U. Gattei

Role of surgery in endometriosis-associated subfertility.

Analysis of published series reveals that no more than a fourth of subfertile patients undergoing surgery for peritoneal endometriotic implants, rectovaginal endometriotic lesions, or recurrent endometriomas achieved conception spontaneously. First-line surgery for ovarian endometriotic cysts appears associated with a better reproductive performance, that is, a mean postoperative pregnancy rate of ∼50%. At the same time, excision of endometriomas paradoxically seems to induce gonadal damage. With the exception of peritoneal disease, no randomized trials are available to assess the effect of surgery in subfertile women with endometriosis. Therefore, it is not possible to define the absolute benefit increase of the treatment of ovarian and rectovaginal lesions. The decision to undergo surgery for endometriosis-associated subfertility must be shared with the woman after detailed information and taking into account several additional conditions, such as presence of pain, large or complex adnexal masses, bowel or ureteral stenosis, and coexisting infertility factors. When considering surgery, a therapeutic equipoise should be reached that includes demonstrated benefits, potential morbidity, and costs of treatment alternatives. Particularly in case of recurrent endometriosis, in vitro fertilization should generally be preferred to surgery. The role of surgery in endometriosis-associated subfertility includes temporary pain relief in symptomatic women desiring a spontaneous conception.

Injection Therapy for the Treatment of Stress Urinary Incontinence in Women

The purpose of this review is to summarize the results of reports on injectable agents in the treatment of female stress urinary incontinence. Six agents were reviewed: Teflon; autologous fat; collagen; silicone microparticles; silicone microballoons, and pyrolytic carbon. Collagen was the most frequently reported agent and yielded a 1-year cure/improvement rate of 60–80%, but results worsened significantly with longer follow-up. Teflon has been used longer in the treatment of stress incontinence, but low long- and short-term success rates and reported complications such as particle migration have prevented its widespread acceptance. Autologous fat has been suggested as a natural injectable but its success rate has been disappointing. The injection of silicone microparticles is associated with a long-term success rate of about 70% in patients with intrinsic sphincter deficiency, and it can now be injected more easily without the need of urethroscopy. Silicone microballoons and pyrolytic carbon has recently been introduced into clinical practice with a short-term success rate of about 70%, but longer follow- up is needed. In conclusion, the long-term durability, cost-effectiveness, and some safety issues still have to be addressed by further clinical trials.

Adenomyosis: Fertility and obstetric outcome. A comprehensive literature review

Adenomyosis is a benign condition characterized by the presence of endometrial glands and stroma deep within the myometrium. In recent years, the potential negative impact of adenomyosis on in vitro fertilization clinical outcomes has gained momentum, as well as, the possible link of this condition with obstetrical complications. The aim of this narrative review is to elucidate the possible association between uterine adenomyosis, infertility, and poor obstetrical outcomes. Several theories have been proposed to clarify the potential harmful impact of adenomyosis on fertility, such as a functional and structural defect of both the eutopic endometrium and the inner myometrium, an impairment of the uterine system of sperm transport, the presence of uterine dysperistalsis and of high levels of free radicals in the uterine milieu of women with the disease. Numerous studies have demonstrated that adenomyosis exerts a detrimental effect on in vitro fertilization outcomes, reducing pregnancy and live birth rates and increasing miscarriage rate. Regarding pregnancy outcomes data are scarce; however, epidemiological studies suggest that women with uterine adenomyosis could be at increased risk of numerous obstetrical complications, in particular, preterm birth and preterm premature rupture of membranes. These preliminary results are valuable for preconception and prenatal counseling of women with adenomyosis and suggest that this category of women necessitate a more cautious prenatal management than previously expected.