Characterization of microRNA in the follicular fluid of patients undergoing assisted reproductive technology.

Female fertility plays a decisive role in the reproduction of mammals, with related issues that include oocyte or embryo quality, establishment of pregnancy, and the physiology of the tissues that contribute to reproduction and metabolic disorders associated with reproductive failure. Although reproductive failure may be attributed to various factors in different species, female infertility is largely controlled by a number of molecular signals that can be regulated in a cycle- and tissue-dependent manner.

Single port entry - are there any advantages?

Minimal-invasive, single-port laparoscopic surgery is a recent innovation that may improve surgical outcomes. In this chapter, we review published research on single-port surgery in gynaecology, and the different surgical instruments available. Challenges, advantages, indications and potential future rules of this new approach are also discussed. Sixty-five studies were available for review: 17 case reports, 32 case studies, 13 retrospective comparative studies, and three randomised-controlled trials (RCTs). The recent availability of advanced instruments has made single-port surgery safer and more feasible for most benign gynaecologic surgeries. Single-port surgery has many potential benefits, but comparative trials have found no differences between single-port surgery and conventional laparoscopy in postoperative complications, postoperative pain, hospital stay, and cosmetic results. Single-port surgery seems to provide another option in the area of minimal invasive surgery, and further development of this technique, along with robotics and natural orifice transgastric endoscopic surgery, will improve dissemination of this approach.

Are you good enough for your patients? The European certification model in laparoscopic surgery.

Quality control, training and education in gynaecological surgery are challenged and urgent measures are emerging. The implementation of a structured and validated program for training and quality control seems the most urgent measurement to be taken. The European Academy of Gynaecological Surgery has made a first attempt to do so. Through a practical and theoretical tests system, the skills of an individual surgeon is measured and the conditions to enter the different level of expertise are clearly defined. This certification system based on the best possible level of scientific evidence provides a first practical tool, universally implementable for a decent quality control and structured training program in Gynaecological laparoscopic surgery.

Salpingoscopic and laparoscopic investigations in relation to fertility outcome.

STUDY OBJECTIVE: To evaluate the correlation between salpingoscopic and laparoscopic findings and their relation to reproductive outcomes. DESIGN: Prospective study (Canadian Task Force classification II-2). SETTING: University-affiliated hospital. PATIENTS: Ninety-one infertile women. INTERVENTION: Salpingoscopy and laparoscopy. MEASUREMENTS AND MAIN RESULTS: Salpingoscopic findings were expressed according to a widely used classification. Tubal morphology at laparoscopy was defined as regular (normal morphology), convoluted (any kind of distortion or adhesion), or hydrosalpinx. Laparoscopic and salpingoscopic findings did not correlate. Seventeen pregnancies occurred within 1 year from the procedures. According to life table analysis, the cumulative pregnancy rate was significantly higher in women with endotubal morphology showing minimal or no tubal damage, than in women with higher grades of endotubal damage. Conversely, tubal morphology at laparoscopy was not able to predict pregnancy outcome. CONCLUSION: Laparoscopy alone might not be sufficient to predict tubal integrity. Performing salpingoscopy with laparoscopy could significantly increase accuracy in predicting short-term fertility outcome. Given its low complication rate and brief duration, salpingoscopy should have a primary role in management of infertility.

Clomiphene citrate increases insulin-like growth factor binding protein-1 and reduces insulin-like growth factor-I without correcting insulin resistance associated with polycystic ovarian syndrome.

The induction of ovulation by clomiphene could be the result of interaction of the drug at various levels: hypothalamus, pituitary and ovary. It was demonstrated that administration of clomiphene to women with polycystic ovarian syndrome (PCOS) is accompanied by a reduction in plasma concentrations of insulin-like growth factor-I (IGF-I). IGF-I seems to have an overall negative effect on normal folliculogenesis and ovulation. The aim of the present study was to evaluate the effect of clomiphene on plasma concentrations of IGF-I and IGF binding protein (IGFBP)-1 and on insulin resistance associated with PCOS. Fifteen patients diagnosed with PCOS were recruited. Clinical diagnosis was based on chronic oligomenorrhoea or amenorrhoea and hyperandrogenaemia. Clomiphene citrate was administered at a dose of 100mg/day to all women from day 5 to day 9 of the spontaneous or medroxyprogesterone acetate (MAP)-induced menstrual cycle. Blood sampling and a 2 h oral glucose loading test (75 g) were performed the day before and after the course of clomiphene. Ovulation was confirmed in 13/15 PCOS patients. Plasma concentrations of IGF-I decreased by 31.5% (434 +/- 84 versus 297 +/- 71 ng/ml; P: < 0.05) after 5 days of clomiphene therapy, whereas plasma concentrations of IGFBP-1 increased by approximately 28.1% (26.3 +/- 4 versus 36.6 +/- 7 ng/ml; P: < 0.05). This gave a 56.5% reduction in the IGF-I:IGFBP-1 ratio (21.9 versus 9.53). No significant changes in basal plasma concentrations of fasting insulin or area under the insulin curve were observed in response to oral loading. The present results show that clomiphene does not cause changes in insulin resistance associated with PCOS but reduces plasma concentrations of IGF-I and increases those of IGFBP-1, with a consequent marked reduction in the IGF-I:IGFBP-1 ratio.

Hysteroscopic metroplasty.

STUDY OBJECTIVE: To evaluate 10 years' experience with hysteroscopic treatment of septate uterus in Italy. DESIGN: Multicenter retrospective study conducted from January 1988 to March 1997 (Canadian Task Force classification II-2). SETTING: Twelve Italian centers for minimally invasive therapy. PATIENTS: Women (total 973) with hysteroscopically diagnosed septate uterus. INTERVENTIONS: Hysteroscopic metroplasty performed with scissors, resectoscope, or neodymium:yttrium-aluminum-garnet laser. MEASUREMENTS AND MAIN RESULTS: Data on indications for hysteroscopic metroplasty, details of patient management from pretreatment to follow-up, and pregnancy course and delivery were collected by questionnaire. Main indications were two or more abortions and primary infertility. Most procedures were performed with the resectoscope, followed by scissors and laser. Few minor complications occurred. Pregnancy rates were good. CONCLUSION: Hysteroscopy is safe and effective treatment of septate uterus in terms of both pregnancy rate and outcome.

Missed hysteroscopic detection of uterine carcinoma before endometrial resection: report of three cases.

Endometrial ablation or resection using hysteroscopy appears to be an effective treatment for menorrhagia resistant to medical therapy. Three patients with endometrial adenocarcinoma missed in the preoperative hysteroscopic and histological assessment and subjected to endometrial resection were collected in a multicenter study. One case was an early adenocarcinoma in the background of late proliferative endometrium in a 39-year-old woman. In the other two patients, ages 51 and 68, the adenocarcinoma developed in a polyp in a background of simple hyperplasia. Since hysteroscopy with endometrial biopsy might not be able to exclude the presence of an early intrauterine cancer, appropriate selection and accurate evaluation of patients are imperative before ablative surgery. Endometrial resection is preferred over endometrial laser ablation since it provides additional tissue for histologic examination.

Intramural Myomectomy Using a Combination of Hysteroscopy and Laparoscopy

Thanks to advances in hysteroscopic surgery and improvements in instrumentation, hysteroscopy can now be performed for intramural myomas. Twelve women with submucous or intramural myomas with a diameter ranging from 3.5 to 5.8 cm received preoperative preparation with 5 months of gonadotropin-releasing hormone analogs. The uterine cavity was distended with sorbitol-mannitol solution infused by an electronic pump. Hysteroscopic resection was performed with a 26F resectoscope and electrosurgical monopolar unit under laparoscopic control in all patients. Four women required a second procedure to complete the resection of myoma. No major complications occurred.

Risks of Virus Transmission During Diagnostic Hysteroscopy

The high frequency of asymptomatic carriers of viral infections represents a major risk for transmission. Viral agents can be transmitted through blood or biologic fluids during diagnostic hysteroscopy. Routine disinfection methods to clean hysteroscopes cannot be considered adequate to prevent transmission. Hepatitis C and B viruses require 1-hour sterilization in glutaric aldehyde or gas sterilization (ethylene oxide) to be decontaminated. Human immunodeficiency virus decontamination of instruments is easier and safer. Blood test screening of patients positive for hepatitis B and C should be performed in all candidates for endoscopic gynecologic procedures to avoid the possibility of virus transmission.

Hysteroscopy and adenocarcinoma.

Although the diagnostic accuracy of hysteroscopy is high, it should be considered a diagnostic technique and used together with endometrial biopsy. Hysteroscopy is useful for excluding those patients with abnormal uterine bleeding who show no signs of intrauterine pathology. The number of cases in which hysteroscopy is sufficient for reaching a diagnosis without the help of a subsequent biopsy will depend directly on the experience of the endoscopist. After a fair amount of practice, it is possible to use hysteroscopy for the identification of patients with either benign or malignant endometrial lesions with about 20% false positives and no false negatives. The combined use of hysteroscopy and biopsy leads to near 100% accuracy in the diagnosis of endometrial neoplasia and its precursors. The combination of hysteroscopy and endometrial biopsy is ideal for use in symptomatic patients for the early detection of endometrial neoplasia, its precursors, and benign lesions that cause abnormal bleeding. With benign and malignant endometrial lesions, the first symptom is generally bleeding. Zampi and coworkers analyzed the hysteroscopic finding and menometrorrhagia in 1295 women. While cystic hyperplasia and endometrial neoplasia gave rise to bleeding in many patients, many other lesions also caused the same symptom. Hysteroscopy represents the ideal technique for the examination of women over the age of 45 who complain of abnormal uterine bleeding. In association with endometrial biopsy, it can detect endometrial adenocarcinoma in its early stages and select those patients who have precursor lesions.

GnRH agonist analogs and hysteroscopic resection of myomas.

OBJECTIVES: The purpose of this study was to evaluate the effects of pretreatment with GnRH analogs and hysteroscopic resection of submucous myomas previously deemed to be contraindicated for this approach. METHODS: Twenty-five patients were included in this study. Patients were assessed by ultrasonography and diagnostic hysteroscopy. They were treated with depot GnRH analogs for 3 months and then scheduled for hysteroscopic surgery. RESULTS: After GnRH therapy the diameter was 61 +/- 10% of the initial diameter. In one patient, therapy was almost ineffective. Hysteroscopic surgery was possible in all 25 patients. Seven patients presented an intramural myoma that was not possible to remove entirely during the first attempt. After dessication and 2 supplementary months of GnRH analog therapy, a second surgical attempt was successful in complete removal of the tumor in all except one case. In one patient hysterectomy 15 days after hysteroscopic surgery was necessary for incoercible bleeding due to a deep adenomiosis. CONCLUSIONS: A combined medical and surgical approach seems to reduce the limit of hysteroscopic surgery and avoid open myomectomy or hysterectomy in a well selected group of patients.

Early detection of endometrial cancer and hyperplasia: a reappraisal.

It is widely recognized that endometrial carcinoma represents one of the most frequent types of pelvic malignancy in women. Recent improved knowledge about population at risk, the criteria of classification of endometrial hyperplasia, different potential for neoplastic transformation for each type of neoplasia, and asymptomatic latency of the pathology allow some considerations. Endometrial cytology is of basic importance in a mass screening programme due to its low cost, accuracy and feasibility. The combination of hysteroscopy and endometrial biopsy is the diagnostic method of choice for symptomatic patients. It permits the elimination of curettage in the diagnostic management in over 95% of cases, with obvious advantages, better diagnostic accuracy and greater convenience for patients and doctors.

Conservative treatment of CIN: a review.

This review examines the indications for and the various therapeutic techniques used in the management of CIN. There is an extensive review of the literature. We believe that conization should be the long-term therapy of choice in over 90% of patients with CIN.

Endometrial carcinoma and its precursors: early detection and treatment.

Endometrial carcinoma is the most frequent genital neoplasia in women. Precursors of this condition include endometrial hyperplasia, particularly when cytologic atypia occurs. Among the frequent early clinical manifestations of endometrial carcinoma is abnormal uterine bleeding that must be differentiated from bleeding associated with benign conditions. Early detection of endometrial carcinoma and its precursors in women at risk is the best prophylactic measure in the final therapeutic outcome. In this review, the accuracy of methods of early diagnosis of endometrial carcinoma and its precursors is assessed, in order to provide early therapy and optimum prognosis. The epidemiology of endometrial carcinoma, as well as the risk factors for the development of this neoplasia, are also reviewed. A histologic classification of endometrial hyperplasia and carcinoma of the endometrium, based on current theories of histopathogenesis, is included.

Is hysteroscopy of value in the investigation of female infertility?

A prospective multicentre study was designed to ascertain the value of hysteroscopy in the evaluation of female infertility. The study comprises 619 CO2 hysteroscopies in women complaining of infertility. Four hundred and ninety nine examinations (80%) were performed without anaesthesia or cervical dilatation. Twenty eight cases of malformation were diagnosed. Adhesions were found in 68 patients (11%), polypi in 56 (9.1%) and submucous fibroids in 51 (8.2%). Endometrial hyperplasia was diagnosed by hysteroscopy in 67 patients, but there was only 42% histological correlation. Examination of the tubal ostia by hysteroscopy revealed 26 patients (4%) with unilateral tubocornual polyps and one with bilateral polyps. The correlation with hysterosalpingography (HSG) in 185 patients was poor. In 20% where the HSG was reported as normal there were hysteroscopically demonstrable lesions whereas there were false positive findings at HSG in 35% of cases. Hysteroscopy is the only technique which provides an accurate clinical evaluation of the uterine cavity although it does not provide significant information about the cervical canal or fallopian tubes.

HIV infection and pregnancy: diagnostic and follow-up program for the pregnant woman and newborn child.

The authors take as their starting point the cases of 8 pregnancies in HIV serologically positive women, admitted for their observation from July 1986 to March 1988. They emphasize the importance of clinical, anamnestic and serological screening in order to identify those subjects at risk, and thereby prevent the vertical transmission of the virus. To this end, they propose a protocol to be used for all women at risk, both pregnant and not, both seropositive and seronegative. They also advise repeated clinical and immunological checks of the children of asymptomatic carrier mothers.

Hysteroscopic detection of heterotopic intrauterine bone formation.

The diagnosis and management of heterotopic intrauterine bone formation was performed hysteroscopically in nine patients. The presenting symptom was secondary infertility in seven, pelvic pain in one and passage of bone fragments in one. All nine patients had a history of spontaneous and therapeutic abortion. Hysteroscopy was more accurate than hysterosalpingography in detecting the condition. Four pregnancies occurred in the seven infertile patients following removal of the bone. In four of nine cases there was clear evidence of remaining bone fragments after the initial removal.