Dual Triggering With Gonadotropin-Releasing Hormone Agonist and Standard Dose Human Chorionic Gonadotropin in Patients With a High Immature Oocyte Rate.

In in vitro fertilization (IVF) cycles, some patients show a high rate of immature oocytes retrieved after controlled ovarian stimulation. In vitro oocyte maturation is an experimental technique, with poorer results than conventional IVF. For this reason, improving in vivo maturation could meliorate the reproductive outcome of these patients. We performed a retrospective, not interventional, study analyzing the difference in the number and percentage of mature oocytes retrieved in patients with more than 50% immature oocytes in a previous IVF cycle triggered with human chorionic gonadotropin (hCG) compared to the number and rate of mature oocytes retrieved in subsequent cycles, triggered with both gonadotropin-releasing hormone agonist (GnRH-a) and hCG. The number of mature oocytes retrieved with a dual trigger was significantly higher than that for hCG alone: 5.3 ± 3.6 (4.4-6.1) versus 2.4 ± 2.2 (2-2.9). The proportion of mature oocytes showed the same tendency (79.6% vs 43.6%). The implantation, clinical, and ongoing pregnancy rates were 17.3%, 26.9%, and 15.3%, respectively, for the hCG trigger and 30.8%, 43.6%, and 31.6%, respectively, for the dual trigger. In patients with a low percentage of retrieved mature oocytes, who were triggered with a combination of GnRH-a and hCG, the number and percentage of retrieved mature oocytes improved. The dual trigger also seemed to meliorate gestational outcomes after IVF.

Impact of vitamin D levels on ovarian reserve and ovarian response to ovarian stimulation in oocyte donors.

Recently, growing interest in vitamin D has emerged from findings that demonstrate a low vitamin D status in populations. Similarly, much interest has been shown in the role that anti-Müllerian hormone (AMH) plays in reproductive physiology. Considerable confusion as to whether vitamin D status is related to ovarian function can be found in the literature. Our retrospective study was performed from June 2014 to April 2015. Oocyte donors were recruited and stimulated under the antagonist protocol with gonadotrophin-releasing hormone (GnRH) agonist to trigger ovulation. In 851 stimulation cycles, we determined the association among serum total and bioavailable vitamin D levels, ovarian reserve and response to ovarian stimulation and the reproductive outcome in their recipients. We showed that vitamin D levels were unrelated to ovarian reserve or ovarian response after ovarian stimulation; in oocyte recipients, gestational outcome did not differ according to a donor's vitamin D serum status. No correlation was observed between serum AMH and vitamin D. Bioavailable vitamin D was not related to recipients' ongoing pregnancy rate. Highly prevalent vitamin D insufficiency neither impaired ovarian reserve nor response or oocyte quality in egg donors. No evidence was found for recommending the analysis of vitamin D status in oocyte donors.

Impact of circulating levels of total and bioavailable serum vitamin D on pregnancy rate in egg donation recipients.

OBJECTIVE: To investigate the correlation between total and bioavailable serum 25-OH vitamin D and the pregnancy rate in recipients of donated oocytes. DESIGN: Retrospective study. SETTING: University-affiliated private IVF center. PATIENT(S): A total of 267 patients who were referred to our clinic for oocyte donation from June 2013 to December 2013. INTERVENTION(S): Serum analysis of vitamin D and bioavailable vitamin D and reproductive outcomes. MAIN OUTCOME MEASURE(S): Pregnancy and implantation rate. RESULT(S): Among all patients, 15.3% (n = 41) were vitamin D replete (vitamin D >30 ng/mL), 50.2% (n = 134) had vitamin D deficiency (20-30 ng/mL), and 34.4% (n = 92) had insufficient vitamin D (<20 ng/mL). Implantation rates were similar among patients with normal, insufficient, or deficient total serum 25-OH vitamin D levels (61%, 63.4%, and 65.2%, respectively). Pregnancy rates did not differ among the three groups (70%, 69.9%, and 73.9%). Ongoing pregnancy rates were also comparable among the three groups (55.9%, 52.7%, and 60.7%). The predictive value of total vitamin D regarding pregnancy rate was analyzed by the receiver operating characteristic curve, and the area under the curve (AUC) was 0.468. The AUC for bioavailable 25-OH vitamin D was 0.499, showing that the analysis of the AUC for vitamin D or bioavailable vitamin D was not informative. CONCLUSION(S): Vitamin D insufficiency and deficiency are frequent conditions in our southern European infertile population. In contrast to previous studies, patients who are not vitamin D replete do not have a decreased chance of becoming pregnant with egg donation. Bioavailable 25-OH vitamin D, which is a better marker of the status than total 25-OH vitamin D, does not correlate with pregnancy rate in recipients of donated oocytes. Thus, at this stage, there is insufficient evidence to recommend vitamin D screening in patients undergoing egg donation.

Estimated intermediate risk endometrial cancer: debate and new perspectives on therapy individualization and prognosis establishment starting from a peculiar case.

The adequate treatment for stage IB endometrial cancer (EC) with G1-G2 grading (intermediate risk patients) is still debated. FIGO guidelines recommend adjuvant radio-therapy in order to avoid recurrences, despite it has been demonstrated that this does not improve the overall survival. Recently, other than the conventional risk-factor (histology, stage and grading), lymph-vascular involvement, tumor size and neoplasia molecular patterns has been proposed with intent to establish the most appropriated EC oncologic treatment and prognosis. We report an interesting case of a patient affected by an early stage EC (estimated intermediate low risk), treated by the adequate surgical staging and subsequent adjuvant radio-therapy that showed, in a follow up period, a very poor prognosis, similarly to patients affected by high risk cancer. Even if the classical validated risk factors remain the "cornerstone" in risk assessment, adjuvant treatments and follow up planning after surgery, the molecular investigation of estimated intermediate risk EC could represent a "keystone" to solve and avoid the "oncologic dilemma" of cases in which the observed prognosis results very different from the expected one. Only a detailed molecular evaluation of these cases could allow a more specific treatment targeting, leading to an individualized therapy and low recurrence-risk. The importance of recurrence-risk reduction is linked to difficulties in both their early detection and appropriate management. The delay in diagnosis as well as the performance of not adequate treatment can potentially make the prognosis of these cases worst that the one detected in case of uterine sarcoma or mixed müllerian tumors.

Hysteroscopic enucleation in toto of submucous type 2 myomas: long-term follow-up in women affected by menorrhagia.

STUDY OBJECTIVE: To evaluate long-term efficacy of type 2 myoma enucleation in toto. DESIGN: Longitudinal retrospective study (Canadian Task Force classification II-2). SETTING: University obstetrics and gynecology clinic. PATIENTS: One hundred twelve women with menorrhagia and at least 1 type 2 submucous myoma who underwent hysteroscopic myoma enucleation in toto. INTERVENTION: Clinical long-term follow-up. MEASUREMENTS AND MAIN RESULTS: Success of the procedure and influence of myoma characteristics on recurrence of menorrhagia were evaluated. Mean (SD) follow-up was 58.4 (19.1) months. The success of the procedure was 88.4% (99 patients). Seventeen patients (15.2%) underwent a 2-step procedure. Among patients with relapsed menorrhagia, 10 (8.9%) underwent a repeat operation. Statistical analysis showed that number and diameter of myomas did not influence the outcome. Localization in the posterior wall of the uterus, compared with other sites, was associated with a higher percentage of resolution of menstrual symptoms (p = .03). There was no significant relationship between myomas features and risk of symptom recurrence during follow-up. The 2-step myomectomy was performed in patients with myomas >30 mm in diameter (p < .001). CONCLUSION: Hysteroscopic enucleation in toto of type 2 myomas is a safe and effective technique in long-term management of premenopausal women with menorrhagia.

Maspin expression, subcellular localization and clinicopathological correlation in endometrial hyperplasia and endometrial adenocarcinoma.

Maspin expression in endometrial hyperplasia and endometrial endometrioid adenocarcinomas was assessed and its correlation with p53 and Ki67 expressions and clinical outcome, as well as its potential to distinguish typical from atypical endometrial hyperplasia, were assessed in this study. Histological sections from 114 cases of endometrial endometrioid adenocarcinoma, 75 cases of endometrial hyperplasia (typical and atypical), and 23 normal endometrial tissue samples were examined. The most representative hematoxylin-eosin slides were selected and 2-3 micron-thick sections were cut for immunohistochemical staining with maspin, p53, and Ki67 antibodies. While there was no maspin expression in normal endometrial cells, it was present in 14.5% of the patients with endometrial hyperplasia without atypia. Staining for maspin was positive in atypical hyperplasia and endometrial adenocarcinoma in, respectively, 45% and 49.1% of the cases studied. No statistically significant correlations were found between maspin and Ki-67 antibodies or p53 expression. Our findings showed that maspin expression, which generally correlates with a less aggressive behavior, is significantly higher in atypical hyperplasia and in endometrial endometrioid adenocarcinoma. Maspin positivity in endometrial hyperplasia could be used to identify pseudo-atypical hyperplasia and could be considered a potentially useful prognostic parameter in those cases in which adenocarcinomas are well differentiated.