Metformin administration versus laparoscopic ovarian diathermy in clomiphene citrate-resistant women with polycystic ovary syndrome: a prospective parallel randomized double-blind placebo-controlled trial

At present, it is unclear what the role is of laparoscopic ovarian diathermy (LOD) and of metformin administration as second-line treatments for ovulation induction in women with polycystic ovary syndrome (PCOS) after failure of clomiphene citrate (CC) treatment. The aim of the present study was to compare in a randomized double-blind placebo-controlled fashion the effectiveness of LOD with metformin administration in the treatment of CC-resistant women with PCOS. A total of 120 overweight primary infertile anovulatory CC-resistant women with PCOS were enrolled and randomized into two groups of treatment. Group A underwent diagnostic laparoscopy, whereas group B underwent LOD. At hospital discharge, the patients were treated for 6 months with metformin cloridrate (group A; 850 mg twice daily) or with multivitamins (group B). The ovulation, pregnancy, abortion, and live-birth rates were evaluated. At the end of the study, the total ovulation rate was not statistically different between both treatment groups (54.8 vs. 53.2% [correction] in groups A and B, respectively), whereas the pregnancy (21.8 [correction] vs. 13.4%), the abortion (9.3 [correction] vs. 29.0%), and the live-birth (86.0 [correction] vs. 64.5%) rates were significantly (P < 0.05) different between the two groups. Our data show that metformin administration is more effective than LOD in overall reproductive outcomes in overweight infertile CC-resistant women with PCOS.

Is plasminogen activator inhibitor-1 a cardiovascular risk factor in young women with polycystic ovary syndrome?

This study aimed to evaluate plasminogen activator inhibitor-1 (PAI-1) activity in PCOS. Thirty women with PCOS - 15 normal-weight and 15 obese - and 30 healthy women matched as a group for age and body mass index (BMI) were recruited. The homeostasis model assessment (HOMA) score was significantly elevated in obese compared with normal-weight women, in both PCOS women and controls. HOMA score was significantly higher in both PCOS groups relative to controls. After further adjustment for BMI, PAI-1 activity (IU/ml +/- SD) was significantly higher in the PCOS groups compared with controls. A significant positive correlation was found between HOMA score and BMI in PCOS and control groups. Serum PAI-1 activity was significantly related to BMI and HOMA score. When considering two BMI subgroups, there was no significant difference in the relationship between serum PAI-1 activity and HOMA score in both the control and PCOS groups. No other significant relationship was found between serum PAI-1 activity and any other hormonal or metabolic parameter. In conclusion, women with PCOS have significantly elevated PAI-1 activity independent of obesity, and it is speculated that elevated PAI-1 activity may be a factor in the increased cardiovascular morbidity seen in PCOS.

Unusual case of cervical pregnancy after curettage for a presumptive diagnosis of intrauterine blighted ovum

A case of cervical pregnancy after curettage for presumptive intrauterine blighted ovum is presented. The woman was successfully treated by vacuum evacuation and curettage. A 29-year-old woman, gravida 2, nulliparous, was admitted to our department at ten weeks and two days of gestation after a diagnosis of cervical pregnancy. She had been treated by curettage five days before for an initial diagnosis of intrauterine blighted ovum. Ultrasound scan examination revealed a gestational sac without foetus in the cervix four days after the first curettage. Vacuum evacuation and curettage of the cervical canal were performed and a Foley catheter was also inserted and left in place for three days. The patient was discharged in good condition on the fourth postoperative day.

[Reliability of ultrasound examination confirmed at autopsy in foetuses suffering from Dandy-Walker Syndrome]

BACKGROUND

The Dandy-Walker Syndrome (DWS) is a congenital malformation of the structures of the posterior cranial fossa with failure of the Luschka and Magendie foramina, which connect the ventricular system to the subarachnoid space, to open. In this syndrome, the cerebellar vermis may be absent or hypoplastic, the hemispheres small, the encephalic trunk and cervical spinal bone marrow flattened, complete or partial absence of cerebellar vermis, cystic dilatation of IV ventricle and frequently hydrocephalus.

METHODS

We evaluated 56 cases of fetal malformations of the central nervous system from January 1998 to May 2001. Of these 56, 11 regarded the Dandy-Walker Syndrome. Ultrasound examinations were carried out at the 9(th) and 10(th) weeks, at the 21(st)-23(rd) weeks and at the 31(st) to 34(th) weeks of gestation so as to assess foetal anatomy and morphology.

RESULTS

The results of the 11 pregnancies with Dandy-Walker Syndrome were as follows: 3 spontaneous miscarriages (at the 15(th), 18(th) and 20(th) weeks of gestation), 5 therapeutic abortions, 3 term pregnancies. Of the 3 newborns we were only able to follow the clinical course of two of them; both newborns underwent an intervention for ventriculo-peritoneal fluid derivation. At the moment both babies, aged respectively 30 and 25 months, are in good physical, intellectual and behavioural condition.

CONCLUSIONS

Bearing in mind the notable clinical and socioeconomic importance of this malformation, we consider foetal morphological ultrasound to be a valid instrument for the correct management of pregnancy. Identification of lesions makes use of the comparison of ultrasound data with the results of histopathological examinations.

High outcome predictability after IVF using a combined score for zygote and embryo morphology and growth rate

BACKGROUND

A scoring system has been developed to determine preimplantation embryo quality, and used to select embryos for transfer into the uterus of patients.

METHODS AND RESULTS

The system was used to study early embryo development and to test whether these scores alone can accurately predict IVF outcome. Following zygote and embryo scores through early development, the data showed that a top quality zygote does not necessarily indicate that the resulting embryo will be top quality after in-vitro culture. The embryo quality score can change dramatically when embryos are cultured to day 2 or 3 post-fertilization. Pregnancy rates and implantation rates were compared with the cumulative and separated zygote and embryo scores. Analysis of the predictability of scoring systems suggested that morphological scores alone are relatively unpredictive of IVF outcome. When weighted for in-vitro growth rate, scores were highly predictive, more so than the rate of development alone.

CONCLUSIONS

These data suggested that a combination of in-vitro growth rate and morphological analysis both of zygotes and embryos was highly indicative of outcome after IVF. The results can be adopted to the single embryo transfer approach to IVF.

[Atelectasis following cesarean section. Personal experience]

Purpose of this paper is to evaluate the risk of ateletasis in patients that underwent surgery of the abdomen (cesarean section), since the reflex of cough in these patients is notably altered for the limitation of the diaphragmatic excursions, due to analgesic contracture. The inhibition of cough's reflex causes retention of secretions with consequent bronchial obstruction and atelectasis. Personal experience in 6 cases of atelectasis following cesarean section is reported.

The effect of ease of transfer and type of catheter used on pregnancy and implantation rates in an IVF program

PURPOSE

To test the effects of type of embryo transfer catheter, transfer difficulty, and observations after the transfer procedure on pregnancy and implantation rates in an IVF programme.

METHODS

Patients were prepared for IVF using standard protocols. Embryo transfer was performed using either Edwards-Wallace or TDT catheter. The difficulty of transfer was graded by a clinician and biologist. Blood observed inside the catheter after the transfer procedure was scored as endometrial damage. Pregnancy and implantation rates were scored.

RESULTS

Type of embryo transfer catheter and the observation of blood did not significantly affect pregnancy and implantation rates when transfer was performed by a single operator.

CONCLUSIONS

In the hands of experienced, skilled operators, neither choice of transfer catheter and difficulty of transfer nor observations of blood on the transfer catheter caused any significant reduction in outcome to the patient.

Rescue of IVF cycles by HMG in pituitary down-regulated normogonadotrophic young women characterized by a poor initial response to recombinant FSH

BACKGROUND

The aim of this study was to investigate the effects of adding human menopausal gonadotrophin (HMG) during controlled ovarian stimulation in normoovulatory normogonadotrophic patients showing an initial suboptimal response to a standardized long protocol therapy with recombinant FSH (rFSH) (300 IU/day).

METHODS

A total of 43 such patients were randomized in two groups. In Group A, 150 IU rFSH was substituted by 150 IU HMG after day 8 of stimulation. The stimulation protocol of Group B involved a simple increase of the daily rFSH dose to 375 IU after day 8. A total of 40 BMI and age matched patients with an optimal ovarian response formed the control group (Group C).

RESULTS

The mean Group A serum concentration of oestradiol on the day of HCG administration and average number of oocytes retrieved were significantly higher than Group B (P < 0.001) and equivalent to Group C. A total of 10 pregnancies (50%) in Group A, 8 (34.8%) in Group B and 19 (47.5%) in the control group were achieved.

CONCLUSIONS

The data suggest that LH supplementation improves the ovarian outcome in patients characterized by an inadequate initial response to rFSH therapy in a long protocol.

Plasma L-arginine is markedly reduced in pregnant women affected by preeclampsia

The objective of this study was to determine the concentration of free L-amino acids and in particular of L-arginine in the plasma of pregnant women affected by preeclampsia compared to healthy pregnant women in order to know if an alteration in the concentrations of these amino acids occurs in preeclamspia. Twelve pregnant women affected by preeclampsia and twelve pregnant control women, ages 28-35 years old and at the 35-36 weeks of pregnancy were studied. The blood analysis of free amino acids was carried out by using a high performance liquid chromatographic (HPLC) fluorometric method and OPA-NAC as derivatizing agent for the amino acid determination. In the blood of women affected by preeclampsia L-arginine is markedly reduced compared to controls (about five-fold lower, P<0.01). The other amino acids also are significantly reduced, but to lesser extents (about 1.5 times lower, P<0.05). Thus, the determination of L-arginine in the blood of pregnant women could potentially constitute an additional marker for the early diagnosis of preeclampsia.

The role of D-aspartic acid and N-methyl-D-aspartic acid in the regulation of prolactin release

In this study, using an enzymatic HPLC method in combination with D-aspartate oxidase, we show that N-methyl-D-aspartate (NMDA) is present at nanomolar levels in rat nervous system and endocrine glands as a natural compound, and it is biosynthesized in vivo and in vitro. D-aspartate (D-Asp) is its natural precursor and also occurs as an endogenous compound. Among the endocrine glands, the highest quantities of D-Asp (78 +/- 12 nmol/g) and NMDA (8.4 +/- 1.2 nmol/g) occur in the adenohypophysis, whereas the hypothalamus represents the area of the nervous system where these amino acids are most abundant (55 +/- 9 and 5.6 +/- 1.1 nmol/g for D-Asp and NMDA, respectively). When D-Asp is administered to rats by ip injection, there is a significant uptake of D-Asp into the adenohypophysis and a significant increase in the concentration of NMDA in the adenohypophysis, hypothalamus and hippocampus, suggesting that D-Asp is an endogenous precursor for NMDA biosynthesis. Experiments conducted on tissue homogenates confirm that D-Asp is the precursor of the NMDA and that the enzyme catalyzing this reaction is a methyltransferase. S-adenosyl-L-methionine (SAM) is the methyl group donor. In vivo experiments consisting of ip injections of sodium D-aspartate show that this amino acid induced a significant serum PRL elevation and this effect is dose and time dependent. In vitro experiments conducted on isolated adenohypophysis or adenohypophysis coincubated with the hypothalamus, showed that the release of PRL is caused by a direct action of D-Asp on the pituitary gland and also mediated by the indirect action of NMDA on the hypothalamus. Then, the latter induces the release of a putative factor that in turn stimulates the adenohypophysis reinforcing the PRL release. In conclusion, our data suggest that D-Asp and NMDA are present endogenously in the rat and are involved in the modulation of PRL release.

Usefulness of a 12-month treatment with finasteride in idiophathic and polycystic ovary syndrome-associated hirsutism

OBJECTIVE

Hirsutism is considered as a skin disease due to increased 5 alpha-reductase activity in the pilosebaceous unit and finasteride is a drug that inhibits this enzymatic activity. This study showed the effectiveness of a chronic treatment with a selective 5 alpha-reductase inhibitor, finasteride, in idiopathic and PCOS-associated hirsutism.

METHODS

Finasteride was administered orally at a daily dose of 5 mg for a period of 12 months to 20 women with IH and 20 women with PCOS.

MAIN OUTCOME MEASURES

Each group was submitted to clinical (with Ferriman-Gallwey method) and serum hormonal (FSH, LH, 17 beta-estradiol, total and free T, delta 4-androstenedione, DHEAS; dihydrotestosterone, 3 alpha-androstanediol glucuronide) studies at baseline and after 3, 6 and 12 months of treatment.

RESULTS

After 3 months of finasteride treatment, a significant decrease in the average hirsutism scores was recorded both in IH (p < 0.0001) and PCOS patients (p < 0.0001). A progressive significant decrease of hirsutism score was observed in IH patients after 6 and 12 months (p < 0.002) and in PCOS patients after 6 but not 12 months. In fact, the maximal therapeutic effect on the hirsutism was obtained after 12 months in the IH and 6 months in PCOS group.

Different sensitivity to sodium valproate in healthy, non-tumoral and tumoral hyperprolactinemic subjects

GABAergic drugs affect PRL secretion in both rat and man. Sodium valproate (SV) inhibits GABA transaminase so increasing the endogenous GABAergic tone. The aim of this study was to evaluate the effects of SV at low and high doses on PRL release in healthy subjects and hyperprolactinemic patients. Fifteen patients with prolactinomas, 8 patients with non-tumoral hyperprolactinemia and 10 healthy subjects were studied: in non consecutive days, all subjects received placebo and SV at the dose of 400 and 800 mg po. Serum PRL levels were assessed 30, 15 and 5 min before and every 30 min for 4 hours after administration. SV at the dose of 400 mg induced a significant decrease of serum PRL in healthy subjects (p < 0.05), whereas no effect was noted in both tumoral and non-tumoral hyperprolactinemia. The administration of 800 mg SV induced a significant decrease of PRL levels in healthy subjects and in patients with non-tumoral hyperprolactinemia (p < 0.05). Conversely, in prolactinomas a paradoxical increase of serum PRL concentration (p < 0.05) was observed 120 min after the administration of the drug. These data confirm the inhibitory activity of SV on PRL release in healthy subjects, and suggest the existence of a partial resistance to GABA in non-tumoral hyperprolactinemia. In prolactinomas, the paradoxical PRL increase after high dose of SV suggests the existence of a complete pituitary resistance to GABA. This finding might be explained by the appearance of the stimulatory effect of GABA at hypothalamic level that could have been unmasked by the lack of pituitary GABA effects on adenomatous lactotrophs.

Prognostic value of desmoplastic reaction and lymphocytic infiltration in the management of breast cancer

OBJECTIVE

To ascertain whether the prognostic value of desmoplastic reaction and lymphocytic infiltration are a good prognostic index to estimate survival in breast cancer patients.

METHODS

From 1987 to 1994, the authors have evaluated the prognostic value of desmoplastic reaction and lymphocytic infiltration related to rode state in 34 patients with breast cancer. For statistical analysis and comparison of means the "t"-test was used. The significance level was 0.01.

RESULTS

The group of patients with abundant desmoplastic reaction shows an overall survival rate lower than the group with poor desmoplastic reaction (p < 0.01) and the survival of the group with abundant desmoplastic reaction was related to lymphnodal status.

CONCLUSIONS

Many prognostic factors have been shown during these years, some connected to patient, some connected to neoplasm and others connected to the treatment. Recently many other prognostic factors have been recognized, among which the possible prognostic role of desmoplasia has been carefully valued. Certainly, today the prognostic value of desmoplastic reaction and lymphocytic infiltration cannot take the place of usual prognostic factors in the evaluation of breast cancer patient yet the desmoplastic reaction is a good prognostic index to estimate the survival in these patients.

Laparoscopic ovarian treatment in infertile patients with polycystic ovarian syndrome (PCOS): endocrine changes and clinical outcome

During the years 1991-1994, 97 anovulatory infertile women with polycystic ovarian syndrome (PCOS) were treated with laparoscopic electrocautery of the ovarian surface after they had failed to ovulate under ovarian stimulation. To assess the endocrinological and clinical outcome and in an attempt to determine the mechanism of action, the serum levels of luteinizing hormone (LH), follicle-stimulating hormone (FSH), androstenedione, testosterone and dehydroepiandrosterone sulfate (DHEAS) were determined before and after laparoscopic ovarian cautery. Fifty regularly cycling women undergoing laparoscopy for investigation of infertility or tubal ligation served as controls. In patients with PCOS but not in controls, the reduction of androgen levels and normalization of cycle length were highly significant. In contrast, LH and FSH levels rose during the first 2 days after the operation. These results resemble those reported after ovarian wedge resection. Ovulation was obtained in 90% (81 of 90) and pregnancy in 81.1% (73 of 90) of the patients; that increased to 84.4%, including the non-responders (nine patients) treated with clomiphene citrate (CC), after electrocautery. The response to ovarian electrocautery was influenced by body weight, with an ovulation rate of 95-96% in the slim and moderately obese women, decreasing to 81-82% in the really obese ones. When ovulation was established, the pregnancy rate was independent of body weight. However, a striking relationship was detected between smoking habits and pregnancy rate subsequent to ovarian electrocautery, ranging from 24% in smokers to 92% in non-smoking couples. In 30 second-look operations, de novo adhesions were found in 23.3% of the patients (7 of 30). Therefore, ovarian electrocautery is an effective procedure to improve the intraovarian mechanism of selecting a dominant follicle for patients with PCOS in whom initial medical management fails, and it appears to be one of the possible treatments for this disease. A possible postoperative complication may be adhesion formation that seem to be lower than after ovarian wedge resection.

Finasteride in the treatment of hirsutism: new therapeutic perspectives

OBJECTIVE

To determine of the clinical and hormonal effects of finasteride (Proscar; Merck, Sharp, and Dohme, Rahway, NJ) in the treatment of idiopathic hirsutism and hirsutism in patients with polycystic ovary syndrome (PCOS).

DESIGN

Controlled clinical study.

SETTING

Istitute of Obstetrics and Gynecology, University of Naples "Federico II."

PATIENTS

Ten women affected by idiopathic hirsutism and 15 women with PCOS.

INTERVENTIONS

Finasteride was administered orally at a daily dose of 5 mg for a period of 6 months.

MAIN OUTCOME MEASURES

Rating of hirsutism with the Ferriman-Gallwey method; serum androgen assays.

RESULTS

Finasteride produced a reduction in the average hirsutism scores ( > 50% in all patients), whereas no change was observed in serum T, androstenedione, and DHEAS levels. A significant reduction was measured in serum dihydrotestosterone and 3 alpha, 17 beta-androstenediol glucuronide levels.

CONCLUSIONS

This study demonstrates that symptomatic hirsutism has to be considered as a skin disease associated with the increased activity of the 5 alpha-reductase. It also indicates that the selective 5 alpha-reductase inhibitor, finasteride, is very effective and well tolerated in the treatment of both idiopathic hirsutism and of hirsutism in patients with PCOS.

Fetal fibronectin as a screening test for premature delivery in multiple pregnancies

OBJECTIVE

To evaluate fetal fibronectin as a screening test for premature delivery in asymptomatic women with multiple pregnancies.

METHODS

In the mid-second trimester, the concentrations of fetal fibronectin in the cervical and vaginal secretions of 68 patients with multiple gestations were sampled weekly by monoclonal antibody immunoassay in order to predict preterm labor.

RESULTS

The results for the prediction of preterm labor differ according to whether we consider a single positive result (fetal fibronectin > 50 ng/ml) as predictive of preterm labor or whether we only consider at least two consecutive positive results as predictive of perterm labor. The fetal fibronectin test had a sensitivity for preterm birth before 37 weeks of 90.9% and 86.6%, respectively, with a specificity of 68.5% vs. 78.9% and a positive and negative values of 73.1% vs. 76.4% and 88.8% vs. 88.2%, respectively. Similar results were obtained for perterm birth before 34 weeks.

CONCLUSIONS

In a condition such as multiple pregnancy which is already at risk for premature delivery the possibility of raising the specificity of the test with virtually no decrease in sensitivity guarantees better recognition of patients likely to develop premature labor. This possibility can be achieved simply by considering two positive consecutive samples as predictive of preterm labor.

Puberal hormonal status and vaginal microbiology

The Autors have examinated endocrine function in girls during puberal age. Have been showed datums relative to cultures effected on vaginal secrets withdrawn from little girls in prepuberal age. They have also studied polimicrobic vaginal flora related to sexual hormone levels. Have been controllated correlations between vaginal microbic status and cytohormonal response at different hormonal situation. The Doderlein presence is as much greater so higher is the oestrogen and progesterone (E/P) ratio, while the Doderlein bacillus isn't present when E/P ratio is lower. Perhaps in puberal age other factors than oestrogen and progesterone levels, could influence vaginal polymicrobic flora.

Menopausal hormonal status and vaginal microbiology

The authors have examined endocrine function in women during postmenopausal age. They have also studied polymicrobic vaginal flora related to sexual hormone levels. Have been controllated correlations between vaginal microbic status and cytohormonal response at different hormonal situation present in the same woman. In postmenopausal women have been formed low oestrogen levels related to low presence of Doderlein. Perhaps in postmenopausal women other factors than oestrogen and progesterone levels, could influence vaginal polymicrobic flora.

Treatment of postmenopausal osteoporosis with salmon calcitonin nasal spray: evaluation by bone mineral content and biochemical patterns

We studied 21 women with postmenopausal osteoporosis, treated with salmon calcitonin nasal spray (100 IU/daily) and calcium (1 g/daily) for six months. Bone mineral content (BMC), measured before and at the end of therapy with lumbar dual photon absorptiometry, showed a significant increase (p < 0.01). At the end of the study, there was also a clear improvement of osteoporotic pain. Among biochemical markers of bone turnover, there was a significant (p < 0.01) reduction of urinary excretion of hydroxyproline. No side effect was registered and all patients had a good compliance to therapy.

[The role of prolactin in endometrial lesions]

The Authors examine serum levels of HPRL in basal conditions and after TRH and sulpiride test in 15 patients with endometrial lesions (hyperplasia) and in 15 patients with endometrial adenocarcinoma included in a age range between 44 and 62 years, in which 7 patients present obesity, 10 patients present hypertension and 2 patients are hyperglycemic. The same examination is carried out in a control group of 30 healthy patients. Then the 15 patients with adenocarcinoma and 3 patients with adenomatosa hyperplasia are subjected to surgery and they estimate HPRL levels in endometrium. The results prove that there is no correlation between HPRL plasma levels and endometrium lesions and between endometrium HPRL. The Authors conclude that HPRL does not play a significant role in the pathogenesis of endometrial lesions; use of HPRL plasma levels as a marker of endometrial lesions is not possible.

Subclinical hypothyroidism and hyperprolactinemia

The authors have studied 25 women aged 22 to 26 years with a diagnosis of prolactinemia moderately increased in primary sterility. Among 25 women under observation, 7 (28%) showed a hormone picture of subclinic hypothyroidism. In fact the evaluation of TSH after stimulation with TRH showed a curve typical of the subclinic hypothyroidism. In 8 women (32%) the authors have found an increase of the thyroid gland, and in 3 patients (12%) galactorrhea. The increase of volume of the thyroid gland was constant in all the women with subclinic hypothyroidism. Considering the results obtained by this study, the authors point out a correlation between subclinic hypothyroidism-hyperprolactinemia and sterility. The data obtained are in accordance with that has been reported in literature.

[Endometrial carcinoma with simultaneous endometrioid carcinoma of the ovary. Report of two clinical cases]

The paper reports two cases of simultaneous endometrial carcinoma and endometrioid carcinoma of the ovary. The clinical and pathological characteristics are examined. Both patients underwent radical surgery with an intraoperative examination for metastatic involvement of the lumbo-aortic, iliac and infundibulo-ovarian lymphonodes. Surgery was followed by antiblastic (cisplatin, adriamycin, cyclophosphamide), hormonal (progestogens) and immuno-modulating (thymostimulin treatment). The two patients (respectively approximately 10 and 7 years after the operation) both enjoy good health.

[Carcinoembryonic antigen in genital infections caused by HPV]

The immunohistochemical search for the carcino-embryonic antigen (CEA) was positive in 28.14 per cent of the cases of plane cervical condylomata, in 25 per cent of the cases of infections of the vulva by HPV, and in up to 40 per cent of the cases of cervical or vulvar lesions. These data are in accordance with those reported in the literature, even if the number of cases studied is too limited to enable us to make a significant comparison. As a result, the CEA might prove to be a useful marker for a more accurate biological and chemical classification of genital lesions by HPV.