Miomatosis uterina: implicaciones en salud reproductiva / Uterine myomatosis: Implications on reproductive health

Resumen OBJETIVO: dar a conocer a los ginecoobstetras un documento donde pueda consultarse, a la luz de los estudios más recientes y con la mejor evidencia en la fisiopatología, prevalencia y significado clínico de los miomas uterinos, así como la mejor evidencia posible acerca de las diversas modalidades de tratamiento. METDOLOGÍA: estudio retrospectivo efectuado por los miembros del Comité de expertos de la Asociación Mexicana de Medicina de la Reproducción, empleando los artículos publicados entre los años 2000 a 2016 en Pubmed y que en el resumen contuvieran los MeSH: leiomyomatosis uterus, leiomyoma, leiomyomatosis uterine, leiomyomatosis uterine in pregnancy. La calidad de la evidencia y la formulación de las recomendaciones se realizaron con la metodología establecida por el sistema GRADE. RESULTADOS: se incluyeron 97 artículos en los que se encontró que la prevalencia en mujeres en edad reproductiva es variable, según la edad (20 a 80%). En la mayoría el diagnóstico se establece entre los 35 y 54 años. Para el tratamiento existen varias opciones con distintos porcentajes de eficacia. CONCLUSIONES: queda de manifiesto la evidencia de la eficacia de varios medicamentos indicados para el control de los síntomas y para mejorar la calidad de vida de las pacientes. En la comparación entre acetato de leuprolide y acetato de ulipristal no se encontraron que originaran síntomas vasomotores, ni disminuyeran la masa ósea. En relación con el último se vislumbra la posibilidad de evitar la cirugía, aunque aún se requiere más investigación a este respecto.

Abstract OBJECTIVE: To make known to the gynecological obstetricians a document where they can be consulted, in the light of the most recent studies and with the best evidence on the pathophysiology, prevalence and clinical significance of uterine fibroids, as well as the best possible evidence about the various treatment modalities. METDOLOGY: A retrospective study carried out by the members of the Committee of experts of the Mexican Association of Reproductive Medicine, using the articles published between 2000 and 2016 in Pubmed and that in the abstract contained MeSH: leiomyomatosis uterus, leiomyoma, Leiomyomatosis uterine, leiomyomatosis uterine in pregnancy. The quality of the evidence and the formulation of the recommendations were made using the methodology established by the GRADE system. RESULTS: 97 articles were included in which the prevalence was found to be variable, according to age (20 to 80%) in women of reproductive age. In most, the diagnosis is established between 35 and 54 years. There are several treatment options with different percentages of effectiveness. CONCLUSIONS: Evidence of the efficacy of several medications indicated for the control of symptoms and to improve the quality of life of the patients is evident. In the comparison between leuprolide acetate and ulipristal acetate, they were not found to cause vasomotor symptoms or to decrease bone mass. Regarding the latter, the possibility of avoiding surgery is envisaged, although more research is still needed in this regard.

[Changes in preovulatory molecular relationship between estradiol and progesterone in patients undergoing controlled ovarian hyperstimulation. Can they be used for the evaluation of ovarian reserve?]. / Cambios en la relación molecular preovulatoria entre estradiol y progesterona en pacientes sometidas a hiperestimulación ovárica controlada. Pueden usarse como evaluación de la reserva ovárica?

The objective was to evaluate if the preovulatory molecular ratio between progesterone and estradiol has age-dependent changes in patients undergone controlled ovarian hyperstimulation. Were studied 180 cycles of conventional in vitro fertilization. Patients were divided in three groups: Group 1 (age less than 30 years; n = 40), group 2 (age between 30 and 35 years; n = 82), and group 3 (age between 36 and 40 years; n = 58). Leuprolide acetate was used in all cases. Molecular progesterone/estradiol ratio was calculate with the following formula: [Serum progesterone (ng/mL) x 3180 (SI x 10(3) divided by serum estradiol (pg/mL) x 3.671 (SI)]. In patients with age more than 38.5 years there was positive correlation between preovulatory progesterone and estradiol (R = 0.55, R2 = 0.30). There were significant difference in molecular progesterone/estradiol ratio between group 1 compared to group 2 (P less than 0.001), group 1 compared to group 3 (P less than 0.0001), as soon as group 1 compared to group 2 plus group 3 (P less than 0.0001). It is concluded that molecular progesterone/estradiol ratio decreases before any endocrino evidence of ovarian aging. The value of this putative test of ovarian reserve is discussed.

[Changes in preovulatory molecular progesterone/estradiol ratio in patients treated with controlled ovarian hyperstimulation. Can they be used in the assessment of ovarian reserve?]. / Cambios en la relación molecular preovulatoria entre estradiol y progesterona en pacientes sometidas a hiperestimulación ovárica controlada. Pueden usarse como evaluación de la reserva ovárica?

The objective was to evaluate if the preovulatory molecular ratio between progesterone and estradiol has age-dependent changes in patients undergoing controlled ovarian hyperstimulation. There were 180 cycles of conventional in vitro fertilization which were studied. Patients were divided in three groups: Group 1 (age less than 30 years; n = 40), group 2 (age between 30 and 35 years; n = 82), and group 3 (age between 36 and 40 years; n = 58). Leuprolide acetate was used in all cases. Molecular progesterone/estradiol ratio was calculated with the following formula: [Serum progesterone (ng/mL) x 3180 (Sl x 10(3)) + serum estradiol (pg/mL) x 3.671 (Sl)]. In patients older than 38.5 years there was positive correlation between preovulatory progesterone and estradiol (R = 0.55, R2 = 0.30). There were significant difference in molecular progesterone/estradiol ratio between group 1 compared to group 2 (P less than 0.001), group 1 compared to group 3 (P less than 0.0001), as well as group 1 compared to group 2 plus group 3 (P less than 0.0001). It is concluded that molecular progesterone/estradiol ratio decreases before any endocrine evidence of ovarian aging. The value of this putative test of ovarian reserve is discussed.

[Methods of pedicle hemostasis in laparoscopically-assisted vaginal hysterectomy (VAVH). Evaluation of results]. / Métodos para la hemostasia de pedículos en histerectomía vaginal asistida laparoscópicamente (LAVH). Evaluación de resultados.

The objective was to evaluate whether use of different techniques of hemostasia have effect on laparoscopically assisted vaginal hysterectomy (LAVH) morbidity. Was performed a review of 53 LAVH cases, parameters analyzed were type of hemostasia method and surgical complications. There were five patients with transoperative bleeding and two with incidental bladder lesion, that were managed successfully without complications. There were no significant differences between types of hemostasia with respect to transoperative bleeding. There were no mayor surgical complications in the studied patients. As conclusion LAVH allows patients a expedite recovery with low postoperative complications. All the methods used in this work to perform hemostasia in LAVH are safe and effective for patients with habitual hysterectomy indications.

[Effect of intrafollicular interleukin-6 levels on the secretion of estradiol and progesterone in patients treated with in vitro fertilization and embryo transfer]. / Efecto de los niveles de interleucina-6 intrafolicular en la secreción de estradiol y progesterona de pacientes tratadas con fertilización in vitro y transferencia de embriones.

The objective was to evaluate the relationship between follicular fluid levels of Interleukin-6 (IL-6) and the seric concentrations of estradiol and progesterone during controlled ovarian hyper-stimulation. The levels of IL-6 were measured in follicular fluid of 15 patients undergone to in vitro fertilization and embryo transfer and correlated with the values of seric estradiol and progesterone. There were a negative correlation between follicular levels of IL-6 and either estradiol and progesterone. Four patients achieved pregnancy following embryo transfer (pregnancy rate 26.6%), one of them aborted. As conclusion, the increased levels of IL-6 may be a reaction to controlled ovarian hyper-stimulation and probably a protective response. According to the reduction of estradiol, there may be a subtle reduction in aromatase action by effect of IL-6 and other cytokines.

[Effect of blood concentrations of preovulatory estradiol on the quality of eggs and pre-embryos in patients treated with fertilization in vitro]. / Efecto de las concentraciones séricas de estradiol preovulatorio en la calidad de óvulos y preembriones en pacientes tratadas con fertilización in vitro.

The objective was to investigate if the preovulatory estradiol concentrations obtained during controlled ovarian hyperstimulation (COH) have effect on reproductive outcome. The study included a total of 198 in vitro fertilization (IVF) cycles. Patients were divided into four groups according to serum preovulatory estradiol concentrations. In low responder patients was observed significantly decreased oocyte and preembryo quality compared with normal or high responders (P < 0.01). In this work high response do not have effect on IVF outcome. The clinical results indicate that low estradiol levels the day of hCG administration are apparently correlated with poor oocyte and embryo quality.

[From theory to clinical practice: recombinant FSH in daily practice]. / De la teoría a la clínica: la FSH recombinante en la práctica cotidiana.

The purpose of the present study is to determine the efficacy of induction ovulation with recombinant FSH in patients treated with in vitro fertilization and embryo transfer (IVF-ET) and basic assisted reproductive techniques (ART). One hundred seven cycles were analyzed. The patients were divided in two groups: Group 1, treated with IVF (n = 12) and group 2, treated with basic ART (n = 95). Only recombinant FSH was utilized for ovulation induction; human corionic gonadotropin (hCG), 10,000 IU, were administered when one or more dominant follicles with diameter > or = 18 mm were presents; oocyte retrieval was performed 34 hour, while intrauterine insemination was practiced at 36 hours after the hCG injection. The pregnancy rate per IVF cycle was 25.0%, and 16.4% for basic ART. It is concluded that ovulation induction with recombinant FSH is a good and efficient alternative for both variations of ART.

[Spontaneous and assisted reproduction-associated heterotopic pregnancy. The clinical characteristics]. / Embarazo heterotópico espontáneo y asociado con reproducción asistida. Características clínicas.

Heterotopic pregnancy is an uncommon obstetric entity with variegated symptomatology. The objective of this report is to describe the clinical findings of the two varieties of heterotopic pregnancy, spontaneous an related with Assisted Reproduction Techniques (ART). Three cases of heterotopic pregnancy are described, two spontaneous and one occurred after in vitro fertilization and embryo transfer (IVF-ET). The two former culminated in miscarriage of intrauterine pregnancy and tubal rupture; and the late obscured for the ovarian hyperstimulation syndrome which prevented accurate ultrasonographic diagnosis. The clinical presentation and key differences are discussed.

[New concepts in the induction of ovulation. A logarithmic assessment of estradiol production during controlled ovarian hyperstimulation for fertilization in vitro]. / Nuevos conceptos en inducción de la ovulación. Una evaluación logarítmica de la producción de estradiol durante la hiperestimulación ovárica controlada para fertilización in vitro.

The objective was to evaluate the exponential response of serum estradiol to controlled ovarian hyperstimulation (COH) in an in vitro fertilization-embryo transfer (IVF-ET) program through measurement of logarithm of serum estradiol area under the curve (LOG-OUC). One hundred three patients undergone conventional IVF-ET with pituitary suppression were studied. For to calculate the LOG-AUC estradiol, trapezoidal formula and ten-fold logarithm definitions were employed. The estradiol synthesis have notorious logarithmic changes during all COH. There was significant difference between estradiol AUC for initial and final phases of controlled ovarian hyperstimulation. As conclusion LOG-AUC of estradiol can be used for to evaluate the ovarian response to superovulation, its prognostic value for following IVF-ET intent is discussed.

Effect of body mass index and follicular synchrony in the ovarian response to ovulation induction with menotropins.

OBJECTIVE: To determine the correlation between body mass index, follicular synchrony, and pregnancy rate in a controlled ovarian hyperstimulation program with menotropins. SUBJECTS AND METHODS: Seventy-nine hyperstimulation cycles were evaluated. Transvaginal ultrasonographic control was performed and 10,000 IU of human chorionic gonadotropin were administered when the dominant follicle reached a diameter > 16 mm. In order to evaluate the follicular response, the ovarian synchrony factor was used (# follicles > or =16 mm/# follicles > 10 mm). For the statistical analysis, linear correlation and chi-square tests were used. RESULTS: When patients had a normal body mass index there was a positive correlation ( r = .52) between body mass index (kg/m(1.5)) and the ovarian synchrony factor. Weight deficiency and obesity had a deleterious effect on the ovarian response ( r = -.47 and r = -.77, respectively). There was a significant difference in the number of pregnancies in patients with ideal weight in relationship to the subgroup with weight deficit. CONCLUSIONS: An adequate body constitution increases the possibilities of achieving success in ovulation induction programs; on the other hand, weight disturbances have a deleterious effect on ovulation.

[Clinical evaluation of patients submitted to open vs conventional gynecologic laparoscopy]. / Evaluación clínica de pacientes sometidas a laparoscopia ginecológica con técnica abierta versus laparoscopia convencional.

The objective was to comparate the clinical evolution and rates of complications for open and conventional gynecological laparoscopy. Were studied the cases of 253 patients divided in two groups: Group 1 (n = 106) patients treated with open laparoscopy, and group 2 (n = 147) patients managed with conventional surgery. The major indication for performing laparoscopy was infertility management. There were not early or I ate complications of trocar insertion or operative laparoscopy in the group 1. However, in group 2 there were four complications (P < 0.05), two related with needle or trocar insertion. As conclusion, in the studied group open laparoscopy can to eliminate the risks of blind insufflation and trocar insertion observed in the classifical technique, is a safe and efficacious method to treat several gynecological pathologies.

[Heterotopic pregnancy with intrauterine dizygotic twins following embryo transfer in the blastocyst phase]. / Embarazo heterotópico con gestación intrauterina dicigótica después de transferencia de embriones en etapa de blastocisto.

Ectopic pregnancy is a common complication of in vitro fertilization and embryo transfer (IVF-ET). On other hand, heterotopic pregnancy complicates 1-2% of all IVF-ET pregnancies. Tubal damage as reason for treatment and multiple embryo transfer might predispose patients to this complication. We present a successful treated case of an infertile patient that developed simultaneous twin intra- and single extra- uterine pregnancy after blastocyst-stage embryo transfer. In IVF-ET patients presence of an intrauterine gestation not exclude the possibility of a concomitant extrauterine pregnancy. Awareness of the possibility of heterotopic pregnancy after IVF-ET plays an important role in the successful treatment of this reproductive complication. Transfer of good quality embryos can be a risk factor to develop heterotopic pregnancy.

[Efficacy of simultaneous use of cryopreserved semen, controlled ovarian hyperstimulation and intrauterine insemination in the treatment of sterility caused by hypergonadotropic azoospermia]. / Eficacia del uso simultáneo de semen criopreservado, hiperestimulación ovárica controlada e inseminaciones intrauterinas para el tratamiento de la esterilidad causada por azoospermia hipergonadotrópica.

The purpose of the present study is to determine the efficacy of an artificial intrauterine insemination program with frozen donor sperm and controlled ovarian hyperstimulation as an alternative therapy for infertility cause by hypergonadotropic azoospermia. Two hundred forty three insemination cycles with frozen donor sperm were analyzed. Clomiphene citrate, pure FSH, recombinant FSH or human menopausal gonadotropins were utilized for ovulation induction; human corionic gonadotropin (hCG), 10,000 IU, was administered when one or more dominant follicles with diameter > or = 16 mm were present; intrauterine insemination was performed 36 hours after the hCG injection. The pregnancy rate per cycle was 19.9%, and the cumulative pregnancy rate was 59.3%. It is concluded that intrauterine insemination with frozen donor sperm and ovulation induction is a good alternative for male factor infertility with no available treatment.

[Clinical use of a quadruple biochemical marker in the prediction of obstetric complications]. / Utilidad clínica del cuádruple marcador bioquímico para predecir el desarrollo de complicaciones obstétricas.

The objective was to evaluate the association of an abnormal second trimester prenatal biochemical screening with the subsecuent development of pregnancy complications in women carrying chromosomally normal fetuses. A prospective study of 123 pregnant patients was performed. Specimens were assayed for alpha-fetoprotein, unconjugated estriol, free alpha hCG, and total hCG. The study included the evaluation of the mean and standard desviation as well as multiple of the median. Six women (4.6%) had positive results. The frequency of pregnancy complications in this group was 33.3%, while in the group with negative screening was 11.1%. As conclusion, positive four marker screening is associated with a adverse pregnancy evolution. However the usefulness of four marker screening for to predict pregnancy complications needs more investigations.

[Gynecologic laparoscopy at the ABC Hospital. Analysis of 882 cases]. / "Laparoscopia ginecológica en el Hospital ABC. Análisis de 882 casos".

The objective was to evaluate the indications and clinical evolution of patients treated with laparoscopy. Eight hundred eighty two women undergoing conventional laparoscopy for gynecological pathology, patients were not preselected, preoperative and postoperative data were registered retrospectively. Main indications to perform laparoscopy were dismenorrhea and infertility. Endometriosis and pelvic adhesions were the most frequent findings detected in the study subjects. Endoscopic treatment resulted in minimal complications and short postoperative stay. As conclusion classic laparoscopy is a safe and efficacious technique for treatment gynecological pathology.

[Clinical evaluation of patients treated with open gynecologic laparoscopy]. / "Evaluación clínica de pacientes sometidas a laparoscopia ginecológica con técnica abierta".

The objective was to evaluate the clinical evolution and rates of complications for open gynecological laparoscopy. Were studied the records of ninety two patients treated with open laparoscopy for gynecological pathology. The major indication for performing laparoscopy was infertility management. There were not early or late complications of trocar insertion or operative laparoscopy. As conclusion, in the studied group open laparoscopy can to eliminate the risks of blind insufflation and trocar insertion observed in the classical technique, is a safe and efficacious method to treat several gynecological pathologies.

[Diagnostic and therapeutic usefulness of laparoscopic surgery in acute abdomen of gynecologic origin]. / "Utilidad diagnóstica y terapéutica de la cirugía laparoscópica en el abdomen agudo de origen ginecológico".

The objective was to determine the usefulness of laparoscopy for treatment of gynecological emergencies. In this work were studied 78 cases of patients which were treated in the Emergency Room of ABC Hospital, with symptomatology associated to reproductive organs. The age of patients was 27.7 +/- 6.3 years. The more frequent diagnosis before surgery were ectopic pregnancy and ovarian cysts, the remainder patients were operated to determine pain etiology. Ectopic pregnancy antecedent was determinant to have same problem (X2, p < 0.05), other determinative factors were infertility and pelvic inflammatory disease. Abdominal pathology was detected in 97.4% of patients; 98.6% with gynecological pathology. The predictive positive value of preoperative diagnosis was 83.3% and 91.3% for ectopic pregnancy and ovarian cysts, respectively. In 25.6% of the cases endoscopy turned in laparotomy; massive hemoperitoneum in tubal rupture in cases of ectopic pregnancy was the most frequent indication of this conduct. As conclusion, laparoscopy is useful in most of cases of gynecological emergencies. Fast detection or abdominal pathology, in special ectopic pregnancy can be to lower conversion of laparoscopy to open surgery.

[Integral treatment of severe ovarian hyperstimulation syndrome by means of autotransfusion of ascitic fluid and intravenous infusion of albumin]. / "Tratamiento integral del síndrome de hiperestimulación ovárica severo mediante autotransfusión de ascitis e infusión intravenosa de albúmina".

Severe ovarian hyperstimulation syndrome (OHSS) is a potential life-threatening condition relationated with ovulation induction. It affects multiple systems. Little is known about it's pathophysiology. The treatment available consists in the correction of fluid, electrolyte and hematologic imbalances. In other hand, is mandatory the prevention of embolic phenomena. Ascitic fluid aspiration result in dramatic improvement of symptoms. The purpose of this study was to assess the effect of autotransfusion of ascitic fluid obtained by paracentesis and the intravenous infusion of albumin for the treatment of severe from of the OHSS.

[A murine model of polycystic ovaries: its use in the evaluation of effects of endoscopic ovulation induction]. / Un modelo murino de síndrome de ovarios poliquísticos: su utilidad para evaluar los efectos de la inducción endoscópica de la ovulación.

The objective was to evaluate the effect of the endoscopic treatment of the polycystic ovary syndrome (PCOS) in a murine model induced with depot estrogen. Three groups with PCOS were studied: group 1 (n = 22) evaluated exclusively using laparoscopy; group 2 (n = 11) one fulguration on both ovaries was performed during laparoscopy; and group 3 (n = 10) three fulgurations were performed. One month after laparoscopy the animal were sacrificed and was carried surgical microscopic examination of the intraabdominal organs, moreover histological evaluation of the gonads was practiced. All the animals showed PCOS. No adhesions were observed in the animals of group 1, while the frequency of adhesion in group 2 was 36.3%, 18.1% of the animals of group 2 showed gonadal atrophy. The frequency of adhesions in the group 3 was 66.6%. The adhesion score was significantly higher in groups 2 and 3 than in group 1. Is concluded that the use of estrogen is useful to induce PCOS in animal models. The procedure can be employed to study the effects of the surgical induction of ovulation, it's utility in other conditions seems promissary.

[A physiopathological overview of climacteric and menopause]. / Un punto de vista fisiopatológico del climaterio y la menopausia.

Today, million of woman in the world lived enough to experience the menopause ant it's seculae. In the last few years the research of the events associated with this age has gained enormous attention. Hormonal replacement therapy has been shown to reduce the incidence of cardiovascular disease, osteoporosis and other complications in postmenopausal woman. In this paper we review the endocrinology of the menopause, benefits and risks of hormonal replacement therapy, Prescription choices, compliance and health care professional attitudes are too analysed.