Hydrosalpinx: Tubal surgery or in vitro fertilisation? An everlasting dilemma nowadays; a narrative review.

The decision on how to treat tubal diseases, specifically hydrosalpinx, is a difficult one. Ιt involves surgical, medical, social, emotional and economic factors. This narrative review aims to increase awareness of tubal disease diagnosis and treatment, to compare between tubal surgery and in vitro fertilisation (IVF) for tubal factor infertility, and to investigate the effect of the combination of both. This way, we can be more effective, safe and provide our patients with better treatment results. The review analysed randomised studies, trials and meta-analysis, which give new aspects on the treatment methods for tubal pathology before IVF. Recent papers published in English have been studied, alongside guidelines and committee opinions from previous years. Tubal surgery and IVF aim to exploit a woman's reproductive potential. IVF and endoscopic tubal surgery must be thought of as complementary, rather than competing techniques in tubal disease cases, in order to improve fertility outcome. The first-line treatment for young women less than 35 years old with minor tubal pathology, is tubal surgery. IVF should be offered if there are other factors in a couple's subfertility, if the patient is >38 years old, if moderate to severe tubal disease is present, and if it has been more than 12 months post-surgery.

Cyclosporine therapy during pregnancy in a patient with ß-thalassemia major and autoimmune haemolytic anemia: a case report and review of the literature.

Recent advances in the management of hemoglobinopathies offer an improved potential for safe pregnancy with favourable outcome in patients with ß-thalassemia major. Autoimmune diseases that are common in women at reproductive age might be fulminant and hardly manageable in pregnant women with thalassemia. Thus immunosuppressant drugs like cyclosporine A could be necessary in order to maintain good maternal and foetal health. We present a case report of a 35-year-old woman with ß-thalassemia major, splenectomy, autoimmune hemolytic anemia and insulin treated diabetes mellitus who was treated with cyclosporine A during her pregnancy, and delivered a healthy male infant. First line therapy with steroids was ineffective, due to deregulation of diabetes mellitus.

Vulvodynia: a case series of a poorly recognized entity.

Vulvodynia remains a poorly recognized entity with unclear pathogenesis. In a case series of six patients with vulvodynia over a five-year period in a tertiary university hospital, we describe the clinical features, the diagnostic procedures, the impact on each patient's emotional status and discuss the necessity and efficacy of the chosen treatment options in accordance with the current therapeutic guidelines.

[Value of injection therapy for degenerative diseases of lumbar spine]. / Stellenwert der Injektionstherapie bei degenerativen Erkrankungen der Lendenwirbelsäule.

Local injection therapy is of great value in the border area between non-operative or operative treatment of discogenic and spinal stenotic radicular syndromes. With a series of deep periradicular infiltrations of local anesthetics and antiphlogistics it is possible to reduce the pain peaks in the spontaneous course of degenerative spinal diseases, so that planned surgery is no longer necessary. For the rare serious palsies immediate surgery is still necessary. On-going improvement is reached by physiotherapy and psychotherapy and with the back school.

A morphometric cadaver study of the anterior lumbar epidural space.

INTRODUCTION: Free disc fragments end often up in the concavity of the anterior epidural space. This space consists of two compartments. The discrepancy between the impressive magnetic resonance imaging findings, clinical symptoms in patients and the problem of treatment options led us to the anatomical determination of anterior epidural space volumes. MATERIALS AND METHODS: For the first time, the left and right anterior epidural volume between the peridural membrane and the posterior concavity of the lumbar vertebral bodies L3-S1 were determined for each segment. A CT scan and a polyester resin injection were used for the in vitro measurements. RESULTS: The volumes determined in human cadavers using this method ranged from 0.23 ccm for L3 to 0.34 ccm for L5. The CT concavity volume determination showed this increase in volume from cranial to caudal, as well. CONCLUSION: This volume is large enough to hold average-sized slipped discs without causing neurological deficits. A better understanding of the anterior epidural space may allow a better distinction of patient treatment options.

Hormonal replacement therapy in ovarian cancer survivors: a survey among Greek gynecologists.

PURPOSE OF INVESTIGATION: In this survey we evaluated the prescription attitude of Greek gynecologists towards hormone replacement therapy (HRT) for ovarian cancer survivors. METHODS: An anonymous questionnaire was sent to 900 members of the Hellenic Society of Obstetrics and Gynecology presenting a hypothetical case of an ovarian cancer survivor with indications for HRT followed by a series of relevant questions. RESULTS: Two hundred and ninety-eight responses were analyzed with regards to age, gender and practice setting. HRT would be prescribed by 48% of Greek gynecologists; regarding type of regimen, 60% would prescribe tibolone, 19% estrogen alone and 21% estrogen plus progestagen. In contrast, 52% of Greek gynecologists would not prescribe HRT due to the fear of ovarian cancer relapse (83%), or the development of breast cancer (6%), or both cancers (9%); among them, 21% would alternatively prescribe CNS medications, 9% SERMs, phyto-estrogens or bisphosphonates, while the remaining 70% would not prescribe anything. CONCLUSIONS: One out of two Greek gynecologists would prescribe HRT in ovarian cancer survivors. An alternative therapy, mainly CNS medications, would be suggested by 21% of the opposers.

A prospective randomized study for evaluation of wound retractors in the prevention of incision site infections after cesarean section.

Surgical site infections (SSIs) after cesarean section appear to be more common than generally believed. We prospectively evaluated 231 consecutive pregnant women who underwent elective or emergency cesarean section, and were assigned to have either the Alexis wound retractor (study group) or a conventional Doyen retractor (control group) during the operation. There was no evidence of SSI, defined as wound dehiscence, pain or tenderness in the lower abdomen, localized swelling, redness, heat or purulent discharge from the wound in any woman in the study group. Moreover, no endometritis occurred in this patient collective. There were three SSI in the control group, but no endometritis. Our preliminary data show excellent protection of wound infections with an additive protective effect to that given by antibiotic cover. After a short learning curve, the handling of the Alexis device became easier and the median insertion time was 18 sec.

[Rupture of the anterior cruciate ligament. Diagnostics and therapy]. / Ruptur des vorderen Kreuzbands. Diagnostik und Therapie.

Rupture of the anterior cruciate ligament (ACL) is the most common ligamentous knee injury. The knee is stabilized by the cruciate ligaments and the collateral ligaments. The ACL originates from the inner surface of the lateral condyle of the femur, runs in an anterior medial direction and inserts at the tibial plateau in the intercondyle area. The most common injury is an indirect knee trauma, typically a joint torsion in sports. Patients often describe a snapping noise followed by hemarthrosis. Concomitant injuries are lesions of the medial collateral ligament, the medial meniscus (unhappy triad) and chondral fractures. The age peak is between 15 and 30 years with a higher incidence in females. The cardinal symptom of the ACL rupture is the giving way phenomenon. The clinical diagnosis is provided by a positive Lachman test, a positive pivot shift test and the anterior drawer test. Fractures can be excluded by X-ray examination. Magnetic resonance imaging (MRI) allows the evaluation of the internal knee structures. ACL repair is carried out by arthroscopically assisted bone-tendon-bone or semitendinosus grafting techniques. Early rehabilitation is important for a good functional outcome.

Broad ligament leiomyosarcoma in a premenopausal nulliparous woman: case report and review of the literature.

Leiomyosarcomas of the broad ligament of the uterus are extremely rare tumors. Most of the time they are diagnosed in older women and despite radical surgical treatment prognosis is dismal. We present a rare case of a 38-year-old nulligravida presenting with a large, firm mass, fixed in the pelvis. After enucleation of the tumor, histological examination revealed the presence of a broad ligament leiomyosarcoma, leading to total abdominal hysterectomy and bilateral salpingo-ophorectomy three weeks later. Management options and cases reported in the literature are reviewed.

ERBB2 (HER2) protein expression in uterine sarcomas.

PURPOSE: Multiple clinical trials in recent years have shown that breast cancer patients with primary tumors overexpressing ERBB2 can be effectively treated with specific forms of modern anti-ERBB2-targeted therapy. The aim of the present study was to analyze the expression of the ERBB2 (HER2) protein in uterine sarcomas, in order to investigate the possibility of applying this treatment modality in uterine sarcomas. METHODS: The expression of ERBB2 has been analyzed immunohistochemically in formalin-fixed paraffin-embedded primary uterine sarcomas (n = 11). RESULTS: Using a semi-quantitative immunohistochemical score, we found that ERBB2 expression was very weak in the majority of tumors, with only three sarcomas showing moderate ERBB2 expression. Published studies evaluating the same issue in small numbers of uterine sarcomas reached similar findings. CONCLUSION: Overall, ERBB2 expression appears to be weak in uterine sarcomas. However, targeted treatment might still be feasible in a subgroup of patients with uterine sarcomas overexpressing ERBB2.

Virilizing ovarian hilus (Leydig) cell tumor with concurrent contralateral hilus cell hyperplasia: a rare diagnosis.

Ovarian hilus or Leydig cell tumor and ovarian hilus cell hyperplasia are rare clinical entities, causing virilization in both pre- and postmenopausal women. Differentiation between these two conditions is not always straightforward; the former is usually unilateral appearing as a single, grossly visible, circumscribed mass of hilus cells, while the latter is usually bilateral, appearing as diffuse microscopic aggregates of hilus cells. We report herein an extremely rare case of ovarian hilus or Leydig cell tumor, presenting concurrently with contralateral ovarian hilus cell hyperplasia in a postmenopausal woman with virilization. To the best of our knowledge, only four such cases have been previously reported in the literature. Ovarian hilus cell tumors and hilus hyperplasia almost always have benign biological behavior, thus making bilateral salpingo-oophorectomy an appropriate and sufficient therapeutic approach.

Awareness of human papillomavirus infection, testing and vaccination in midwives and midwifery students in Greece.

Midwives play an important role in the implementation of cervical cancer screening. We assessed the knowledge of human papillomavirus (HPV) infection and of its relationship with cervical cancer in 107 midwives and 29 graduating midwifery students. The majority of midwives (78.5%) were aware that a viral infection causes cervical cancer, whereas only 48.3% of the students knew this (p = 0.003). Only one midwife (0.9%) was not aware of HPV infection compared with 10.3% of the students (p = 0.029). Midwives were also more knowledgeable of the relationship between HPV infection and cervical cancer and of the availability of a vaccine against HPV infection (p = 0.005 and p < 0.0001, respectively). In conclusion, Greek midwives have a satisfactory level of knowledge about cervical cancer and HPV infection, in contrast to midwifery students. It is important to better educate midwifery students in order to facilitate the incorporation of HPV testing and vaccination in clinical practice.

Steroid receptor expression in human endometrium during the follicular phase of stimulated cycles.

BACKGROUND: No data are currently available regarding kinetics of human endometrial steroid receptors in stimulated cycles. METHODS: In 31 patients (age <39 years) stimulated with gonadotrophins and GnRH antagonists for intrauterine insemination (IUI) an endometrial biopsy was performed on the first day after the end of menstruation and a second biopsy was performed two (Group 0 + 2, n = 10) or four (Group 0 + 4, n = 11) days after the first biopsy, or on the day of hCG administration (Group 0 + hCG, n = 10). Expression of progesterone (PR) and estrogen (ER) receptor was investigated by immunohistochemistry using monoclonal antibodies. RESULTS: PR and ER levels were significantly increased in the second versus the first biopsy, in all groups analyzed (P = 0.01), in both stromal and glandular cells. Between the three groups compared, a significant increase in PR expression was observed for glandular cells (P = 0.03), with the highest value observed in Group 0 + 4. Moreover, the increase in PR expression in stromal cells differed between groups (P = 0.01), with the highest value observed in the Group 0 + hCG. CONCLUSIONS: In stimulated cycles for IUI, ER expression in both glandular and stromal endometrial cells, after an initial increase, does not appear to change significantly during the follicular phase. On the contrary, during the same period of time, following an initial rise, PR expression in glandular and stromal cells continues to increase.

A unique case of palatinate tonsil metastasis from endometrial cancer.

Metastases from malignancies of the female genital tract to the tonsils have never been reported. A case of a 55-year-old woman presenting with a palatinate tonsil tumour two and half years after primary diagnosis of endometrioid endometrial adenocarcinoma (FIGO Stage IB, G2) and six months after local disease recurrence is presented. The tonsillar malignancy was poorly differentiated and tumour cells were immunohistochemically positive to LMW keratin and EMA, and negative to HMW keratin and LCA, strongly suggesting a possible endometrial origin of the tumour. Metastatic disease was treated with systemic chemotherapy, but the patient soon succumbed due to rapid disease progression. In conclusion, a unique case of a palatinate tonsil tumour as the first metastatic site in an endometrial cancer patient is reported.

Human placental lactogen and color Doppler in predicting expulsion of retained adherent placenta: a new clinical observation.

PURPOSE: To present a new clinical observation made in three cases of retained adherent placenta, a rare obstetrical complication, associated with potentially life-threatening hemorrhage. METHODS: Three consecutive cases of retained adherent placenta are presented. RESULTS: Diagnosis of placenta increta in two and placenta percreta in one case was established with ultrasound and MRI. Methotrexate 50 mg i.v. (300 mg total dose) and follinic acid 0.1 mg/kg were administered on alternating days, over 12 days. On follow-up, placental perfusion on color Doppler was present up to the point when circulating hPL levels were no longer detectable; this was followed in all cases by spontaneous placental expulsion within 10 days. CONCLUSIONS: The observation that both color Doppler and human placental lactogen can be used to monitor response to therapy and predict placental expulsion should be evaluated in future cases of retained adherent placenta.

[Back school - an update]. / Rückenschule heute.

AIM: The aim of this paper is to present an update of the Back School concept including recent randomised controlled studies, systematic reviews and guidelines. METHOD: After definition and classification of the origins of the Back School concept, results of randomised controlled studies and systematic reviews within the framework of the Cochrane Collaboration Back Review Group are presented with their consequences with regard to German and International guidelines for the rehabilitation and prevention of low-back pain. RESULTS: The Back School, integrated into a multidisciplinary programme, is effective in the rehabilitation and prevention of recurrent and chronic low-back pain. It is not effective for acute back problems when compared to other treatment modalities. There is moderate evidence suggesting that back schools in an occupational setting reduce pain and improve function and return to work status. CONCLUSION: The classic structure of the Back School with information, back protection exercises and gymnastics can be practiced successfully for chronic low-back pain and in an occupational setting. Insurance companies should consider the low-cost technology. For children, adolescents and for older people with osteoporosis and lumbar spinal stenosis, a special age-orientated design of the Back School is necessary.

[Epidural injection therapy with local anaesthetics versus cortisone in the lumbar spine syndrome: a prospective study]. / Die epidurale Injektionsbehandlung mit Lokalanästhetikum versus Kortison beim chronischen lumbalen Nervenwurzelkompressionssyndrom: eine prospektive Studie.

AIM: The prospective randomised double-blind study analyses follow-up data of the therapeutic effects of cortisone versus local anaesthetics using an injection technique close to the nerve root in chronic lumbar spine syndrome. METHODS: 57 patients were included with an MRI-assured clinical diagnosis. The study was performed over a 6-month period to evaluate long-term effects. The level of disability (ODQ), the quantitative and qualitative sensations of pain were separately determined. The t-test was used for interval and relation variables, the chi (2) test for nominal variables and the Mann-Whitney-U-test for ordinal variables. RESULTS: Significant differences in favour of cortisone were not found for the measured parameters at any time. An improvement for all parameters was seen in both groups between the time t0 and the definite times t1 and t2. CONCLUSION: The advantage of a combined injection of local anaesthetics and cortisone versus a injection of local anaesthetics alone in epidural-peridural technique in the inpatient treatment of the chronic lumbar spine root compression syndrome could not be detected.

[Angle of needle position for the epidural-perineural injection at the lumbar spine]. / Einstichwinkel bei der epidural-perineuralen Injektion an der Lendenwirbelsäule.

AIM: The aim of this study was to find the correct angle of the needle position for the epidural perineural injection at the lumbar spine without any help by imaging. METHODS: In 11 human cadaver lumbar spines besides dura, nerve roots and bones all soft tissue had been removed to allow us to look into the anterior lateral epidural spaces between L3 and S1 in different angles with an operation microscope. The area between the dura (medial), facet joint (lateral) and the laminae (cranial and caudal) were photographed and planimetrically measured. This area is called the width of the injection canal. RESULTS: Degenerative lumbar spines show a width of the injection canal of 29.61 mm(2) in L5/S1 with an angle of the needle position of 15 degrees to the midline. The optimal angle position of the needle brought a width of the injection canal in L4/5 only for 7.3 mm(2) and in L3/4 for 3.5 mm(2). In non-degenerative spines the injections canals were much wider. DISCUSSION: The epidural-perineural injection into the anterolateral epidural space only makes sense in the segment L5/S1. Here the L5 nerve root is reached as well as the S1 root - the main causes of sciatica. In upper segments the injection canal is far smaller even at optimal injection angles. In case of nerve root compression at L4 and upwards other epidural injection techniques should be used such as the epidural dorsal loss of resistance technique or the transforaminal technique. CONCLUSION: With some training it is possible to perform epidural-perineural injection for sciatica without the help of imaging.