Veronica Giorgione

Fertility preservation in women with borderline ovarian tumours

Borderline ovarian tumours (BOT) may occur in young women and have an excellent survival rate. Therefore, there is the obligation to put emphasis on fertility preservation in affected women. On the other hand, it has also been underlined that the disease should be managed with caution because these tumours can relapse and, albeit rare, malignant transformation can also occur. Unfortunately, evidence on fertility preservation in women with BOT is scanty. In this opinion paper, we tried to draw some clinical indications based on the few available studies on the clinical management of BOT and their possible relation with controlled ovarian hyper-stimulation (COH). We ultimately came to the following conclusions: (1) Fertility counselling should become an integral part of the clinical management of women with BOT. Conservative management without pre-surgical counselling may expose women without reasonable chances of future conceptions to undue risks. (2) Despite some epidemiological concerns on the possible relation between COH and BOT, the conservative surgical treatment should be associated to oocyte cryopreservation considering the high risk of recurrence of the disease. (3) Letrozole during COH should be considered to temper the theoretical risk of increased recurrences. (4) Pregnancy should not be delayed in women at low-moderate risk of recurrences. Fertility preservation may be avoided in these women provided that they start active pregnancy seeking early. (5) Albeit experimental, oocytes retrieval from affected ovaries removed at the time of surgery can be considered. Conversely, ovarian cortex cryopreservation is not justified given the possible risks of malignant reseeding.

An investigative study into psychological and fertility sequelae of gestational trophoblastic disease: the impact on patients' perceived fertility, anxiety and depression.

Objectives Gestational Trophoblastic Disease (GTD) comprises a group of disorders that derive from the placenta. Even if full recovery is generally expected, women diagnosed with GTD have to confront: the loss of a pregnancy, a potentially life-threatening diagnosis and delays in future pregnancies. The aim of the study is to evaluate the psychological impact of GTD, focusing on perceived fertility, depression and anxiety. Methods 37 patients treated for GTD at San Raffaele Hospital, Milan, took part in the study. The STAI-Y (State-Trait Anxiety Inventory), the BDI-SF (Beck Depression Scale-Short Form) and the FPI (Fertility Problem Inventory) were used. Patients were grouped on the basis of presence of children (with or without), age (< or ≥35) and type of diagnosis (Hydatidiform Mole, HM, or Gestational Trophoblastic Neoplasia, GTN). Differences in the values between variables were assessed by a t-type test statistic. Three-way ANOVAs were also carried out considering the same block factors. Results The study highlights that women suffering from GTN had higher depression scores compared to women suffering from HM. A significant correlation was found between anxiety (state and trait) and depression. Younger women presented higher Global Stress scores on the FPI, especially tied to Need for Parenthood and Relationship Concern subscales. Need for Parenthood mean scores significantly varied between women with and without children too. Conclusions We can conclude that fertility perception seems to be negatively affected by GTD diagnosis, particularly in younger women and in those without children. Patients should be followed by a multidisciplinary team so as to be supported in the disease’s psychological aspects too.

Risk of spontaneous preterm birth in singleton pregnancies conceived after IVF/ICSI treatment: meta‐analysis of cohort studies

Preterm birth (PTB) is more common in pregnancies conceived by in‐vitro fertilization (IVF) as compared with those conceived naturally. However, the extent to which this is attributed to spontaneous labor or to iatrogenic indications has not been determined. The aim of this study was to quantify the risk of spontaneous PTB (sPTB) in singleton pregnancies resulting from IVF or intracytoplasmic sperm injection (ICSI) treatment as compared with that in spontaneously conceived pregnancies.

Nuchal translucency measurement, free β-hCG and PAPP-A concentrations in IVF/ICSI pregnancies: systematic review and meta-analysis.

So far, data on the effect of assisted reproductive technologies (ART) on the components of first trimester combined screening for Down syndrome are still controversial. A systematic search of the literature was performed in order to identify the effect of ART, particularly in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) with fresh embryo transfer, on the nuchal translucency, free beta‐human chorionic gonadotrophin and pregnancy‐associated plasma protein‐A measurements. Moreover, a meta‐analysis and a descriptive graphical representation of the ratios between ART and spontaneous pregnancies (controls) values of median of the multiple of median (m0MoM) were performed. Free beta‐human chorionic gonadotrophin test showed slightly higher values in the ICSI group than controls (RR = 1.09, 95%CI: 1.03–1.16) but not in the IVF group (RR = 1.03, 95%CI: 0.94–1.12). Pregnancy‐associated plasma protein‐A values for IVF/ICSI, IVF and ICSI showed lower values in comparison with controls (RR, 95%CI 0.85, 0.80–0.90; 0.82, 0.74–0.89 and 0.83, 0.79–0.86, respectively). The nuchal translucency measurement did not show any statistical differences between study groups (IVF and ICSI) and controls (RR = 1.00, 95%CI: 0.94–1.08 and RR = 1.01, 95%CI: 0.97–1.05, respectively). These results may be due to alterations in the placentation of ART pregnancies. Differentiating further subgroups of ART pregnancies may explain the differences in biomarker concentrations, in prenatal behavior and in obstetric outcomes between ART and spontaneous pregnancies.

Advances in improving fertility in women through stem cell-based clinical platforms

ABSTRACT Introduction: Due to their regenerative ability, stem cells are looked at as a promising tool for improving infertility treatments in women. As the main limiting factor in female fertility is represented by the decrease of ovarian reserve, the main goals of stem cell-based clinical platforms would be to obtain in vitro or in vivo neo-oogenesis. Refractory endometrial factor infertility also represents an obstacle for female reproduction for which stem cells might provide novel treatment strategies. Areas covered: A systematic search of the literature was performed on MEDLINE/PubMed database to identify relevant articles using stem-cell based clinical or research platforms in the field of female infertility. Expert opinion: In vitro oogenesis has not so far developed beyond the stage of oocyte-like cells whose normal progression to mature oocytes and ability to be fertilized was not proved. Extensive epigenetic programming of gamete precursors and the complex interactions between somatic and germ cells required for human oogenesis likely represent the main obstacles in stem-cell-based neo-oogenesis. Also resuming oogenesis in vivo in adulthood still appears a distant hypothesis, as there is still a lack of consensus about the existence and functionality of adult ovarian stem cells.

Congenital heart defects in IVF/ICSI pregnancy: systematic review and meta‐analysis

There is no consensus in current practice guidelines on whether conception by in-vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) techniques is an indication for performing a fetal echocardiogram. The aim of the study was to assess whether congenital heart defects (CHD) occur more often in pregnancies conceived after IVF/ICSI as compared with those conceived spontaneously.

A case of pre-eclampsia and foetal growth restriction after embolisation for a postmolar uterine arteriovenous malformation

Introduction Arteriovenous malformations (AVMs) of the uterus are rare vascular lesions that may be congenital or more commonly acquired aft er medical or surgical abortion, spontaneous miscarriage, dilation and curettage (DC) and gestational trophoblastic neoplasia (GTN) (Timmerman et al. 2000). Uterine artery embolisation (UAE) is the most common treatment option in symptomatic women: it appears to be eff ective with few complications and it may allow the preservation of fertility (Badawy et al. 2001). Th e actual risk of possible complications during pregnancy aft er uterine AVM embolisation is unknown. Th e most frequent pregnancy-related complications reported in a few cases are placental abnormalities, such as placenta accreta and increta, uterine atony, uterine rupture and foetal growth restriction (FGR) (Chow et al. 1995, Delotte et al. 2006). In this article, we report the fi rst case of pre-eclampsia and FGR aft er UAE for AVM in a woman treated for GTN.

EP29.13: The role of uterine artery pulsatility index and a new ultrasound-guided approach to uterine biopsy in the preoperative evaluation of placental site trophoblastic tumour

appear like a solid mass with irregular borders with eterogeneous echogenicity, highly vascularised at power Doppler investigation. Bowel volvulus was suspected by abnormal morphology of visceral wall, by intestinal contents and by clinical symptoms. Conclusions: Not only can the genital tract be visualised during TVU, but with this imaging method it is possible to visualise other pathological conditions as well, including those unrelated to gynecology.

OP23.02: Percutaneous transvesical chorionic villus sampling: an alternative method for difficult procedures

Objectives: Cervical cerclage is performed in patients with cervical insufficiency to reduce risks of abortion/extreme prematurity. Severe complications can occur if performed in patients with intra-amniotic infection. High levels of intraamniotic interleukin-6 (IL-6) are associated with histological chorioamnionitis. In expert hands amniocentesis is considered a safe procedure which we use routinely in management of PPROM. The aim of our study is to validate our strategy diagnostic amniocentesis prior to cerclage. Methods: Prospective cohort study in Centre of Fetal Medicine in 2014-16. We included 29 patients with cervical insufficiency eligible for emergency cerclage. In all cases we performed transabdominal amniocentesis. Amniotic fluid was tested for IL-6 (Roche Diagnostics) and bacterial DNA (PCR Mycoplasma, Ureaplasma). In patients with IL-6 <2000 ng/l McDonald transvaginal cerclage with Mersilene tape (Ethicon) was performed. Between 2000–4999 ng/l therapeutic dose of IV antibiotics was administered (Clarithromycin or Clindamycin) and amniocentesis was repeated in one week. If IL-6 lower, we performed cerclage. Patients with IL-6 >5000 ng/l were ruled out and managed conservatively. Results: We performed 29 amniocenteses. 21 patients were tested negative and proceeded with cerclage. 4 intermediate received antibiotics, had second amniocentesis (all with lower IL-6) and a cerclage afterwards. 4 patients were ruled out and managed expectantly. We performed cerclage in 25 cases. Mean gestational age at surgery was 22.1 (min 16.2, max 26.0). Mean IL-6 was 1046 ng/l (min 215, max 4254). In 1 case there was an abortion after cerclage. In all other 24 cases (96%) live fetuses were born. Mean gestational age at delivery 33.1 (min 24.5, max 41.1), mean birth weight 2072g (min 542, max 3770). Out of the 4 ruled out patients: 3 had a septic abortion within 1 week, 1 patient had an emergency Caesarean at 26 weeks for sepsis and bleeding. Conclusions: Invasive diagnostic to rule out intra-amniotic infection seems beneficial before emergency cerclage.

Tumori del trofoblasto di origine gestazionale: impatto psicologico e ruolo dei meccanismi di difesa nel percorso di malattia

UNLABELLED Gestational Trophoblastic Disease (GTD) is a group of disorders that derive from the placenta and arise after a rare gestational event. They can be divided into pre-malignant forms (partial and complete hydatidiform mole) and malignant forms called Gestational Trophoblastic Neoplasia (GTN). Despite a favourable prognosis, the nature of this group of disorders can be a source of stress for patients who are affected by this disease. METHODS Thirty-one patients diagnosed with GTD completed a battery of self-administered questionnaires aimed at analysing the psychological adaptation of the patients to the disease. The variables analysed were the following: defense mechanisms, anxiety, depression and infertility-related stress. RESULTS Patients with GTN use mature defense mechanisms significantly more than patients with hydatidiform mole. Regression analyses highlight that, considering demographic and clinical variables, immature defense mechanisms are significantly related to state anxiety. Immature defence mechanisms also significantly predict infertility-related global stress. CONCLUSIONS The results show the importance of taking into consideration defense mechanisms used by patients, as they are involved in the modulation of psychological adaptation to GTD.