Renato Venezia

Hysteroscopic resection of the septum improves the pregnancy rate of women with unexplained infertility: a prospective controlled trial.

OBJECTIVE To assess fecundity of infertile women after surgical correction of uterine septum. DESIGN Prospective controlled trial. SETTING Three academic infertility clinics. PATIENT(S) Forty-four women affected by septate uterus and otherwise unexplained infertility represented the study group (group A), and 132 women with unexplained infertility were enrolled as control subjects (group B). INTERVENTION(S) Hysteroscopic metroplasty was performed in group A, and group B was managed expectantly. All women were followed-up for 1 year without any other intervention. MAIN OUTCOME MEASURE(S) Fecundity rate was calculated as the number of pregnancies per 100 person-months. RESULT(S) Pregnancy rate (38.6% vs. 20.4%) and live birth rate (34.1% and 18.9%) were significantly higher in group A than in group B. The survival analysis showed that the probability of a pregnancy in the twelve-months follow up was significantly higher in patients who had undergone metroplasty than in women with unexplained infertility. The corresponding fecundity (10-week pregnancy) rates were 4.27 and 1.92 person-months in women who had undergone metroplasty and in women with unexplained infertility, respectively. CONCLUSION(S) Hysteroscopic resection of the septum improves fecundity of women with septate uterus and otherwise unexplained infertility. Patients with septate uterus and no other cause of sterility have a significantly higher probability of conceiving after removal of the septum than patients affected by idiopathic sterility.

Detection of oncogenic human papillomavirus genotypes on spermatozoa from male partners of infertile couples

OBJECTIVE To evaluate the prevalence of human papillomavirus (HPV) sperm infection and its correlation with sperm parameters in patients who attended a fertility clinic. DESIGN Cross-sectional clinical study. SETTING University-affiliated reproductive medicine clinic. PATIENT(S) A total of 308 male partners of couples undergoing in vitro fertilization techniques. INTERVENTION(S) Specimens of semen were collected from all patients. MAIN OUTCOME MEASURE(S) Sperm parameters were evaluated according to the World Health Organization manual. The presence of HPV DNA was researched by the combined use of two HPV assays and a highly sensitive nested polymerase chain reaction assay followed by HPV genotyping. To examine whether HPV was associated with the sperm, in situ hybridization (ISH) analysis was performed. RESULT(S) Results of HPV investigation were compared with sperm parameters and ISH analysis. Twenty-four out of 308 semen samples (7.8%) were HPV DNA positive, but HPV infection did not seem to affect semen quality. Moreover, ISH revealed a clear HPV localization at the equatorial region of sperm head in infected samples. CONCLUSION(S) Oncogenic HPV genotypes were detected on spermatozoa from asymptomatic subjects, but a role of the infection in male infertility was not demonstrated.

Initial experience of a new linear everting falloposcopy system in comparison with hysterosalpingography

OBJECTIVE To assess the endolumenal portion of the fallopian tube from ostium to fimbria using a specially designed linear everting catheter and microendoscope. The study compared falloposcopy results with those obtained with hysterosalpingography (HSG) in the same patients and explored the systems ability to classify internal tubal conditions. DESIGN A prospective study of a new diagnostic technique, falloposcopy, versus conventional means of evaluating tubal status. SETTING A tertiary university infertility center. PATIENTS Eighteen infertile patients with a previous history of infertility of at least 2 years duration. INTERVENTION Diagnostic falloposcopy was performed on a total of 31 tubes. RESULTS Although the results of HSG and falloposcopy were in agreement in 19 cases, falloposcopy findings were at significant variance with HSG in 12 cases (40%). Seventeen of the tubes visualized by falloposcopy were considered to be normal, 10 showed mild disease, and 4 were severely damaged. CONCLUSION Falloposcopy using the linear everting catheter is rapid and atraumatic. It provides more complete information concerning tubal status than HSG and as such constitutes an important advance in diagnosis and therapy planning.

Chronic renal failure and endometrial osseous metaplasia: a hypothetical pathway.

Sir, We would like to bring to general attention the case of a 44year-old woman who came to our clinic because of spotting and occasional periods of amenorrhea. She had had menarche at the age of 14 years, followed by regular menstrual cycles. Her medical history revealed that she had one living child, and had subsequently experienced two miscarriages. The patient was human immunodeficiency virus (HIV) and hepatitis C virus positive. In addition, she was suffering from HIV-related chronic renal failure, HIV-related neuropathy and hepatitis C virus-related chronic hepatopathy. Physical and pelvic examinations were unremarkable. Transvaginal ultrasound examination revealed a hyperechogenic area in the uterine cavity measuring 14 mm 9 6 mm. The patient underwent a diagnostic hysteroscopy, which showed a 20 mm 9 10 mm white meshwork of bony spicules arising from the posterior wall, with a hard tactile consistency (Figure 1). A resectoscopic excision was then performed. The histological examination showed trabeculae of woven bone, and was consistent with osseous metaplasia of the endometrium. Concomitant endometrial histology showed a secretory endometrium. Two weeks after surgery, the patient again underwent a second transvaginal ultrasound examination, which revealed no trace of the original, abnormal ultrasound finding. Osseus metaplasia is rarely encountered, with less than 100 cases reported in the international literature (1). There is controversy regarding the pathogenic mechanisms related to the histogenesis of heterotopic bone in the endometrium. A number of theories have been proposed, as follows: continuous and strong endometrial estrogenic stimulation; osteogenesis in the surrounding endometrium, which is promoted by retained fetal bones; implantation of embryonic parts without pre-existing bone after early-stage abortions; dystrophic calcification of retained and necrotic tissues, usually after an abortion; chronic endometrial inflammation, such as endometritis or pyometra; and metastatic calcification and metabolic disorders, such as hypercalcemia, hypervitaminosis D or hyperphosphatemia (1–3). The most recent and accepted theory is metaplasia of the endometrial stromal cells, usually fibroblasts, which change into osteoblasts and thus produce bone in the endometrium. A previous history of abortion is present in most of the reported cases, with osseous changes in the endometrium. Usually, the reproductive age group (between 20 and 40 years of age) is involved, although it has also been reported in the menopausal years (1). In the few reported cases in the literature, the time between the antecedent abortion and discovery of the endometrial ossification varies from eight weeks to 23 years (4). Chronic renal failure is a known cause of abnormal calcium–phosphorous metabolism with metastatic calcifications; this may be the pathway of osseous metaplasia observed in our patient. Ultrasound examination plays a primary role in the diagnosis of patients with osseous metaplasia. The characteristic hyperechogenic pattern is strongly suggestive of osseous tissue within the uterus and should be confirmed by hysteroscopic examination (2). Today, hysteroscopy is accepted as the gold standard for diagnosis and treatment. Bone formation in the endometrium is rare, but can be seen in malignant mixed M€ ullerian tumors and in teratomas, which should be considered in the differential diagnosis (1). Clinicians and pathologists should bear this chance in mind, particularly in light of the fact that an erroneous diagnosis may well result in unnecessary hysterectomy.

Parasitic dermoid cyst coexisting with absence of an adnexa

Sir, We would like to bring to attention a case of acute compartment syndrome (ACS) of the lower limb, due to its possible relevance and implications for the obstetrical clinical routine. Acute compartment syndrome is defined as a condition in which increased pressure within a closed musculofascial compartment compromises blood circulation and biomechanical function. This clinical emergency usually occurs in the setting of traumatic injury or as a complication after prolonged surgery. In obstetric care, ACS is a rare but severe complication, which occurs during and after labor. Its estimated prevalence is about two manifestations per 10 000 births (1). We encountered the case of a 32-year-old primigravida, who was admitted at 38+4weeks gestation with spontaneous onset of labor and rupture of membranes after an uncomplicated pregnancy. Seven hours after admission, the treating obstetrician opted for cesarean section due to failure to progress in the first stage of labor and a nonreassuring fetal heart rate. Cesarean section was performed without intra-operative complications and a healthy infant delivered. Five hours after the intervention, the patient complained of spasm-like pain in her right lower leg. Upon examination, a distinctive tenseness and swelling of the right pretibial region was observed. A Doppler ultrasound examination, conducted to exclude deep vein thrombosis, showed no pathology, and symptomatic analgesic treatment was started. Clinical symptoms did not improve and the patient was re-examined one hour later. The initial tenseness and swelling had progressed, and a difference in the calf diameters of 10mm was observed. Pedal pulses and sensibility were normal and tendon reflexes symmetrical. Due to the acute aggravation of clinical symptoms, a decision for surgical exploration was taken. Intraoperatively, an ACS of the anterior tibial compartment was found and a fasciotomy without resection of muscular tissue performed. In the following postoperative course, full functional recovery of the limb was achieved. As presented, ACS in obstetric care typically occurs in the setting of cesarean delivery, especially if the operation is complicated by increased blood loss, such as due to disseminated intravascular coagulopathy (2). In addition, ACS has been reported following vaginal delivery, particularly with retained placenta leading to hypovolemia (3), prolonged hypotensive episodes in the context of epior peridural pain management and the use of oxytocin to induce labor, presumably due to its vasoconstrictive properties (4). Functional outcome after an ACS is directly related to prompt surgical intervention, hence it is essential to be aware of ACS as a possible differential diagnosis in severe lower limb pain, occurring intraand postpartum.