Vincenzo Campo

Infertility and adenomyosis.

Classically, the diagnosis of adenomyosis has only been possible on a hysterectomy specimen, usually in women in their late fourth and fifth decades, and, therefore, evaluating any relationship with infertility was simply not possible. As a consequence, to this day, no epidemiologic data exists linking adenomyosis to a state of subfertility. Today, new imaging techniques have enabled a noninvasive diagnosis at a much earlier time and a number of single-case or small series reports have appeared showing that medical, surgical, or combined treatment can restore fertility in women with adenomyosis, an indirect proof of an association. At the functional level, several anomalies found in the so-called junctional zone, or inner myometrium, in adenomyosis patients have been shown to be associated with poor reproductive performance, mainly through perturbed uterine peristalsis. Additional evidence for an association comes from experimental data: in baboons, adenomyosis is associated with lifelong primary infertility, as well as to endometriosis. Finally, indirect proof comes from studies of the eutopic and ectopic endometrium in women with adenomyosis proving the existence of an altered endometrial function and receptivity. In conclusion, sufficient indirect proof exists linking adenomyosis to infertility to warrant systematic clinical studies.

A case of metastatic struma ovarii treated with 131I therapy: Focus on preservation of fertility and selected review of the literature

Struma ovarii is a rare monodermal ovarian teratoma composed predominantly of mature thyroid tissue. We describe herein the case of a 22-year-old woman who underwent a right salpingo-oophorectomy for struma ovarii at the age of 12 years, who was admitted 8 years later with signs and symptoms of a left pelvic tumor. Laparoscopy detected a left ovarian endometriotic cyst and multiple nodules on the pelvic peritoneum, right lateral abdominal wall, diaphragm, vesical plica and liver. The diagnosis was abdominal and pelvic widespread dissemination of recurrent struma ovarii, with features consistent with the follicular variant of papillary thyroid carcinoma. The patient was treated with a combination of conservative surgery and two 131I administrations (cumulative activity of 350 mCi after dosimetric evaluation). Because of the high degree of hormonogenesis shown by the metastases, the first administration was performed following use of recombinant human (rh) thyroid-stimulating hormone (TSH) to reach adequate TSH levels. To avoid the ‘stunning effect’ and to obtain high-quality scintigraphy, a whole-body scan was performed with 123I after rh-TSH and before the 131I therapy. We also discuss the potential role and the possible benefit of using gonadotropin-releasing hormone analogs and ovarian tissue cryopreservation to preserve fertility in women treated with 131I for pelvic metastases from malignant struma ovarii.

Endothelial dysfunction but not increased carotid intima-media thickness in young European women with endometriosis.

BACKGROUND Atherosclerosis is a chronic and degenerative disease developing typically in the elderly; nonetheless, a condition of accelerated atherosclerosis can be observed precociously in the presence of some diseases. Endometriosis, a chronic benign gynecological disorder, shows some characteristics, such as oxidative stress, systemic inflammation and a pro-atherogenic lipid profile, which could increase the risk of developing accelerated atherosclerosis. The aim of our study was to evaluate markers of subclinical atherosclerosis in young European women with endometriosis. METHODS This cross-sectional study included 37 women with endometriosis and 31 control subjects. The presence of subclinical atherosclerosis was investigated by ultrasound evaluation of common carotid intima-media thickness (ccIMT) and flow-mediated dilation (FMD); in addition, serum levels of lipids, inflammatory and coagulation parameters, as well as markers of endothelial inflammation and activation, were determined. RESULTS Women with endometriosis showed significantly lower values of FMD compared with controls [mean difference: -4.62, 95% confidence interval (CI): -6.52, -2.73; P < 0.001], whereas no significant differences in ccIMT values were found between the two groups. As regards markers of endothelial inflammation and activation, women with endometriosis had significantly higher values of inter-cellular adhesion molecule 1 (P < 0.001), vascular cell adhesion molecule 1 (P < 0.001), E-selectin (P < 0.001), von Willebrand factor (P = 0.004) and ristocetin cofactor (P = 0.001) compared with controls. CONCLUSIONS Our study suggests that women with endometriosis have more subclinical atherosclerosis, resulting in a higher risk of developing cardiovascular disorders. Moreover, our findings demonstrate that endothelial dysfunction can occur in the absence of structural atherosclerotic changes; its evaluation might be helpful in young women with endometriosis.

Endometriosis, need for a multidisciplinary clinical setting: the internist’s point of view

Endometriosis is a common condition characterized by proliferation of endometrial tissue outside the uterus, both in the pelvis and in other extra-pelvic sites. The clinical picture of endometriosis is widely heterogeneous. A correct diagnostic work-up of these patients can sometimes be very difficult, since there are a number of gynecological, intestinal and systemic diseases mimicking endometriosis, as well as other conditions that could be associated with or are a consequence of this disorder. Therefore, multidisciplinary care should be encouraged to ensure correct evaluation and improve the management of these patients.

A modified technique to reduce spillage and operative time: laparoscopic ovarian dermoid cyst enucleation 'in a bag'

Background: To describe the outcomes of a modified technique for conservative laparoscopic enucleation of ovarian dermoid cyst, placing the ovary in an endobag during enucleation to prevent intraperitoneal spillage. Methods: Laparoscopic dermoid cyst enucleation was performed in 35 cases of premenopausal patients placing the ovary in an endobag at the beginning of the procedure and removing the cyst from the abdominal cavity by the same endobag. Results: Dermoid cysts with a mean diameter of 6.3 ± 2.7 cm were enucleated and removed laparoscopically ‘in a bag’ without intra- or postoperative complications. Cyst rupture occurred in 10 cases (28.5%), but evident peritoneal contamination occurred in only 2 (5.7%; 95% confidence interval: 0.7–19.2%), because in 8 patients spillage was contained by the surrounding bag. The mean operative time was 64.6 ± 27 min. No signs or symptoms of peritonitis were observed. The mean postoperative hospitalization was 1.6 ± 1.4 days. Among the 12 infertile patients, 7 spontaneous pregnancies (58%) occurred. Conclusions: Laparoscopic conservative excision of dermoid cysts placing the ovary in an endobag at the beginning of surgery and removing the cyst by the same bag is a safe and effective approach to reduce intraperitoneal spillage and operative time.

Twin pregnancy using recombinant gonadotropins in a woman with hypogonadotropic hypogonadism.

In women with hypogonadotropic hypogonadism both follicle-stimulating hormone (FSH) and luteinizing hormone (LH) are required to induce optimal follicular growth and steroidogenesis. The development of molecular genetic technology has led to the availability of recombinant FSH and LH for the induction of follicular growth and ovulation. We describe a first case of a twin pregnancy in a 36-year-old patient presenting with primary hypogonadotropic amenorrhea and empty sella syndrome and treated with recombinant FSH and LH. This therapy led to the maturation of two follicles, both of which were fertilized. A twin pregnancy ensued and two normal infants were delivered.

Looking for Celiac Disease in Italian Women with Endometriosis: A Case Control Study

In the last years, a potential link between endometriosis and celiac disease has been hypothesized since these disorders share some similarities, specifically concerning a potential role of oxidative stress, inflammation, and immunological dysfunctions. We investigated the prevalence of celiac disease among Italian women with endometriosis with respect to general population. Consecutive women with a laparoscopic and histological confirmed diagnosis of endometriosis were enrolled; female nurses of our institution, without a known history of endometriosis, were enrolled as controls. IgA endomysial and tissue transglutaminase antibodies measurement and serum total IgA dosage were performed in both groups. An upper digestive endoscopy with an intestinal biopsy was performed in case of antibodies positivity. Presence of infertility, miscarriage, coexistence of other autoimmune diseases, and family history of autoimmune diseases was also investigated in all subjects. Celiac disease was diagnosed in 5 of 223 women with endometriosis and in 2 of 246 controls (2.2% versus 0.8%; P = 0.265). Patients with endometriosis showed a largely higher rate of infertility compared to control group (27.4% versus 2.4%; P < 0.001). Our results confirm that also in Italian population an increased prevalence of celiac disease among patients with endometriosis is found, although this trend does not reach the statistical significance.

How Predictable Is the Operative Time of Laparoscopic Surgery for Ovarian Endometrioma

Endometriosis is a tricky albeit common disease whose management largely relies on laparoscopy. We have studied the operative times of laparoscopic endometrioma surgery in order to assess their predictability and possible predictors. One hundred forty-eight laparoscopies were included, with a median operative time of 70 minutes (mean 75.14; 95% CI: 70.03–80.24). Half of the cases had a duration within 15–20 minutes above or below the median (IQR: 55–93.75), but the whole dataset ranged from 20 to 180 minutes, and the standard deviation was relatively large (31.4). Surgical times were significantly related to technical (number and size of the cysts) and nontechnical factors (age, parity, dysmenorrhea, and family history). At multiple logistic regression, after adjusting for number and size of the cysts, surgical times below the first quartile were associated with older age (>30 years old: aOR: 3.590; 95% CI: 1.417–9.091) and parity (≥1 delivery: aOR: 3.409; 95% CI: 1.343–8.651). Longer times, above the third quartile, were instead predicted by a familial anamnesis of endometriosis (aOR: 3.639; 95% CI: 1.246–10.627). Our findings indicate highly variable surgical times, which are predicted by unexpected nontechnical factors. This is consistent with the complexity of endometriosis and its treatment. Productivity and efficiency in endometriosis surgery should focus on the quality of healthcare outcomes rather than on the time spent in the operating theatres.

Regression of endothelial dysfunction in patients with endometriosis after surgical treatment: a 2-year follow-up study

STUDY QUESTION How does endothelial function change in women with endometriosis after surgical treatment? SUMMARY ANSWER Surgical treatment of endometriosis leads to endothelial function improvement, resulting in reduction of cardiovascular risk. WHAT IS KNOWN ALREADY Some recent studies have demonstrated that in young women with endometriosis, even if structural alterations are absent, endothelial dysfunction, expressed as flow-mediated dilation (FMD) impairment, can nevertheless occur. However, there are no data about changes of endothelial function in women with endometriosis after surgical treatment of endometriosis. STUDY DESIGN, SIZE, DURATION This is a follow-up study carried out in 68 women enrolled in a previous study. Endothelial function was evaluated 2 years after surgical procedure and compared with baseline values. PARTICIPANTS/MATERIALS, SETTING, METHODS Twenty-two patients who had undergone surgical treatment of endometriosis (named as patients with STE) and 10 control subjects without endometriosis, from the original study sample participated in this follow-up study. Assessment of endothelial function by FMD evaluation and measurements of serum markers of endothelial activation and inflammation were done in all these subjects. MAIN RESULTS AND THE ROLE OF CHANCE After a 2-year follow-up period, FMD increased significantly with respect to baseline values among patients with STE [average pre- to post-difference: 5.07%, 95% confidence intervals (CI) 3.50, 6.63%; P < 0.001] but not among controls (average pre- to post-difference: 1.56%, 95% CI -0.55, 3.67%; P = 0.13). Follow-up FMD values were not significantly different between patients with STE and controls (average difference 1.50%, 95% CI -1.24, 4.23%; P = 0.27). Follow-up markers of inflammation and endothelial cells activation were similar among patients with STE and controls. LIMITATIONS, REASONS FOR CAUTION Although this study represents the first in the literature assessing endothelial function after surgical treatment of endometriosis, further longitudinal studies are desirable to define better the real risk that women with a history of endometriosis will develop cardiovascular events. WIDER IMPLICATIONS OF THE FINDINGS Endothelial dysfunction may be a better predictor of future cardiovascular events than traditional risk factors and the improvement in endothelial function we observed in patients after STE may have significant implications for their future cardiovascular risk. STUDY FUNDING/COMPETING INTEREST(S) No external funding has been either sought or obtained for this study. There are no conflicts of interest to declare.