Hysteroscopic laser ablation of symptomatic uterine fibroids: insights from a prospective study.

OBJECTIVE: This study aimed to evaluate the feasibility and efficacy of in-office hysteroscopic ablation of submucous uterine fibroids using a diode laser. METHOD: A pilot study was conducted between January 2018 and January 2019 in a tertiary care university hospital. Patients with at least one symptomatic, class 0-2 FIGO classification, uterine fibroid ≤7 cm in size were eligible for inclusion. Evaluation of the changes in fibroid size and vascularity was performed using three-dimensional Doppler ultrasonography. Vaporization of the fibroid core was conducted using a 980-1470 nm wavelength diode laser inserted through the hysteroscope's working channel. The primary outcome was evaluation of the fibroid volume before and at 2 months after the procedure. RESULTS: Twenty women were enrolled in the study. At 2-month follow-up, the volume of the fibroids was significantly reduced (51.6 ± 22.5 vs. 33.4 ± 17.1 mm3; p < 0.001). A major reduction of three-dimensional sonographic color Doppler vascularity (observed by the same operator and confirmed by four blind reviewers) was also achieved in 12/20 patients (60%; p = 0.03) while a reported symptom of heavy menstrual bleeding decreased from 18/20 (90%) to 2/18 (10%; p < 0.01). CONCLUSION: Hysteroscopic laser ablation represents a feasible and effective alternative for treating women with symptomatic submucous fibroids in the office setting. Further studies with larger sample size and longer follow-up periods are needed to validate this promising technique.Key messageThis pilot study shows that in-office hysteroscopic laser ablation (HLA) could be a feasible alternative to treat symptomatic submucous uterine fibroids by coagulating their core, reducing their size and vascularization.

Hysteroscopic treatment of submucosal fibroids in perimenopausal women: when, why, and how?

Uterine fibroids are a common finding in premenopausal women. They considerably reduce the quality of life by provoking abnormal uterine bleeding and consequent anemia and pelvic pain. Over the past 20 years, radical surgery (hysterectomy) for symptomatic fibroids has been partially replaced with minimally invasive surgical procedures that spare the uterus, with lower costs and reduced morbidity. Outpatient and inpatient operative hysteroscopy have been validated as safe and effective minimally invasive treatment options for both submucosal and intramural fibroids. In such a scenario, several technological innovations and the possibility of pharmacological pretreatment have enhanced the hysteroscopic approach. However, the counseling and treatment of perimenopausal women remain a challenge for the gynecologist. The main purpose of this review is to provide an updated guide to the management of submucosal fibroids in perimenopausal women, depicting how, when, and why hysteroscopic treatment is a valuable choice to eliminate symptoms and satisfy the patient's wish to improve their overall quality of life.

Office hysteroscopy in the management of women with postmenopausal bleeding.

Postmenopausal bleeding (PMB) is a relevant aspect for health-care providers in clinical practice: the first objective is to rule out potential gynecological cancer. The purpose of this narrative review is to evaluate the role of office hysteroscopy in the management of PMB. Office hysteroscopy is a minimally invasive procedure allowing direct visualization of uterine pathology without the need for general anesthesia and the use of an operating room, generating cost savings and greater compliance among patients. Here, we focus on major intrauterine diseases (polyps, submucosal myomas, endometrial hyperplasia, and cancer) as causes of PMB. Office hysteroscopy appears to be safe and feasible, and could allow accurate diagnosis of intrauterine pathologies, especially that with a focal growth pattern, otherwise misdiagnosed with blinded procedures. However, studies focusing exclusively on postmenopausal women are still few, so further research, especially randomized controlled trials, is needed.

Pharmacological and non-pharmacological pain relief for office hysteroscopy: an up-to-date review.

In-office hysteroscopy is considered the standard technique for visualization of the uterine cavity and the diagnosis of intrauterine pathologies. Moreover, nowadays, it is possible to treat a vast number of intracavitary diseases in the office, without the need for the inpatient setting. However, in some cases, pain might occur, and this is the most common reason for not completing the procedure. Over the last 20 years, many efforts have been carried out to miniaturize the instrumentation and to improve the techniques in order to avoid discomfort. Nonetheless, hysteroscopy still provokes distress for many patients. For this reason, pharmacological and non-pharmacological treatments for intraoperative and postoperative pain relief have been widely used for in-office hysteroscopy, with different results in various groups of women. The purpose of this review was to analyze the current literature on pharmacological aids (non-steroidal anti inflammatory drugs, cyclooxygenase-2 inhibitors, antispasmodics, local anesthetics, prostaglandins, opioids) and non-pharmacological interventions (transcutaneous electrical nerve stimulation, uterine stretching, uterine pressure, warming of distension medium, hypnosis, music, vocal-local) and to evaluate their impact on the relief from pain experienced during in-office hysteroscopy.

Vitamin D in human reproduction: the more, the better? An evidence-based critical appraisal.

OBJECTIVE: Vitamin D is a fat-soluble secosteroid hormone that regulates calcium, magnesium, and phosphate homeostasis and plays a pivotal role as antiproliferative and immunomodulatory mediator. Considering the different sources of synthesis and dietary intake as well as the pleiotropic actions in extremely diverse (micro)environments of the body, the supplementation of this Vitamin should be carefully evaluated taking into account the several pathways that it regulates. In the current brief review, we aimed to summarize the available evidence about the topic, in order to suggest the best evidence-based supplementation strategy for human reproduction, avoiding the unuseful (and sometimes hazardous) empiric supplementation. MATERIALS AND METHODS: Narrative overview, synthesizing the findings of literature retrieved from searches of computerized databases. RESULTS: Accumulating evidence from in vitro fertilization (IVF) trials suggests that fertilization rate decreases significantly with increasing levels of 25OH-D in follicular fluid; in addition, Vitamin D levels in the follicular fluid are negatively correlated to the quality of embryos and the higher values of Vitamin D are associated with lower possibility to achieve pregnancy. Both low and high Vitamin D serum concentrations decrease not only spermatozoa count, but their progressive motility as well as increase morphological abnormalities. Finally, studies in animal models found that severe hypervitaminosis D can reduce the total skeletal calcium store in embryos and may compromise the postnatal survival. CONCLUSIONS: Based on the retrieved data, we solicit to be extremely selective in deciding for Vitamin D supplementation, since its excess may play a detrimental role in fertility.

Myo-inositol as a male fertility molecule: speed them up!

Myo-inositol (MYO) usually represents a therapeutic option for female infertility associated with insulin resistance. Recently, several evidences are accumulating about the potential use of MYO for the treatment of male infertility. This article summarizes the rationale for MYO in the treatment of male infertility. In particular, it illustrates the potential antioxidant and prokinetic role of MYO, and its importance for the modulation of hormonal regulation. In the final part of the manuscript has been added a proposal for a clinical algorithm reserved for patients with asthenozoospermia, where probably MYO could exert specific pharmacological effects.

Hormonal treatment with transdermal testosterone in patients with male accessory gland inflammation (MAGI): Effects on sperm parameters.

Recently, it has been reported that treatment with testosterone (T) could have favourable effects on prostate inflammation; however, the data appear inconsistent. The main evidences concern experimental studies, and there is lower information obtainable from clinical studies. This study was conducted on patients with diagnosis of male accessory gland infection (MAGI) and a concomitant hormonal condition of acquired hypergonadotropic hypogonadism and has evaluated the effects on sperm parameters of the administration of a transdermal formulation of T gel for 3 months. The treated patients showed a significantly increased percentage of spermatozoa with normal form and progressive motility (p < .05 vs baseline), a significant reduction of CD45pos leucocytes in the semen (p < .05 vs baseline) and finally a significant increase of the seminal concentrations of zinc, fructose and alpha-glucosidase (p < .05 vs baseline) identified as key parameters associated to secretory function of the male accessory glands. The results of this study suggest the use of transdermal T in hypogonadal patients with MAGI for favourable effects on sperm parameters.

Ultrasonographic evaluation of placental cord insertion at different gestational ages in low-risk singleton pregnancies: a predictive algorithm.

OBJECTIVE: To evaluate the accuracy of ultrasound in visualizing placental cord insertion (PCI) at different gestational ages in order to recommend the most feasible period during pregnancy to identify it. Secondary aim was to propose a predictive algorithm for PCI visualization. METHODS: We performed a single-center, prospective cohort study. We enrolled patients with singleton low-risk pregnancies who underwent fetal ultrasound scan at different gestational ages. We excluded patients with body mass index of 30 Kg/m2 or more, uterine fibroids larger than 5 cm, high-risk pregnancies, fetal weight lower than < 10° percentile or higher than > 90° percentile, increased ("deep pocket" > 80 mm) or decreased ("deep pocket" < 20 mm) amniotic fluid. RESULTS: Among the 468 recruited patients, the visualization of PCI was not possible in 5.77% of the cases. Furthermore, we showed that PCI visualization was lower as the gestational age increased (p = 0.049) and more difficult in case of posterior placenta (p = 0.001). CONCLUSIONS: PCI should be evaluated in the first trimester or as early as possible during the second trimester. Moreover, we propose a feasible model to predict the possibility of PCI visualization according to gestational age and uterine site of implantation.

Otorrhagia and Nosebleed as first signs of Intravascular Absorption Syndrome During Hysteroscopy: From Bench to Bedside.

Hysteroscopic surgery is indicated for the treatment of several intrauterine diseases. The surgeon needs to be aware of, and know how to prevent, possible complications related to these procedures. In the case of operative hysteroscopy, the systemic effects of low-viscosity fluid uptake must be considered in order to prevent the complications in the patient. We report on two unusual clinical signs of intravascular absorption syndrome (IAS) that developed during an operative hysteroscopy with glycine 1.5% as the fluid of distension. Based on our experience, we recommend that practitioners reduce operating times, monitor fluid balances, check electrolytes and kinetic heart rates, and monitor for symptoms including otorrhagia and nosebleed, in order to identify and possibly prevent IAS due to an overload of low-viscosity fluids.

Dental management in pregnancy: recent trends.

This review analyzes the changes that occur during normal pregnancy and describes the main odontogenic infections, suggesting the actual best approach in dental management. Several studies support the hypothesis that periodontal disease is associated with preterm labour and other conditions complicating pregnancy, such as pre-eclampsia and fetal growth restriction. Appropriate dental care and prevention during pregnancy may reduce poor prenatal outcomes and eliminating risk factors. Dental examination before pregnancy is strongly suggested in order to act early on dental and periodontal diseases. Prevention means reducing the presence of bacterial plaque through professional hygiene sessions, education, and motivation to proper oral hygiene at home, education in proper nutrition, a balanced diet, and low intake of sugars. For these reasons, it is essential to have a more intense interdisciplinary collaboration between gynecologist and dentist in order to achieve an optimal women's health, during this particular time in their lives.

Pelvic arterial embolization for postpartum hemorrhage: long term results of a single center experience in 29,091 deliveries.

PURPOSE OF INVESTIGATION: To evaluate the rate of all postpartum hemorrhages (PPHs) treated with uterine embolization in a third level delivery center. MATERIALS AND METHODS: Since January 2008 to March 2014, 29,091 deliveries were registered in the present hospital in Bergamo, Italy. Among these deliveries, 2,002 cases (6.8%) of PPHs occurred. Seventy-three patients with severe obstetric hemorrhage underwent uterine artery embolization (UAE) (47 cases, 1.61/1,000 deliveries) or hysterectomy (26 cases, 0.89/1,000 deliveries). All identified cases were followed up by telephone on January 2015 in order to evaluate long term results. RESULTS: Embolization was performed successfully in 45 patients (95.7%). Two women underwent total abdominal hysterectomy: one patient for uterine atony and one for adherent placenta. In the follow up all the women interviewed reported the return of their menstrual cycle and 95.2% of women reported regular cycles. CONCLUSIONS: Embolization showed a success rate of 95.7%. For this reason, in the authors' opinion, it is the best choice as second line treatment of PPH, when patient is hemodynamically stable.

Concomitant chemoradiation treatment in selected Stage I endometrioid endometrial cancers.

PURPOSE OF INVESTIGATION: To evaluate chemotherapy with concomitant radiotherapy (RT) in "high risk" endometrial cancer (EC) patients. Furthermore to develop a new algorithm for management and treatment. MATERIALS AND METHODS: The study included 182 Stage I endometrioid EC patients who underwent definitive surgery after a first treatment. Stage, grade, ploidy DNA index, lymphovascular space involvement (LVSI), tumor diameter (TD), and p53 were considered to identify "high-risk" patients. Twenty-seven women received adjuvant concomitant chemoradiation (CR). Toxicity related to the CR treatment, disease free interval (DFI), and status of the patients were considered. RESULTS: Twenty-seven patients according to the present algorithm treatment were considered at "high risk". Median follow up was 43 months (range 16-68). Twenty-five (92%) patients completed CR treatment. Overall, grade 3/4 hematological toxicity was 18% while gastrointestinal toxicity was 15%. Four patients relapsed with a five-year rate of 14% of recurrences. CONCLUSIONS: Adjuvant concomitant CR is well tolerated and is a feasible regimen in "high risk" patients. The authors' new algorithm treatment could be used for management and further clinical studies.

Laparoendoscopic single-site surgery for the assessment of peritoneal carcinomatosis resectability in patients with advanced ovarian cancer.

PURPOSE OF INVESTIGATION: To evaluate the feasibility, safety, and effectiveness of laparoendoscopic single site surgery (LESS) for the assessment of peritoneal carcinomatosis resectability in patients with advanced stage ovarian cancer (AOC). MATERIALS AND METHODS: The authors retrospectively reviewed the medical records of patients affected by advanced stage ovarian cancer who underwent LESS for operative work-up. A standard cytoreductive laparotomy surgery (CRS) was performed. RESULTS: Fifty-two women affected by AOC underwent LESS for operative work-up. The peritoneal cancer score was completed in 49 (94%) patients by use of LESS; 34/37 (92%) patients considered with a resectable disease were effectively optimally debulked and 15/52 (28%) patients considered with an unresectable disease received before neoadjuvant chemotherapy (NACT) and then underwent surgery. CONCLUSION: LESS is feasible, safe, and is an alternative minimally invasive procedure to assess the resectability of AOC patients.

P16INK4a as a progression/regression tumour marker in LSIL cervix lesions: our clinical experience.

PURPOSE OF INVESTIGATION: The aim of this prospective study was the evaluation of low-grade intraepithelial lesion (LSIL) lesions evolvement in woman with evidence of high risk HPV infection and p 16 4a negative expression. MATERIALS AND METHODS: 150 women with cytological diagnosis of LSIL were selected to be underwent to three years of follow-up consisting in smear test, colposcopy, and protein p16I4a investigation every six months and HPV-test every 12 months. RESULT: Final follow-up showed 45 cases of spontaneous lesion regression and 42 cases of persistence with absence of protein p164NK4a in all of them. There were three cases of disease progression to CIN2, two at 18-month follow-up and one at last follow-up. Disease progression was characterized of p16NK4a expression. CONCLUSION: p16l4a should help to identify which LSIL cases are inclined to the progression of the disease and focalize which patients are eligible for specific treatment.

Diagnosis, antenatal surveillance and management of prolonged pregnancy: current perspectives.

Prolonged pregnancy is defined as a pregnancy that extends beyond 42 weeks of gestation (294 days) from the first day of the last normal menstrual period. An accurate estimation of the 'natural' incidence of prolonged pregnancy would require meticulous early pregnancy dating. The use of ultrasound to establish gestational age reduces the number of pregnancies that are classified as prolonged. Prolonged pregnancy is associated with an increased perinatal mortality and morbidity in pregnancies which appear to be otherwise low risk. Postterm births are easily preventable by intervening to deliver with the use of induction of labor. Thus, this potentially problematic condition deserves further attention and careful consideration. The focus of this article is to review and challenge some current concepts surrounding the diagnosis and management of prolonged pregnancy. We outline how to identify those women with prolonged pregnancy and which is the appropriate moment to start monitoring the fetal wellbeing. Finally we address the question of benefits and hazards of induction of labor strategies.

Soy isoflavones, inulin, calcium, and vitamin D3 in post-menopausal hot flushes: an observational study.

PURPOSE OF INVESTIGATION: To evaluate the effect of soy isoflavones and inulin (SII) on hot flushes (HF) and quality of life in a clinical setting, the authors conducted an observational study. MATERIALS AND METHODS: The authors performed an observational, prospective, multicentric study on women in peri-/post-menopause treated or untreated with a product present on the Italian market, consisting in a mixture of calcium (500 mg), vitamin D3 (300 IU), inulin (3 g) and soy isoflavones (40 mg). RESULTS: A total of 135 patients, 75 (55.6%) in the SII group and 60 (44.4%) in the untreated group entered the study. After three months, the mean number of HF declined of 2.8 (SD 3.7) in the SII group and 0.0 in the untreated one. The corresponding values after six months were -3.7 (SD 2.7) in the SII group and -0.9 (SD 5.3) in the control group (p = 0.02). CONCLUSION: This observational trial suggests a possible beneficial effect of a dietary soy supplement containing 40 mg of isoflavone/day plus inulin in the management of menopausal symptoms such as hot flashes.

Cellular and biochemical mechanisms, risk factors and management of preterm birth: state of the art.

Preterm birth (PTB) is usually defined as a delivery before 37 completed weeks or 259 days of gestation. World Health Organization estimates a worldwide incidence of PTB of 9.6%. Infants born preterm are at higher risks than infants born at term for mortality, and acute and chronic morbidity. Major causes of PTB are the following: spontaneous preterm labor with intact membranes (50%), labor induction or caesarean delivery for maternal or fetal indications (30%), and preterm premature rupture of membranes or PPROM (20%). The aim of this review is to analyze this medical condition, focusing on cellular and biochemical mechanisms, maternal risk factors and role of inflammation and infections in preterm premature rupture of membranes (PPROM) and PTB. Moreover we will discuss about the proper therapeutic strategies for its management. Although different methods have been introduced to predict the advent of preterm labour in asymptomatic women, possibilities for real primary prevention are rare. An early estimation of potential risk factors is pivotal in the secondary prevention of PTB. Finally most efforts so far have been tertiary interventions. These measures have reduced perinatal morbidity and mortality. Advances in primary and secondary care will be needed to prevent prematurity-related illness in infants and children.

Beta-Thalassemia major and pregnancy.

OBJECTIVE: It was studied the clinical management and the medical outcomes of 6 pregnancies in 5 women affected by Beta Thalassemia major, based on last guidelines and pharmacological treatments. BACKGROUND: Paediatric Department and Department of Obstetrics and Gynaecology of the University of Catania. METHODS: These patients were taken among a group of 116 women affected by beta-thalassemia major divided into three subgroups, according to the characteristics of their menstrual cycle: 1) women with primitive amenorrhoea, 2) women with secondary amenorrhoea and 3) women with normal menstruation. Only one woman, affected by primitive amenorrhoea, needed the induction of ovulation. An accurate and detailed pre-pregnancy assessment was effected before each conception. This was constituted by a series of essays, including checks for diabetes and hypothyroidism, for B and C hepatitis and for blood group antibodies. Moreover were evaluated: cardiac function, rubella immunity and transaminases. Other pregnancy monitoring, and cares during labour and delivery were effected according to usual obstetrics practice. RESULTS: All the women were in labour when they were 38 week pregnant, and the outcome were six healthy babies born at term. There were no complications related to the pregnancy and to the immediate outcome after delivery. CONCLUSIONS: The improvements of current treatments, especially in the management of iron deposits, the prolongation of survival rate, will result in a continuous increase of pregnancies in thalassemic women. Pregnancy is now a real possibility for women affected by such disease. Although numerous complications can occur, vigilant monitoring by both experienced obstetricians and hematologists can lead to successful pregnancy outcomes (Tab. 1, Fig. 1, Ref. 16).

[Personality traits in adults with autism spectrum disorders measured by means of the Temperament and Character Inventory]. / Persoonlijkheidsaspecten bij volwassenen met autismespectrumstoornissen gemeten met de 'Temperament and Character Inventory' (TCI).

BACKGROUND: There is growing interest in autism spectrum disorders (asd) in adulthood. Someone can be diagnosed with ASD, but the diagnosis tells us very little about the patient’s temperament, character and personality. Comparatively little is known about the personality traits of persons with ASD. AIM: To map personality traits of persons with asd. METHOD: The Temperament and Character Inventory (tci) was administered to a group of 68 men diagnosed with asd at the Lucertis Sarr expertise centre for Autism and at the Department of Psychiatry, Erasmus mc, Rotterdam, the Netherlands. The control group, specified in the instructions for the tci, consisted of a group of 447 men from the general population. RESULTS: Compared to the control group, men with asd scored higher on the scale Harm Avoidance, but lower on Sociability, Novelty Seeking, Reward Dependence, Self-directedness, and Cooperativeness. CONCLUSION: The score pattern found in men with asd is consistent with the clinical picture of asd and corresponds to earlier results of research done in Sweden. In our study we argue that negatively interpreted temperament and character traits can often be interpreted in a positive way.