Sérgio Reis Soares

Diagnostic accuracy of sonohysterography, transvaginal sonography, and hysterosalpingography in patients with uterine cavity diseases

OBJECTIVE To evaluate the diagnostic accuracy of sonohysterography (SHG) in uterine cavity diseases in infertile patients, comparing its results with those of hysterosalpingography (HSG) and transvaginal sonography (TVS). Hysteroscopy was the gold standard. DESIGN Descriptive, prospective study. SETTING A tertiary university referral center. PATIENT(S) Sixty-five infertile women 19 to 43 years of age. INTERVENTION(S) Patients underwent SHG, conventional TVS, HSG, and hysteroscopy. MAIN OUTCOME MEASURE(S) The results of each examination were compared with those obtained by the gold standard. The following diagnoses were considered separately: polypoid lesions, uterine malformations, intrauterine adhesions, and endometrial hyperplasia (EH). Sensitivity, specificity, positive and negative predictive values (PPV and NPV, respectively), and 95% confidence intervals were calculated. RESULT(S) Sonohysterography had the same diagnostic accuracy as the gold standard for polypoid lesions and EH, with no equivocal diagnosis. Hysterosalpingography showed a sensitivity of 50% and a PPV of 28.6% for polypoid lesions and a sensitivity of 0% for EH. Transvaginal sonography had both sensitivity and PPV of 75% for polypoid lesions and EH. For uterine malformations, SHG had a sensitivity of 77.8%, whereas TVS and HSG both had a sensitivity of 44.4%. Sonohysterography and HSG had a sensitivity of 75% in the detection of intrauterine adhesions and respective PPVs of 42.9% and 50%. Transvaginal sonography showed sensitivity and PPV of 0% for this diagnosis. CONCLUSION(S) Sonohysterography was in general the most accurate test. Its diagnostic accuracy was markedly superior for polypoid lesions and EH, with total agreement with the gold standard. In diagnosis of intrauterine adhesions, SHG had limited accuracy, similar to that obtained by HSG, with a high false-positive diagnosis rate.

Physiology and pathology of ovarian hyperstimulation syndrome.

Ovarian hyperstimulation syndrome (OHSS) occurs when ovaries primed with follicle-stimulating hormone/leuteinizing hormone (LH) are subsequently exposed to human chorionic gonadotropin (hCG). The ultimate pathophysiological step underlying this clinical picture is increased vascular permeability (VP). With the administration of hCG, the expression vascular endothelial growth factor (VEGF) and VEGF receptor 2 (VEGFR-2) mRNA increases significantly rising to a maximum coinciding with peaked VP. Immunohistochemistry shows the presence of VEGF and VEGFR-2 proteins in the granulosa-lutein and endothelial cells of the entire corpus luteum. These findings suggest that the syndrome can be prevented by inducing ovulation with LH or gonadotropin-releasing hormone analogs, which prevent VEGF overexpression. Also, coadministration of a dopamine agonist inhibits phosphorylation of the receptor VEGFR-2. In a trial of 69 oocyte donors, the incidence of moderate OHSS was 20% with the dopamine agonist cabergoline and 44% with a placebo ( P = 0.04). Another dopamine agonist, quinagolide, was also effective in nonpregnant patients, but those pregnant did not benefit from dopamine agonist administration. In conclusion, the pathophysiological mechanisms involved in OHSS show that targeting VEGF/VEGFR2 is an effective preventive approach to treat the syndrome. Pharmaco-prevention through dopamine agonists is effective only in nonpregnant high-risk OHSS women. Embryo cryopreservation plus dopamine agonist administration might be the most appropriate way to prevent OHSS in high-risk patients.

Clinical factors affecting endometrial receptiveness in oocyte donation cycles.

OBJECTIVE To provide a summary of the actual knowledge about the clinical factors affecting the oocyte recipient (other than those associated with uterine cavity abnormalities) on the outcome of oocyte donation cycles. DESIGN Review of the literature. SETTING Information regarding the association between age, body mass index (BMI), endometrial priming, tobacco consumption, hydrosalpinx, and endometriosis/adenomyosis in oocyte recipients and the results of oocyte donation cycles. RESULT(S) Recipient age and the presence of hydrosalpinx are clearly associated with a poorer outcome in oocyte donation cycles. The negative impact of tobacco consumption has recently been confirmed. The exact relevance of an elevated BMI is under debate but it is likely that it determines a lower ongoing pregnancy rate (PR). Endometriosis may be significant for endometrial receptiveness in the context of a natural cycle, but no negative impact is detected when standard endometrial priming protocols are used in oocyte donation. The same may be true for adenomyosis, although its relevance to endometrial receptiveness is less clear. CONCLUSION(S) Accumulated knowledge in the field of oocyte donation has led to the recognition of clinical variables that affect cycle outcome by impairing endometrial receptiveness. Many studies are being carried out on endometrial molecular and gene expression changes taking place in these circumstances. In the near future a comprehensive understanding of these processes should be achieved, from a genetic, molecular, and clinical perspective. These advances in the collective knowledge will lead to an improvement in the diagnosis and treatment of infertile patients.

Etiology of OHSS and use of dopamine agonists.

Vascular endothelial growth factor is the factor that causes increased capillary permeability and therefore the most serious manifestations of ovarian hyperstimulation syndrome. Dopamine agonists can both prevent and treat ovarian hyperstimulation syndrome by blocking expression of the vascular endothelial growth factor receptor.