 g, and in the second group 2620 g. The mean gestational age at delivery was 36.7 weeks for Group A and 35.1 weeks for Group B. No significant differences were observed for any two‐paired values considered. There was no perinatal mortality in either group. We therefore conclude that selective feticide of an affected fetus is as safe in the second trimester as it is in the first. Copyright

Human Chorionic Gonadotropin: The Pregnancy Hormone and More

To thoroughly review the uses of human chorionic gonadotropin (hCG) related to the process of reproduction and also assess new, non-traditional theories. Review of the international literature and research studies. hCG and its receptor, LH/CGR, are expressed in numerous sites of the reproductive tract, both in gonadal and extra-goanadal tissues, promoting oocyte maturation, fertilization, implantation and early embryo development. Moreover, hCG seems to have a potential role as an anti-rejection agent in solid organ transplantation. Future research needs to focus extensively on the functions of hCG and its receptor LH/CGR, in an effort to reveal known, as well as unknown clinical potentials.

The Impact of Genetics Profile (Gene Polymorphisms) in Obese Non- PCOS Women Entering an IVF/ICSI Program

Data concerning the effects of increased body mass index (BMI) on ovarian and pregnancy outcome are rich, but the results are rather controversial. Regarding pharmacogenetics, gene polymorphisms of hormonal receptor genes, such as Estrogen Receptor alpha (ESR1), Estrogen Receptor beta (ESR2) and FSH receptor (FSHR) genes, are associated with ovarian stimulation and pregnancy outcome and may constitute a useful tool for ART experts for the prediction of this outcome. The aim of this study is to track differences in the distribution of gene polymorphisms among obese non-PCOS and non-obese patients concerning three distinct genes which are involved in the ovarian stimulation mechanism: PvuII polymorphism of ESR1 gene, RsaI polymorphism of ESR2 gene and Ser680Asn variation of FSHR gene, using restriction fragment length polymorphism analysis and real-time polymerase chain reaction. A total of 151 normally ovulating female patients underwent IVF or ICSI. Interestingly, the pregnancy rate in the BMI≥30 kg/m² group was higher in a statistically significant way (40.9% versus 17.8%, p=0.023). The obese patients of this study were in need of increased total FSH dose in order to achieve a satisfactory oocyte number (p<0.001) and needed more days of stimulation (p=0.002), but also presented lower basal FSH levels (p=0.032), which may explain, to an extend, the better pregnancy outcome. Concerning the polymorphisms of ESR1, ESR2 and FSHR genes, we did not observe differences in the genotype distribution when we compared the obese non-PCOS population with the non-obese population. Thus, obesity does not constitute an additional indication to perform a genetic analysis before entering an IVF/ICSI program.