Surgical diminished ovarian reserve after endometrioma cystectomy versus idiopathic DOR: comparison of in vitro fertilization outcome

STUDY QUESTION

Does the live birth rate after IVF depend on the etiology of diminished ovarian reserve (DOR)?

SUMMARY ANSWER

IVF outcome and live birth rate are significantly impaired in women with DOR caused by a previous cystectomy for endometrioma compared with women with idiopathic DOR.

WHAT IS KNOWN ALREADY

The safety of the surgical treatment of endometriomas is being discussed in terms of damage to ovarian reserve. Several studies have reported a poor response to controlled ovarian stimulation and a significantly impaired IVF outcome in women with DOR consecutive to an endometrioma cystectomy compared with women with tubal factor infertility.

STUDY DESIGN, SIZE, DURATION

Retrospective case-control study conducted in women aged under 40 treated in our Reproductive Medicine Center between January 2010 and January 2014 for a DOR defined by anti-Müllerian hormone level <2 ng/ml. Two groups of patients were selected: group A included patients with a DOR diagnosed after cystectomy(s) for endometrioma(s), group B included patients with an idiopathic DOR. In each group, subgroups of patients 'poor ovarian responders', based on the ESHRE criteria ('Bologna criteria'), have been established.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 51 patients in group A were matched to 116 patients in group B, representing respectively 125 and 243 IVF cycles. Among them, 39 patients in group A and 78 patients in group B validated strictly by the Bologna criteria, representing 99 and 189 IVF cycles, respectively. Each patient underwent a controlled ovarian hyperstimulation and IVF with fresh embryo transfer. Primary end-point was the live birth rate. Secondary end-points were the number of retrieved oocytes, fertilization rate, implantation rate, clinical pregnancy rate, spontaneous abortion rate and cycle cancelation rate.

MAIN RESULTS AND THE ROLE OF CHANCE

Significantly lower pregnancy (11.2% in group A versus 20.6% in group B, P = 0.02) and live birth (7.2 versus 16.9% respectively, P = 0.01) rates per cycle were assessed in women in group A compared with women in group B. The same results were obtained in the Bologna criteria subgroup analysis with a significantly lower pregnancy (9.1 versus 20.1%, P = 0.016) and live birth (5.1 versus 15.3%, P = 0.001) rates per cycle in women in subgroup A compared with women in subgroup B. Patients in group A required significantly higher gonadotrophins doses (2881 IU ± 1111 versus 2526 IU ± 795, P = 0.005), longer ovarian stimulation (10.6 Days ± 2.8 versus 9.9 Days ± 2.4, P = 0.019) and higher cancelation rate for poor response (12 versus 6.2%, P = 0.05). Despite a mean number of retrieved oocytes similar with the group B (5.4 ± 3.1 and 5.1 ± 3.2, NS), and a significantly higher fertilization rate (65.7 versus 47.2%, P < 0.001), women in group A showed a significantly lower implantation rate (7.2 versus 13.5%, P = 0.03). Abortion rate, ectopic pregnancy rate and multiple pregnancy rate were similar in both groups.

LIMITATIONS, REASONS FOR CAUTION

Data were collected retrospectively using the database of our Department. Sample size is relatively small but our study provides statistically significant evidence that the chances of IVF success are decreased in women with DOR after cystectomy for endometrioma. Further larger series are needed to confirm these findings.

WIDER IMPLICATIONS OF THE FINDINGS

To our knowledge, this is the first study evaluating IVF outcome in patients with DOR after cystectomy(s) for endometrioma(s) versus in patients with an idiopathic DOR. In addition to the risk of damaging ovarian reserve, we hypothesize that endometrioma surgery would not have qualitative benefits on results in IVF in patients with DOR.

STUDY FUNDING/COMPETING INTERESTS

The authors have no competing interests to declare.

[Indications for methotrexate in gynecology outside the first-line treatment of ectopic tubal pregnancies]

The objective of this work is to discuss the indications for methotrexate in gynecology outside the first-line treatment of tubal ectopic pregnancy. In tubal ectopic pregnancy, the prophylactic use of systemic methotrexate can be discussed when performing laparoscopic salpingotomy. In case of failure of salpingotomy, administration seems justified especially if it avoids re-intervention. The combination of methotrexate with other therapies such as mifepristone, potassium chloride or gefitinib is not recommended in the treatment of ectopic pregnancy. For non-tubal ectopic pregnancy, the intramuscular or local administration of methotrexate is an acceptable treatment for uncomplicated interstitial pregnancies. For uncomplicated cervical or cesarean scar pregnancies, the local administration of methotrexate should be considered as a first-line treatment. For ovarian pregnancies, methotrexate should not be a first-line treatment, surgical treatment remains the standard. Asymptomatic women presenting with a pregnancy of unknown location and plateauing serum hCG concentration<2000 UI/L can be managed expectantly: it is recommended to take an additional quantitative hCG serum level after 48 hours. Thus, methotrexate is not recommended in the first intention. Other gynecological indications were discussed: methotrexate is not recommended in the management of first-trimester miscarriages or in the management of placenta accreta.

[Repeated surgery for recurrent intrauterine adhesions?]

Recurrence of intrauterine adhesions is high even though a correct hysteroscopic treatment is performed. So, primary and secondary means to prevent intrauterine adhesions is important. Patient information is a key point on the obstetrical prognosis of this disease.

[Influencing factors on surgical duration of ovarian cystectomy by single-port access]

OBJECTIVES

To evaluate the factors influencing the operative duration of ovarian cystectomy by single-port access (SPA).

MATERIALS AND METHODS

Observational monocentric study from June 2010 to September 2012. Inclusive patients were patients with an indication of ovarian cystectomy may be done by laparoscopy. The procedures were performed by the SPA system LESS®. Factors evaluated were BMI of the patient, histological nature and size of the cyst.

RESULTS

We performed 54 cystectomy in 49 patients. SPA surgery was successfully completed in 53 patients. The median operative time was statistically longer for endometriotic cysts than dermoid cysts or serous-mucinous cysts (P=0.003). Cases exceeding 60minutes were significantly higher in the endometriosis group (P=0.005). There wasn't correlation found between the BMI of the patient and operative time (P=0.5). The operating time wasn't increased according to the size of the cyst (P=0.9).

CONCLUSION

Endometriotic cysts nature appears to be the only limiting factor of cystectomy by SPA. Further studies are needed to evaluate the factors that may limit the SPA actions.

Effects of Difaprost® on voiding dysfunction, histology and inflammation markers in patients with benign prostatic hyperplasia who are candidates for surgical treatment

AIM

Although previous studies assessed the effects of Serenoa repens, quercetin and β-sitosterol on inflammatory parameters, no randomized studies have tested the combination of these agents neither on BPH symptoms nor on the inflammatory pattern. The aim of this trial was to evaluate the effects of Difaprost® on voiding dysfunction, histological inflammatory alterations and apoptotic molecular mechanisms in BPH patients.

METHODS

We included 36 patients affected by BPH with obstructive symptoms eligible for surgery. Patients were randomly assigned to two groups: 18 patients received Difaprost® for three months before surgery, and 18 patients did not receive any additional therapy and were scheduled for surgery. All patients receiving Difaprost® were evaluated with uroflowmetry with post-void residual volume (PVR) evaluation, serum PSA, and IPSS questionnaire before and after treatment. Moreover, we evaluated inflammatory patterns in prostatic specimens at final pathology.

RESULTS

Even without statistically significant differences on inflammatory pattern between patients receiving Difaprost® and controls, patients receiving Difaprost® had lower presence of edema and angiectasia at histological evaluation of prostate specimens. Moreover, patients included in the treatment group had a clinically significant reduction of PVR (46.1 vs. 25.2 mL; P=0.1) and a slight increase in Qmed (5.6 vs. 6.5 mL/s; P=0.9) after three months of chronic treatment with Difaprost®. No statistically significant differences were recorded in other clinical parameters between patients receiving Difaprost® and controls.

CONCLUSION

Although not statistically significant, patients treated with Difaprost® showed an improvement in voiding function compared to controls (namely, an increase in Qmed and a reduction of PVR). Future trials with a larger number of patients and a longer treatment period could be necessary to evaluate the clinical efficacy of Difaprost®.

Predictive value of hemoperitoneum for outcome of methotrexate treatment in ectopic pregnancy: an observational comparative study

OBJECTIVE

To assess the predictive value of hemoperitoneum for the outcome of methotrexate (MTX) treatment of ectopic pregnancy (EP).

METHODS

This observational prospective single-center study included women presenting with EP treated with MTX from November 2007 to November 2009. The percentage of women with hemoperitoneum at the beginning of MTX treatment was compared between two groups: those whose treatment was successful and those whose treatment failed. The rate of hemoperitoneum in each group and its value in predicting the outcome of MTX treatment of EP were assessed.

RESULTS

MTX treatment was successful in 69 of 93 (74%) cases. The percentage of women with hemoperitoneum at the beginning of treatment was significantly higher in women in whom MTX treatment failed as compared to those in whom it was successful (15/24 (62.5%) vs 17/69 (24.6%); P = 0.001). The likelihood of requiring surgery following treatment with MTX was higher in women with hemoperitoneum (odds ratio, 5.1; 95% CI, 1.74-15.14). Study of the diagnostic performance of hemoperitoneum in predicting the need for surgical treatment after MTX treatment revealed a sensitivity of 0.63, a specificity of 0.76, a positive predictive value of 0.47 and a negative predictive value of 0.85.

CONCLUSIONS

The presence of hemoperitoneum appears to be a risk factor for MTX treatment failure. It is important to inform women as fully as possible about the risk of such failure. Nonetheless, the predictive value of this sign is insufficient for either routinely excluding women with hemoperitoneum from MTX treatment or omitting post-treatment monitoring.

Mitigating the environmental impacts of milk production via anaerobic digestion of manure: case study of a dairy farm in the Po Valley

This work analyzes the environmental impacts of milk production in an intensive dairy farm situated in the Northern Italy region of the Po Valley. Three manure management scenarios are compared: in Scenario 1 the animal slurry is stored in an open tank and then used as fertilizer. In scenario 2 the manure is processed in an anaerobic digestion plant and the biogas produced is combusted in an internal combustion engine to produce heat (required by the digester) and electricity (exported). Scenario 3 is similar to scenario 2 but the digestate is stored in a gas-tight tank. In scenario 1 the GHG emissions are estimated to be equal to 1.21 kg CO2 eq.kg(-1) Fat and Protein Corrected Milk (FPCM) without allocation of the environmental burden to the by-product meat. With mass allocation, the GHG emissions associated to the milk are reduced to 1.18 kg CO2 eq.kg(-1) FPCM. Using an economic allocation approach the GHG emissions allocated to the milk are 1.13 kg CO2 eq.kg(-1) FPCM. In scenarios 2 and 3, without allocation, the GHG emissions are reduced respectively to 0.92 (-23.7%) and 0.77 (-36.5%) kg CO2 eq.kg(-1) FPCM. If land use change due to soybean production is accounted for, an additional emission of 0.53 kg CO2 eq. should be added, raising the GHG emissions to 1.74, 1.45 and 1.30 kg CO2 eq kg(-1) FPCM in scenarios 1, 2 and 3, respectively. Primary energy from non-renewable resources decreases by 36.2% and 40.6% in scenarios 2 and 3, respectively, with the valorization of the manure in the biogas plant. The other environmental impact mitigated is marine eutrophication that decreases by 8.1% in both scenarios 2 and 3, mostly because of the lower field emissions. There is, however, a trade-off between non-renewable energy and GHG savings and other environmental impacts: acidification (+6.1% and +5.5% in scenarios 2 and 3, respectively), particulate matter emissions (+1.4% and +0.7%) and photochemical ozone formation potential (+41.6% and +42.3%) increase with the adoption of a biogas plant. The cause of the increase is mostly emissions from the CHP engine. These impacts can be tackled by improving biogas combustion technologies to reduce methane and NOx emissions. Freshwater eutrophication slightly increases (+0.8% in both scenarios 2 and 3) because of the additional infrastructures needed. In conclusion, on-farm manure anaerobic digestion with the production of electricity is an effective technology to significantly reduce global environmental impacts of dairy farms (GHG emissions and non-renewable energy consumption), however local impacts may increase as a consequence (especially photochemical ozone formation).

First Report of Blackleg Caused by Leptosphaeria maculans on Canola in Idaho

Canola (Brassica napus L.) is produced in the dryland agriculture areas of eastern Washington State and northern Idaho, often in rotation with cereal cropping systems. Canola is also used as a rotation crop in irrigated circles in the Columbia Basin of Washington and southern Idaho, where potato is the main cash crop. In 2011, 7,700 ha of canola were harvested in Idaho and 4,200 ha in Washington. One of the major diseases of canola around the world is blackleg, caused by Leptosphaeria maculans (aggressive) and L. biglobosa (non-aggressive). Both Washington and Idaho have been considered blackleg-free, and production of canola in Idaho is subject to government regulations. Canola seed originating from outside of Washington and Idaho should have a phytosanitary certificate. This disease is widespread in Canada and the U.S. Northern Plains, Midwest, and South, and is the major disease of canola in these areas. In August 2011, a sample from a canola field in Bonners Ferry, Idaho, was brought for diagnosis to Washington State University. The canola stems showed the typical gray to dark grey lesions with black pycnidia. The pycnidia and conidia were examined microscopically, and found to be similar to descriptions of Phoma lingam, the anamorph of L. maculans (2). Samples were sent to the University of Manitoba for confirmation with PCR. The pathogen was cultured out of stems on V8 juice agar amended with streptomycin and 22 single pynidiospore isolates were made from the cultures. DNA was extracted from the cultures using methods described in Fernando et al. (1) and a multiplex PCR was performed with species-specific primers for L. maculans and L. biglobosa. The reaction should produce a 330-bp amplicon for L. maculans and a 440-bp amplicon for L. biglobosa. Based on this, all 22 isolates were identified as L. maculans. The susceptible cultivar Westar was inoculated with the isolates, by wound inoculating 7-day-old cotyledons with a concentration of 10⁷ spores/ml. Plants were kept in a moist chamber at 23°C. After 14 days, plants were rated for disease with a 0 to 9 scale, where 0 = no infection and 9 = tissue collapse and appearance of pycnidiospores. Isolates with rating ≥5 are considered virulent. All isolates produced a rating of 7 to 9, indicating a high level of virulence. The source of the seed used in the infested fields is not known at this time. This disease is seedborne, and may pose a threat to the two major vegetable and oilseed brassica seed production areas of Washington: the Skagit River valley of western Washington and the Columbia Basin area of central Washington. In addition, the susceptibility of Pacific Northwest varieties of canola and other brassica oilseeds is largely unknown. References: (1) W. G. D. Fernando et al. Plant Dis. 90:1337, 2006. (2) S. Roger Rimmer et al. Compendium of Brassica Diseases, APS Press, 2007.

[Comparative study of patients with placenta accreta with or without a history of cesarean section]

OBJECTIVE

To evaluate characteristics of placenta accreta (PA) in patients without previous cesarean section.

MATERIAL AND METHODS

Retrospective cohort study from December 1993 to April 2010 in two departments of obstetrics in university hospitals, Marseille, France. Comparison of clinical characteristics, circumstances of diagnosis, maternal morbidity and treatment was performed between PA diagnosed in patients with (n=63) and without prior cesarean section (n=35).

RESULTS

In group of patients without previous caesarean section, rate of placenta praevia, and antenatal diagnosis were lower (16/35 [46 %] vs. 44/63 [70 %], [P: 0.02]) and (4/35 [11 %] vs. 28/63 [44 %], [P<0.001]) and rate of pregnancies obtained by IVF was higher (5/35 [15 %] vs. 2/63 [3 %], [P=0.05]). In this group, no hysterectomy was performed but risk of uterus necrosis following embolization was increased (3/35 [8.6 %] patients vs. 0/63 patients [P: 0.02]).

CONCLUSIONS

Patients without previous caesarean section have specific characteristics in terms of risk factor and of management.

New insights into the brain involvement in patients with Crohn's disease: a voxel-based morphometry study

BACKGROUND

Crohn's disease (CD) is a chronic intestinal disorder characterized by overproduction of inflammatory cytokines and recurrent abdominal pain. Recently, brain morphological abnormalities in the pain matrix were found in patients with chronic pain disorders including irritable bowel syndrome. To investigate potential structural brain changes associated with CD, we used magnetic resonance imaging (MRI). Furthermore, we tested whether in patients gray matter (GM) volumes correlated with disease duration.

METHODS

Eighteen CD patients in remission and 18 healthy controls underwent structural MRI. Voxel-based morphometry (VBM) is a fully automated technique allowing identification of regional differences in the amount of GM enabling an objective analysis of the whole brain between groups of subjects. VBM was used for comparisons and correlation analysis.

KEY RESULTS

With respect to controls, CD patients exhibited decreased GM volumes in portion of the frontal cortex and in the anterior midcingulate cortex. Disease duration was negatively correlated with GM volumes of several brain regions including neocortical and limbic areas.

CONCLUSIONS & INFERENCES

Crohn's disease is associated with brain morphological changes in cortical and subcortical structures involved in nociception, emotional, and cognitive processes. Our findings provide new insight into the brain involvement in chronic inflammatory bowel disorders.

Prevention of complications related to the use of prosthetic meshes in prolapse surgery: guidelines for clinical practice

The objective of the study was to provide guidelines for clinical practice from the French College of Obstetrics and Gynecology (CNGOF), based on the best evidence available, concerning adverse events related to surgical procedures involving the use of prosthetic meshes. French and English-language articles from Medline, PubMed, and the Cochrane Database were searched, using key words (mesh; pelvic organ prolapse; cystocele; rectocele; uterine prolapse; complications; adverse event; sacral colpopexy; extrusion; infection). As with any surgery, recommendations include perioperative smoking cessation (Expert opinion) and compliance with the prevention of nosocomial infections (regulatory recommendation). There is no evidence to recommend routine local or systemic estrogen therapy before or after prolapse surgery using mesh, regardless of the surgical approach (Grade C). Antibiotic prophylaxis is recommended, regardless of the approach (Expert opinion). It is recommended to check for pre-operative urinary tract infection and treat it (Expert opinion). The first procedure should be undertaken under the guidance of a surgeon experienced in the relevant technique (Grade C). It is recommended not to place a non-absorbable synthetic mesh into the rectovaginal septum when a rectal injury occurs (Expert opinion). Placement of a non-absorbable synthetic mesh into the vesicovaginal septum may be considered after suturing of a bladder injury if the suture is considered to be satisfactory (Expert opinion). If a synthetic mesh is placed by vaginal route, it is recommended to use a macroporous polypropylene monofilament mesh (Grade B). It is recommended not to use polyester mesh for vaginal surgery (Grade B). It is permissible to perform hysterectomy associated with the placement of a non-absorbable synthetic mesh placed by the vaginal route but this is not routinely recommended (Expert opinion). It is recommended to minimize the extent of the colpectomy (Expert opinion). The laparoscopic approach is recommended for sacral colpopexy (Expert opinion). It is recommended not to place and suture meshes by the vaginal route when a sacral colpopexy is performed (Grade B). It is recommended not to use silicone-coated polyester, porcine dermis, fascia lata, and polytetrafluoroethylene meshes (Grade B). It is recommended to use polyester (without silicone coating) or polypropylene meshes (Grade C). Suture of the meshes to the promontory can be performed using thread/needle or tacks (Grade C). Peritonization is recommended to cover the meshes (Grade C). If hysterectomy is required, it is recommended to perform a subtotal hysterectomy (Expert opinion). Implementation of this guideline should decrease the prevalence of complications related to surgical procedures involving the use of prosthetic meshes.

[Port-site metastasis after retroperitoneal lymphadenectomy for endometrial adenocarcinoma]

Port-site metastasis is a rare but serious complication of laparoscopic surgery. The etiologies are poorly identified and multiple. We report the case of port-site metastasis after laparoscopic retroperitoneal lymphadenectomy for endometrial adenocarcinoma. In the literature, three cases of port-site metastasis after laparoscopic retroperitoneal lymphadenectomy are reported: two cases concerning cervical cancer and one case concerning a kidney cancer. To our knowledge, this is the only case about port site metastasis after laparoscopic retroperitoneal lymphadenectomy for endometrial adenocarcinoma.

Primary neuroendocrine carcinoma of the fallopian tube: A case report

► This case is an exceptionally rare primary neuroendocrine carcinoma of the fallopian tube, with a clinical presentation as torsion. ► TTF1 immunoreactivity can be found in neuroendocrine carcinomas originating from the fallopian tube.

[Clinical and ultrasonographic factors affecting successful medical treatment of early pregnancy failure]

OBJECTIVES

To assess clinical and echocardiographic factors impacting the effectiveness of misoprostol in early pregnancy failure.

PATIENTS AND METHODS

An observational study was carried out within the gynaecological emergency service from 01/06/2000 to 15/05/2010. Patients had pregnancy failure in the first 12 weeks at ultrasonic examination. The patient received 4 misoprostol tablets (800 μg) intravaginally with clinical and ultrasound examination 24 hours later. The treatment was considered effective if the endometrial thickness was lower than 15 mm by ultrasound examination and absence of secondary endo-uterine aspiration. If the treatment was considered as a failure, an endo-uterine aspiration was carried out. Variables studied were clinical (patient age, date of the last menstrual period, gravidity, parity, history of miscarriage, endouterine aspiration, ectopic pregnancy, vaginal delivery, caesarean section) and ultrasound-based (presence or absence of an embryo, CRL, gestational sac diameter).

RESULTS

Five hundred and one patients were included. The success rate was 336/501 (67.1%). After univariate analysis, the averages of parity (P=0.048) and caesarean section (P=0.002) were significantly higher in failure cases. The history of one or more caesarean section was a significant risk factor for failure (P=0.001). There was no significant difference for the other criteria. In multivariate analysis, the average number of caesarean sections (P=0.003) and the history of one or more caesarean section remained significant (P=0.002).

DISCUSSION AND CONCLUSION

The ultrasound criteria and gestational age do not impact the effectiveness of misoprostol in the treatment of early pregnancy failure. The history of one or more caesarean section (s) significantly decreased the success rate. It has to be confirmed by other studies. This new data can be an aid to decision-making for the patient and the physician in case of early pregnancy failure.