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Centini G, Cannoni A, Ginetti A, Colombi I, Giorgi M, Schettini G, Martire FG, Lazzeri L, Zupi E. Tailoring the Diagnostic Pathway for Medical and Surgical Treatment of Uterine Fibroids: A Narrative Review. Diagnostics (Basel) 2024; 14:2046. [PMID: 39335725 PMCID: PMC11431597 DOI: 10.3390/diagnostics14182046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2024] [Revised: 09/03/2024] [Accepted: 09/10/2024] [Indexed: 09/30/2024] Open
Abstract
Uterine leiomyomas are the most common benign uterine tumors in women and are often asymptomatic, with clinical manifestation occurring in 20-25% of cases. The diagnostic pathway begins with clinical suspicion and includes an ultrasound examination, diagnostic hysteroscopy, and, when deemed necessary, magnetic resonance imaging. The decision-making process should consider the impairment of quality of life due to symptoms, reproductive desire, suspicion of malignancy, and, of course, the woman's preferences. Despite the absence of a definitive cure, the management of fibroid-related symptoms can benefit from various medical therapies, ranging from symptomatic treatments to the latest hormonal drugs aimed at reducing the clinical impact of fibroids on women's well-being. When medical therapy is not a definitive solution for a patient, it can be used as a bridge to prepare the patient for surgery. Surgical approaches continue to play a crucial role in the treatment of fibroids, as the gynecologist has the opportunity to choose from various surgical options and tailor the intervention to the patient's needs. This review aims to summarize the clinical pathway necessary for the diagnostic assessment of a patient with uterine fibromatosis, presenting all available treatment options to address the needs of different types of women.
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Affiliation(s)
- Gabriele Centini
- Department of Molecular and Developmental Medicine, University of Siena, 53100 Siena, Italy
| | - Alberto Cannoni
- Department of Molecular and Developmental Medicine, University of Siena, 53100 Siena, Italy
| | - Alessandro Ginetti
- Department of Molecular and Developmental Medicine, University of Siena, 53100 Siena, Italy
| | - Irene Colombi
- Department of Molecular and Developmental Medicine, University of Siena, 53100 Siena, Italy
| | - Matteo Giorgi
- Department of Molecular and Developmental Medicine, University of Siena, 53100 Siena, Italy
| | - Giorgia Schettini
- Department of Molecular and Developmental Medicine, University of Siena, 53100 Siena, Italy
| | | | - Lucia Lazzeri
- Department of Molecular and Developmental Medicine, University of Siena, 53100 Siena, Italy
| | - Errico Zupi
- Department of Molecular and Developmental Medicine, University of Siena, 53100 Siena, Italy
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Patel DJ, Chaudhari K, Acharya N, Shrivastava D, Dave A, Patel A. Navigating Pregnancy With Uterine Fibroids: A Case Study. Cureus 2024; 16:e64793. [PMID: 39156440 PMCID: PMC11330289 DOI: 10.7759/cureus.64793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Accepted: 07/18/2024] [Indexed: 08/20/2024] Open
Abstract
Benign uterine tumors, known as leiomyomas or uterine fibroids, can result in severe pain, bleeding, and infertility. They impact a woman's overall well-being, ability to conceive, and the course of her pregnancy. Fibroids are associated with increasing maternal age. When a patient with fibroids is considering pregnancy, ultrasonography and a detailed pelvic examination should be performed to determine the size and location of any fibroids. This case study details a 30-year-old female patient who had fibroids during her pregnancy and responded well to treatment.
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Affiliation(s)
- Dharmesh J Patel
- Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Kamlesh Chaudhari
- Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Neema Acharya
- Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Deepti Shrivastava
- Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Apoorva Dave
- Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Archan Patel
- Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Al-Hendy A, Segars JH, Taylor HS, González F, Siblini H, Zamah M, Alkelani H, Singh B, Flores VA, Christman GM, Johnson JJ, Huang H, Zhang H. Fibroids and unexplained infertility treatment with epigallocatechin gallate: a natural compound in green tea (FRIEND) - protocol for a randomised placebo-controlled US multicentre clinical trial of EGCG to improve fertility in women with uterine fibroids. BMJ Open 2024; 14:e078989. [PMID: 38216200 PMCID: PMC10806662 DOI: 10.1136/bmjopen-2023-078989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 12/15/2023] [Indexed: 01/14/2024] Open
Abstract
INTRODUCTION Uterine fibroids affect 30%-77% of reproductive-age women and are a significant cause of infertility. Surgical myomectomies can restore fertility, but they often have limited and temporary benefits, with postoperative complications such as adhesions negatively impacting fertility. Existing medical therapies, such as oral contraceptives, gonadotropin hormone-releasing hormone (GnRH) analogues and GnRH antagonists, can manage fibroid symptoms but are not fertility friendly. This study addresses the pressing need for non-hormonal, non-surgical treatment options for women with fibroids desiring pregnancy. Previous preclinical and clinical studies have shown that epigallocatechin gallate (EGCG) effectively reduces uterine fibroid size. We hypothesise that EGCG from green tea extract will shrink fibroids, enhance endometrial quality and increase pregnancy likelihood. To investigate this hypothesis, we initiated a National Institute of Child Health and Human Development Confirm-funded trial to assess EGCG's efficacy in treating women with fibroids and unexplained infertility. METHODS AND ANALYSIS This multicentre, prospective, interventional, randomised, double-blinded clinical trial aims to enrol 200 participants with fibroids and unexplained infertility undergoing intrauterine insemination (IUI). Participants will be randomly assigned in a 3:1 ratio to two groups: green tea extract (1650 mg daily) or a matched placebo, combined with clomiphene citrate-induced ovarian stimulation and timed IUI for up to four cycles. EGCG constitutes approximately 45% of the green tea extract. The primary outcome is the cumulative live birth rate, with secondary outcomes including conception rate, time to conception, miscarriage rate, change in fibroid volume and symptom severity scores and health-related quality of life questionnaire scores. ETHICS AND DISSEMINATION The FRIEND trial received approval from the Food and Drug adminstration (FDA) (investigational new drug number 150951), the central Institutional Review Board (IRB) at Johns Hopkins University and FRIEND-collaborative site local IRBs. The data will be disseminated at major conferences, published in peer-reviewed journals and support a large-scale clinical trial. TRIAL REGISTRATION NUMBER NCT05364008.
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Affiliation(s)
- Ayman Al-Hendy
- Department of Obstetrics and Gynecology, The University of Chicago, Chicago, Illinois, USA
| | - James H Segars
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hugh S Taylor
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University, New Haven, Connecticut, USA
| | - Frank González
- Department of Obstetrics and Gynecology, University of Illinois Chicago, Chicago, Illinois, USA
| | - Hiba Siblini
- Department of Obstetrics and Gynecology, The University of Chicago, Chicago, Illinois, USA
| | - Musa Zamah
- Department of Obstetrics and Gynecology, The University of Chicago, Chicago, Illinois, USA
| | - Hiba Alkelani
- Department of Obstetrics and Gynecology, The University of Chicago, Chicago, Illinois, USA
| | - Bhuchitra Singh
- Department of Gynecology and Obstetrics, Johns Hopkins, Baltimore, Maryland, USA
| | - Valerie A Flores
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Gregory M Christman
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Jeremy J Johnson
- Department of Pharmacy Practice, University of Illinois Chicago, Chicago, Illinois, USA
| | - Hao Huang
- Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut, USA
| | - Heping Zhang
- Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut, USA
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Dou Y, Zhang L, Liu Y, He M, Wang Y, Wang Z. Long-term outcome and risk factors of reintervention after high intensity focused ultrasound ablation for uterine fibroids: a systematic review and meta-analysis. Int J Hyperthermia 2024; 41:2299479. [PMID: 38164630 DOI: 10.1080/02656736.2023.2299479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 12/21/2023] [Indexed: 01/03/2024] Open
Abstract
OBJECTIVES To quantify the reintervention rate and analyze the risk factors for reintervention after high-intensity focused ultrasound (HIFU) ablation of uterine fibroids. METHODS Eighteen studies were selected from the seven databases. A meta-analysis was applied to synthesize the reintervention rates for fibroids across various follow-up durations. Subgroup-analysis was conducted based on the year of surgery, sample size, guide methods, and non-perfusion volume ratio (NPVR). Signal intensity of T2-weighted imaging (T2WI) was independently evaluated for reintervention risk. RESULTS The study enrolled 5216 patients with fibroids treated with HIFU. There were 3247, 1239, 1762, and 2535 women reaching reintervention rates of 1% (95% confidence interval (CI): 1-1), 7% (95% CI: 4-11), 19% (95% CI: 11-27), and 29% (95% CI: 14-44) at 12, 24, 36, and 60-month after HIFU. The reintervention rates of patients treated with US-guided HIFU (USgHIFU) were significantly lower than those of patients treated with MR-guided focused ultrasound surgery (MRgFUS). When the NPVR of fibroids was over 50%, the reintervention rates at 12, 36 and 60-month after HIFU were 1% (95% CI: 0.3-2), 5% (95% CI: 3-8), and 15% (95% CI: 9-20). The reintervention risk for hyper-intensity fibroids on T2WI was 3.45 times higher (95% CI: 2.7-4.39) for hypo-/iso-intensity fibroids. CONCLUSION This meta-analysis showed that the overall reintervention rates after HIFU were acceptable and provided consultative suggestions regarding treatment alternatives for patients with fibroids. Subgroup-analysis revealed that USgHIFU, NPVR ≥ 50%, and hypo-/iso-intensity of fibroids on T2WI were significant factors in reducing reintervention. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42023456094.
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Affiliation(s)
- Yuya Dou
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China
- Department of Obstetrics and Gynecology, Southwest Hospital, Army Military Medical University, Chongqing, China
| | - Lian Zhang
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China
| | - Yu Liu
- Department of Obstetrics and Gynecology, Hainan Hospital of PLA General Hospital, Sanya, China
| | - Min He
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China
| | - Yanzhou Wang
- Department of Obstetrics and Gynecology, Southwest Hospital, Army Military Medical University, Chongqing, China
| | - Zhibiao Wang
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China
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Cianci S, Gulino FA, Palmara V, La Verde M, Ronsini C, Romeo P, Occhipinti S, Incognito GG, Capozzi VA, Restaino S, Vizzielli G, Palumbo M. Exploring Surgical Strategies for Uterine Fibroid Treatment: A Comprehensive Review of Literature on Open and Minimally Invasive Approaches. MEDICINA (KAUNAS, LITHUANIA) 2023; 60:64. [PMID: 38256325 PMCID: PMC10820219 DOI: 10.3390/medicina60010064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 12/19/2023] [Accepted: 12/27/2023] [Indexed: 01/24/2024]
Abstract
Background and Objectives: Uterine myomas represent one of the most prevalent pathologies affecting the female population. These benign neoplasms originate from the smooth muscular cells of the uterus, and they can be either single or multiple. Often associated with debilitating symptoms such as pelvic heaviness, pain, constipation, and urinary dysfunctions, the surgical management of myomectomy exhibits considerable variability. This diversity in approaches is influenced by factors such as the number and size of myomas, the patient's age, and overall clinical conditions. This study aims to elucidate and compare the advantages and disadvantages of different surgical approaches, specifically endoscopic procedures versus open surgery, providing valuable insights for clinical decision making. Materials and Methods: A comprehensive bibliographic search spanning from 2013 to 2023 was systematically conducted across databases including Medline, Embase, the Cochrane Database of Systematic Reviews, and ClinicalTrials.gov. The search utilized keywords such as "myomectomy laparoscopic and open", "myomectomy open and minimally invasive", "myomectomy open and laparoscopic", and "myomectomy open vs. laparoscopic." The research methodology, along with predetermined inclusion and exclusion criteria, was established prior to the search, ensuring a systematic and rigorous approach. Subsequently, data analysis was carried out. Results: Following the study selection process, 25 articles met the eligibility criteria for inclusion in this analysis. The average numbers of myomas were 3.7 (ranging from 1 to 13.7) and 5.4 (ranging from 1 to 13.5) for the minimally invasive surgery and open surgery groups, respectively. In terms of myoma size, the total averages across studies were 7 cm (ranging from 4.8 to 14) for the minimally invasive group and 8 cm (ranging from 3.9 to 11.2) for the open surgery group. The average pregnancy and delivery rates were 29.7% (ranging from 1.8 to 100) for the minimally invasive group and 28.5% (ranging from 1.8 to 100) for the open surgery group. Regarding complications, the average rate was 14.2% (ranging from 0 to 50) for the endoscopic group and 22.3% (ranging from 0 to 60.3) for the laparotomic group. Conclusions: In conclusion, a critical factor influencing the choice of surgical approach is primarily the size and quantity of fibroids. The mini-laparotomic approach emerges as a viable alternative to endoscopy, demonstrating favorable surgical outcomes and aesthetic results. Interestingly, the type of surgical procedure appears to have no significant impact on the pregnancy rate.
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Affiliation(s)
- Stefano Cianci
- Unit of Gynecology and Obstetrics, Department of Human Pathology of Adult and Childhood “G. Barresi”, University of Messina, 98122 Messina, Italy; (F.A.G.); (V.P.); (P.R.)
| | - Ferdinando Antonio Gulino
- Unit of Gynecology and Obstetrics, Department of Human Pathology of Adult and Childhood “G. Barresi”, University of Messina, 98122 Messina, Italy; (F.A.G.); (V.P.); (P.R.)
| | - Vittorio Palmara
- Unit of Gynecology and Obstetrics, Department of Human Pathology of Adult and Childhood “G. Barresi”, University of Messina, 98122 Messina, Italy; (F.A.G.); (V.P.); (P.R.)
| | - Marco La Verde
- Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (M.L.V.); (C.R.)
| | - Carlo Ronsini
- Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (M.L.V.); (C.R.)
| | - Paola Romeo
- Unit of Gynecology and Obstetrics, Department of Human Pathology of Adult and Childhood “G. Barresi”, University of Messina, 98122 Messina, Italy; (F.A.G.); (V.P.); (P.R.)
| | - Sara Occhipinti
- Department of General Surgery and Medical Surgical Specialties, University of Catania, 95124 Catania, Italy; (S.O.); (G.G.I.); (M.P.)
| | - Giosuè Giordano Incognito
- Department of General Surgery and Medical Surgical Specialties, University of Catania, 95124 Catania, Italy; (S.O.); (G.G.I.); (M.P.)
| | - Vito Andrea Capozzi
- Department of Obstetrics and Gynecology, University of Parma, 43125 Parma, Italy;
| | - Stefano Restaino
- Clinic of Obstetrics and Gynecology, “Santa Maria della Misericordia” University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy; (S.R.); (G.V.)
| | - Giuseppe Vizzielli
- Clinic of Obstetrics and Gynecology, “Santa Maria della Misericordia” University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy; (S.R.); (G.V.)
- Department of Medicine, University of Udine, 33100 Udine, Italy
| | - Marco Palumbo
- Department of General Surgery and Medical Surgical Specialties, University of Catania, 95124 Catania, Italy; (S.O.); (G.G.I.); (M.P.)
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Michos G, Dagklis T, Papanikolaou E, Tsakiridis I, Oikonomou K, Mamopoulos AM, Kalogiannidis IA, Athanasiadis A. Uterine Leiomyomas and Infertility: A Comparison of National and International Guidelines. Cureus 2023; 15:e50992. [PMID: 38259363 PMCID: PMC10802214 DOI: 10.7759/cureus.50992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2023] [Indexed: 01/24/2024] Open
Abstract
Uterine leiomyomas are the most common benign tumors of the female genital track, causing various symptoms and problems, including a possible impact on fertility. The relationship between fibroids and infertility has long been a debate among gynecologists. Management of fibroids in women with otherwise unexplained infertility worldwide lacks standardized, evidence-based guidelines. Therefore, a review of guidelines from the Royal Australian and New Zealand College of Obstetricians and Gynecologists, the American College of Obstetricians and Gynecologists, the Society of Obstetricians and Gynecologists of Canada, the Collège National des Gynécologues et Obstétriciens Français, and the American Society of Reproductive Medicine was conducted. There is agreement among all guidelines that the effect of fibroids on fertility is related to their position in the uterus and the alteration of the endometrial cavity. However, whether surgical intervention (laparotomy, laparoscopy, or hysteroscopy) is required varies among committees. More specifically, for submucous myomas, all guidelines agree that surgical intervention is needed. On the other hand, regarding intramural myomas, there is no consensus on what the approach may be. Novel treatments such as uterine artery embolization (UAE) and magnetic resonance-guided focused ultrasound surgery (MRgFUS) should only be used in clinical trial settings. Nevertheless, all guidelines agree that medical management of fibroids further delays efforts to conceive and has no role as a stand-alone treatment of fibroids; though, the use of GnRH analogues preoperatively can be useful to improve anemia and/or reduce fibroid volume. There is a need for updated international protocols to be introduced, in order to help clinicians dealing with fibroids and infertility to better suggest the optimal treatment.
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Affiliation(s)
- Georgios Michos
- 3rd Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Themistoklis Dagklis
- 3rd Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Evangelos Papanikolaou
- 3rd Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Ioannis Tsakiridis
- 3rd Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Kyriakos Oikonomou
- 3rd Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Apostolos M Mamopoulos
- 3rd Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Ioannis A Kalogiannidis
- 3rd Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Apostolos Athanasiadis
- 3rd Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki, GRC
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Bouko-Levy E, Vialaret C, Sallée C, Marquet P, Margueritte F, Dion L, Lavoue V, Gauthier T. Estimation of the prevalence of uterine infertility and its different causes in France according to data from a literature review. J Gynecol Obstet Hum Reprod 2023; 52:102684. [PMID: 37866776 DOI: 10.1016/j.jogoh.2023.102684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/20/2023] [Indexed: 10/24/2023]
Abstract
INTRODUCTION Uterine infertility (UI) is defined as the complete absence of a uterus (absolute uterine infertility or AUI) or the presence of a non functional uterus (non-absolute uterine infertility or NAUI). The exact prevalence of uterine infertility is currently unknown. Our aim was to assess the number of French women concerned by Uterine Infertility according to a recent literature review. MATERIALS AND METHODS We have previously conducted a systematic review of the literature on UI and its various causes in the world. Based on these study and demographic data of 2022 from INSEE (Institut National de la Statistique et des Études Économiques), we attempted to estimate the number of women under 40 years of age in France affected by potential UI using direct standardization. RESULTS AND DISCUSSION Based on the estimation from INSEE data, approximately 2066 women of childbearing age would have MRKH syndrome in France, 380 the Androgen Insensitivity Syndrome and 3700 had an haemostasis hysterectomy in France. We did not find data on the prevalence of hysterectomies before the age of 40 in France. For the following pathologies: uterine malformations, radiation uterus, synechiae, myomas and adenomyosis there was a huge amount of missing data, which does not allow us to estimate the number of potentially infertile patients. CONCLUSION Prevalence of UI is poorly known. UI probably concerns several thousand patients in France. The creation of a UI registry would make enable to assess the number of patients potentially eligible for adoption, uterus transplantation or even surrogacy.
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Affiliation(s)
- E Bouko-Levy
- Department of Gynecology and Obstetrics, Mother and Child Hospital, University Hospital Center of Limoges, Limoges 87000, France
| | - C Vialaret
- Department of Gynecology and Obstetrics, Mother and Child Hospital, University Hospital Center of Limoges, Limoges 87000, France
| | - C Sallée
- Department of Gynecology and Obstetrics, Mother and Child Hospital, University Hospital Center of Limoges, Limoges 87000, France
| | - P Marquet
- Pharmacology and Transplantation, INSERM U1248, Université de Limoges, 2 Rue du Pr Descottes, Limoges 87000, France
| | - F Margueritte
- Department of Gynecology and Obstetrics, Mother and Child Hospital, University Hospital Center of Limoges, Limoges 87000, France
| | - L Dion
- Department of Obstetrics and Gynecology, Hopital Universitaire de Rennes, Rennes 35000, France
| | - V Lavoue
- Department of Obstetrics and Gynecology, Hopital Universitaire de Rennes, Rennes 35000, France
| | - T Gauthier
- Department of Gynecology and Obstetrics, Mother and Child Hospital, University Hospital Center of Limoges, Limoges 87000, France; Pharmacology and Transplantation, INSERM U1248, Université de Limoges, 2 Rue du Pr Descottes, Limoges 87000, France.
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Stringer E, Topçu G. Contemporary issues in women's health. Int J Gynaecol Obstet 2023; 163:463-465. [PMID: 37737014 DOI: 10.1002/ijgo.15158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Affiliation(s)
- Elizabeth Stringer
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Goknur Topçu
- Istanbul Health and Technology University, Istanbul, Turkey
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Pan H, Zhang M, Bai W, Li B, Wang H, Geng H, Zhao X, Zhang D, Li Y, Chen M. An Instance Segmentation Model Based on Deep Learning for Intelligent Diagnosis of Uterine Myomas in MRI. Diagnostics (Basel) 2023; 13:diagnostics13091525. [PMID: 37174917 PMCID: PMC10177878 DOI: 10.3390/diagnostics13091525] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 04/16/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023] Open
Abstract
Uterine myomas affect 70% of women of reproductive age, potentially impacting their fertility and health. Manual film reading is commonly used to identify uterine myomas, but it is time-consuming, laborious, and subjective. Clinical treatment requires the consideration of the positional relationship among the uterine wall, uterine cavity, and uterine myomas. However, due to their complex and variable shapes, the low contrast of adjacent tissues or organs, and indistinguishable edges, accurately identifying them in MRI is difficult. Our work addresses these challenges by proposing an instance segmentation network capable of automatically outputting the location, category, and masks of each organ and lesion. Specifically, we designed a new backbone that facilitates learning the shape features of object diversity, and filters out background noise interference. We optimized the anchor box generation strategy to provide better priors in order to enhance the process of bounding box prediction and regression. An adaptive iterative subdivision strategy ensures that the mask boundary details of objects are more realistic and accurate. We conducted extensive experiments to validate our network, which achieved better average precision (AP) results than those of state-of-the-art instance segmentation models. Compared to the baseline network, our model improved AP on the uterine wall, uterine cavity, and myomas by 8.8%, 8.4%, and 3.2%, respectively. Our work is the first to realize multiclass instance segmentation in uterine MRI, providing a convenient and objective reference for the clinical development of appropriate surgical plans, and has significant value in improving diagnostic efficiency and realizing the automatic auxiliary diagnosis of uterine myomas.
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Affiliation(s)
- Haixia Pan
- College of Software, Beihang University, Beijing 100191, China
| | - Meng Zhang
- College of Software, Beihang University, Beijing 100191, China
| | - Wenpei Bai
- Department of Obstetrics and Gynecology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Bin Li
- Department of MRI, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Hongqiang Wang
- College of Software, Beihang University, Beijing 100191, China
| | - Haotian Geng
- College of Software, Beihang University, Beijing 100191, China
| | - Xiaoran Zhao
- College of Software, Beihang University, Beijing 100191, China
| | - Dongdong Zhang
- College of Software, Beihang University, Beijing 100191, China
| | - Yanan Li
- College of Software, Beihang University, Beijing 100191, China
| | - Minghuang Chen
- Department of Obstetrics and Gynecology, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
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Tyan YS, Shen CY, Tantoh DM, Hsu SY, Chou YH, Nfor ON, Liaw YP. Association between ESR1 rs2234693 single nucleotide polymorphism and uterine fibroids in Taiwanese premenopausal and postmenopausal women. JOURNAL OF HEALTH, POPULATION, AND NUTRITION 2023; 42:16. [PMID: 36890612 PMCID: PMC9993586 DOI: 10.1186/s41043-023-00357-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 02/28/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Uterine fibroids (UFs) are uterine smooth muscle neoplasms that affect women, especially during the reproductive stage. Both genetic and lifestyle factors affect the onset of the disease. We examined the association between the estrogen receptor 1 (ESR1) rs2234693 variant (whose genotypes are TT, TC, and CC) and UFs in Taiwanese premenopausal and postmenopausal women. METHODS We linked individual-level data of 3588 participants from the Taiwan Biobank to the National Health Insurance Research Database at the Health and Welfare Data Science Center. The association of the ESR1 rs2234693 variant and other variables with UFs was determined by multiple logistic regression, and the results were presented as odds ratios and 95% confidence intervals (CIs). RESULTS The 3588 participants comprised 622 cases and 2966 controls. In all the participants, the ESR1 rs2234693 TC and CC genotypes compared to the reference genotype (TT) were associated with a lower risk of UFs. However, the results were significant only for the CC genotype (OR; 95% CI = 0.70; 0.52-0.93). Noteworthy, the association of TC and CC with UFs was dose-dependent (p-trend = 0.012). Based on menopausal status, both TC and CC were significantly and dose-dependently associated with a lower risk of UFs in premenopausal women (OR; 95% CI = 0.76; 0.59-0.98 for TC and 0.64; 0.43-0.95 for CC: p-trend = 0.010). CONCLUSION The TC and CC genotypes of the ESR1 rs2234693 variant may reduce susceptibility to UFs, especially in premenopausal women.
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Affiliation(s)
- Yeu-Sheng Tyan
- Department of Medical Imaging, Chung Shan Medical University Hospital, Taichung City, 40201, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung City, 40201, Taiwan
- School of Medical Imaging and Radiological Sciences, Chung Shan Medical University, Taichung City, 40201, Taiwan
- Medical Imaging and Big Data Center, Chung Shan Medical University Hospital, Taichung City, 40201, Taiwan
| | - Chao-Yu Shen
- Department of Medical Imaging, Chung Shan Medical University Hospital, Taichung City, 40201, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung City, 40201, Taiwan
- School of Medical Informatics, Chung Shan Medical University, Taichung City, 40201, Taiwan
| | - Disline Manli Tantoh
- Department of Medical Imaging, Chung Shan Medical University Hospital, Taichung City, 40201, Taiwan
- Department of Public Health and Institute of Public Health, Chung Shan Medical University, No. 110, Sec. 1 Jianguo N. Rd., Taichung City, 40201, Taiwan
| | - Shu-Yi Hsu
- Department of Public Health and Institute of Public Health, Chung Shan Medical University, No. 110, Sec. 1 Jianguo N. Rd., Taichung City, 40201, Taiwan
| | - Ying-Hsiang Chou
- School of Medical Imaging and Radiological Sciences, Chung Shan Medical University, Taichung City, 40201, Taiwan
- Department of Radiation Oncology, Chung Shan Medical University Hospital, Taichung, 40201, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung City, 40201, Taiwan
| | - Oswald Ndi Nfor
- Department of Public Health and Institute of Public Health, Chung Shan Medical University, No. 110, Sec. 1 Jianguo N. Rd., Taichung City, 40201, Taiwan
| | - Yung-Po Liaw
- Department of Medical Imaging, Chung Shan Medical University Hospital, Taichung City, 40201, Taiwan.
- Medical Imaging and Big Data Center, Chung Shan Medical University Hospital, Taichung City, 40201, Taiwan.
- Department of Public Health and Institute of Public Health, Chung Shan Medical University, No. 110, Sec. 1 Jianguo N. Rd., Taichung City, 40201, Taiwan.
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11
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Dokuzeylül Güngör N, Önal M, Madenli AA, Ağar M. Surgical removal of FIGO type 0 and 1 fibroids ameliorates the expression of endometrial proinflammatory transcription factors and receptivity modulators. Fertil Steril 2023; 119:504-513. [PMID: 36473610 DOI: 10.1016/j.fertnstert.2022.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 11/24/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To reveal whether hysteroscopic removal of the International Federation of Gynecology and Obstetrics (FIGO) types 0 and 1 fibroids makes any changes in the expression of homeobox genes (HOXA10, HOXA11), leukemia inhibitory factor, and nuclear factor-kappa B (NF-kB). DESIGN A case-control study. SETTING University-based in vitro fertilisation center. PATIENT(S) This study consisted of a total of 29 participants, 21 with FIGO types 0 and 1 fibroids and 8 with normal uterine cavity without fibroids. INTERVENTION(S) Patients in FIGO types 0 and 1 fibroids group underwent hysteroscopic myomectomy. The patients in the control group underwent laparoscopic tubal ligation. Endometrial cells were collected by flushing method from all participants before and 3 months after myomectomy. Real-time polymerase chain reaction was used to detect HOXA10, HOXA11, and LIF mRNA expressions in endometrial flushing samples. The relative expressions of homeobox and LIF mRNA were calculated with comparative ΔCt method. Endometrial NF-kB concentration was measured quantitatively by enzyme-linked immunosorbent assay. MAIN OUTCOME MEASURE(S) To compare endometrial HOXA10, HOXA11, and LIF mRNA expressions as well as endometrial NF-kB concentration before and after myomectomy. RESULT(S) Premyomectomy NF-kB levels of type 0 (4.22 ± 1.02 ng/mL) and type 1 fibroid (6.44 ± 2.30 ng/mL) were significantly higher than the values of control group (0.54 ± 0.10 ng/mL). Surgical removal of type 0 and 1 fibroids resulted in a significant decrease in endometrial NF-kB levels (1.33 ± 0.02 ng/mL vs 1.65 ± 0.27 ng/mL, respectively). In type 0 fibroid group, after myomectomy, there was a 11.1-fold increase in HOXA10 mRNA, 4.23-fold in HOXA11 mRNA, and 7.63-fold in LIF mRNA. In the type 1 fibroid group, after myomectomy, there was a 16.3-fold increase in HOXA10 mRNA, 8.34-fold in HOXA11 mRNA, and 9.38-fold in LIF mRNA. A nonsignificant change was detected in homeobox and LIF mRNA after tubal sterilization. A negative and significant correlation was found between endometrial NF-kB and HOXA10 (r=-0.67), HOXA11 (r=-0.71) and LIF (r=-0.54). CONCLUSION(S) High proinflammatory NF-kB concentration and low homeobox and LIF mRNA expressions were detected in the presence of type 0 or 1 fibroids that returned to normal values after hysteroscopic myomectomy.
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Affiliation(s)
- Nur Dokuzeylül Güngör
- Department of Obstetrics and Gynecology, Bahcesehir University Goztepe Medicalpark Hospital, Istanbul, Turkey.
| | - Murat Önal
- Department of Obstetrics and Gynecology, Gynolife Hospital, Nicosia, Cyprus
| | - Asena Ayar Madenli
- Department of Obstetrics and Gynecology, Liv Hospital Vadistanbul, Istanbul, Turkey
| | - Mehmet Ağar
- Obstetrics and Gynecology, Private Office, Sanliurfa, Turkey
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Lei Y, Yang L, Yang H, Li M, Ou L, Bai Y, Dong T, Gao F, Wei P. The efficacy and safety of Chinese herbal medicine Guizhi Fuling capsule combined with low dose mifepristone in the treatment of uterine fibroids: a systematic review and meta-analysis of 28 randomized controlled trials. BMC Complement Med Ther 2023; 23:54. [PMID: 36803997 PMCID: PMC9938629 DOI: 10.1186/s12906-023-03842-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 01/11/2023] [Indexed: 02/19/2023] Open
Abstract
OBJECTIVE Guizhi Fuling Capsule (GZFL), a classic traditional Chinese medicine prescription, is often recommended for the treatment of uterine fibroids (UFs). However, the efficacy and safety of GZFL in combination with low-dose mifepristone (MFP) remains controversial. MATERIALS AND METHODS We searched eight literature databases and two clinical trial registries for randomized controlled trials (RCTs) of the efficacy and safety of GZFL combined with low-dose MFP in the treatment of UFs from database inception to April 24, 2022. Data analysis was performed using the Meta package in RStudio and RevMan 5.4. GRADE pro3.6.1 software was used for the assessment of evidence quality. RESULTS Twenty-eight RCTs were included in this study, including a total of 2813 patients. The meta-analysis showed that compared with low-dose MFP alone, GZFL combined with low-dose MFP significantly reduced follicle stimulating hormone (p < 0.001), estradiol (p < 0.001), progesterone (p < 0.001), luteinizing hormone (p < 0.001), uterine fibroids volume (p < 0.001), uterine volume (p < 0.001), menstrual flow (p < 0.001) and increased clinical efficiency rate (p < 0.001). Meanwhile, GZFL combined with low-dose MFP did not significantly increase the incidence of adverse drug reactions compared with low-dose MFP alone (p = 0.16). The quality of the evidence for the outcomes ranged from "very low" to "moderate." CONCLUSION This study suggests that GZFL combined with low-dose MFP is more effective and safe in the treatment of UFs, and it is a potential treatment for UFs. However, due to the poor quality of the included RCTs formulations, we recommend a rigorous, high-quality, large-sample trial to confirm our findings.
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Affiliation(s)
- Yiming Lei
- Shaanxi University of Chinese Medicine, Xianyang, China
| | - Lili Yang
- Shaanxi University of Chinese Medicine, Xianyang, China
| | - Honglian Yang
- The Second Affiliated Hospital of Shaanxi University of Chinese Medicine, Xianyang, China
| | - Min Li
- Shaanxi University of Chinese Medicine, Xianyang, China
| | - Li Ou
- Shaanxi University of Chinese Medicine, Xianyang, China
| | - Yang Bai
- The Second Affiliated Hospital of Shaanxi University of Chinese Medicine, Xianyang, China
| | - Taiwei Dong
- Shaanxi University of Chinese Medicine, Xianyang, China
| | - Feng Gao
- Shaanxi University of Chinese Medicine, Xianyang, China.
| | - Peifeng Wei
- The Second Affiliated Hospital of Shaanxi University of Chinese Medicine, Xianyang, China.
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Siblini H, Al-Hendy A, Segars J, González F, Taylor HS, Singh B, Flaminia A, Flores VA, Christman GM, Huang H, Johnson JJ, Zhang H. Assessing the Hepatic Safety of Epigallocatechin Gallate (EGCG) in Reproductive-Aged Women. Nutrients 2023; 15:320. [PMID: 36678191 PMCID: PMC9861948 DOI: 10.3390/nu15020320] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/01/2023] [Accepted: 01/02/2023] [Indexed: 01/11/2023] Open
Abstract
A similar abstract of the interim analysis was previously published in Fertility and Sterility. EPIGALLOCATECHIN GALLATE (EGCG) FOR TREATMENT OF UNEXPLAINED INFERTILITY ASSOCIATED WITH UTERINE FIBROIDS (PRE-FRIEND TRIAL): EARLY SAFETY ASSESSMENT. Uterine fibroids are the most common cause of unexplained infertility in reproductive-aged women. Epigallocatechin gallate (EGCG), a green tea catechin, has demonstrated its ability to shrink uterine fibroids in prior preclinical and clinical studies. Hence, we developed an NICHD Confirm-funded trial to evaluate the use of EGCG for treating women with fibroids and unexplained infertility (FRIEND trial). Prior to embarking on that trial, we here conducted the pre-FRIEND study (NCT04177693) to evaluate the safety of EGCG in premenopausal women. Specifically, our aim was to assess any adverse effects of EGCG alone or in combination with an ovarian stimulator on serum liver function tests (LFTs) and folate level. In this randomized, open-label prospective cohort, participants were recruited from the FRIEND-collaborative clinical sites: Johns Hopkins University, University of Chicago, University of Illinois at Chicago, and Yale University. Thirty-nine women, ages ≥18 to ≤40 years, with/without uterine fibroids, were enrolled and randomized to one of three treatment arms: 800 mg of EGCG daily alone, 800 mg of EGCG daily with clomiphene citrate 100 mg for 5 days, or 800 mg of EGCG daily with Letrozole 5 mg for 5 days. No subject demonstrated signs of drug induced liver injury and no subject showed serum folate level outside the normal range. Hence, our data suggests that a daily dose of 800 mg of EGCG alone or in combination with clomiphene citrate or letrozole (for 5 days) is well-tolerated and is not associated with liver toxicity or folate deficiency in reproductive-aged women.
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Affiliation(s)
- Hiba Siblini
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, IL 60637, USA
| | - Ayman Al-Hendy
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, IL 60637, USA
| | - James Segars
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Frank González
- Department of Obstetrics and Gynecology, University of Illinois Chicago, Chicago, IL 60607, USA
| | - Hugh S. Taylor
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University, New Haven, CT 06520, USA
| | - Bhuchitra Singh
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Ainna Flaminia
- Department of Obstetrics and Gynecology, University of Illinois Chicago, Chicago, IL 60607, USA
| | - Valerie A. Flores
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University, New Haven, CT 06520, USA
| | - Gregory M. Christman
- Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, FL 32610, USA
| | - Hao Huang
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT 06510, USA
| | - Jeremy J. Johnson
- Department of Pharmacy Practice, University of Illinois Chicago, Chicago, IL 60607, USA
| | - Heping Zhang
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT 06510, USA
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Celik O, Celik N, Gungor ND, Celik S, Arslan L, Morciano A, Tinelli A. Biomechanical Forces Determine Fibroid Stem Cell Transformation and the Receptivity Status of the Endometrium: A Critical Appraisal. Int J Mol Sci 2022; 23:ijms232214201. [PMID: 36430682 PMCID: PMC9692870 DOI: 10.3390/ijms232214201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/13/2022] [Accepted: 11/14/2022] [Indexed: 11/18/2022] Open
Abstract
Myometrium cells are an important reproductive niche in which cyclic mechanical forces of a pico-newton range are produced continuously at millisecond and second intervals. Overproduction and/or underproduction of micro-forces, due to point or epigenetic mutation, aberrant methylation, and abnormal response to hypoxia, may lead to the transformation of fibroid stem cells into fibroid-initiating stem cells. Fibroids are tumors with a high modulus of stiffness disturbing the critical homeostasis of the myometrium and they may cause unfavorable and strong mechanical forces. Micro-mechanical forces and soluble-chemical signals play a critical role in transcriptional and translational processes' maintenance, by regulating communication between the cell nucleus and its organelles. Signals coming from the external environment can stimulate cells in the format of both soluble biochemical signals and mechanical ones. The shape of the cell and the plasma membrane have a significant character in sensing electro-chemical signals, through specialized receptors and generating responses, accordingly. In order for mechanical signals to be perceived by the cell, they must be converted into biological stimuli, through a process called mechanotransduction. Transmission of fibroid-derived mechanical signals to the endometrium and their effects on receptivity modulators are mediated through a pathway known as solid-state signaling. It is not sufficiently clear which type of receptors and mechanical signals impair endometrial receptivity. However, it is known that biomechanical signals reaching the endometrium affect epithelial sodium channels, lysophosphatidic acid receptors or Rho GTPases, leading to conformational changes in endometrial proteins. Translational changes in receptivity modulators may disrupt the selectivity and receptivity functions of the endometrium, resulting in failed implantation or early pregnancy loss. By hypermethylation of the receptivity genes, micro-forces can also negatively affect decidualization and implantation. The purpose of this narrative review is to summarize the state of the art of the biomechanical forces which can determine fibroid stem cell transformation and, thus, affect the receptivity status of the endometrium with regard to fertilization and pregnancy.
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Affiliation(s)
- Onder Celik
- Department of Obstetrics and Gynecology, Private Clinic, Usak 64000, Turkey
| | - Nilufer Celik
- Department of Biochemistry, Behcet Uz Children’s Hospital, Izmir 35210, Turkey
| | - Nur Dokuzeylul Gungor
- Department of Obstetrics and Gynecology, School of Medicine, Bahcesehir University, Istanbul 34732, Turkey
| | - Sudenaz Celik
- Medical Faculty, Sofia University “St. Kliment Ohridski”, 1407 Sofia, Bulgaria
| | - Liya Arslan
- Medical Faculty, Medical University of Sofia, 1431 Sofia, Bulgaria
| | - Andrea Morciano
- Department of Obstetrics and Gynecology, “Cardinal Panico” General Hospital, 73020 Lecce, Italy
| | - Andrea Tinelli
- Department of Obstetrics and Gynecology and CERICSAL (Centro di RIcerca Clinica SALentino), “Veris Delli Ponti Hospital”, 73020 Lecce, Italy
- Correspondence:
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15
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Lasmar RB, Lasmar BP, Moawad NS. HYSTEROSCOPIC MYOMECTOMY. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1627. [PMID: 36422166 PMCID: PMC9692806 DOI: 10.3390/medicina58111627] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 10/31/2022] [Accepted: 11/04/2022] [Indexed: 08/13/2023]
Abstract
Leiomyomas are the most common pelvic tumors. Submucosal fibroids are a common cause of abnormal bleeding and infertility. Hysteroscopic myomectomy is the definitive management of symptomatic submucosal fibroids, with high efficacy and safety. Several techniques have been introduced over time and will be covered in depth in this manuscript. Advances in optics, fluid management, electrosurgery, smaller diameter scopes, and tissue removal systems, along with improved training have contributed to improving the safety and efficiency of hysteroscopic myomectomy.
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Affiliation(s)
- Ricardo Bassil Lasmar
- Department of Surgery and Specialized, Faculty of Medicine, Universidade Federal Fluminense, UFF, Niterói 24020-141, RJ, Brazil
| | - Bernardo Portugal Lasmar
- University of the Maternal-Infant Department of the Faculty of Medicine, Universidade Federal Fluminense, UFF, Niterói 24020-141, RJ, Brazil
- Estácio de Sá University, São João de Meriti 25550-100, RJ, Brazil
- Gynecological Endoscopy, Hospital Central Aristarcho Pessoa HCAP–CBMERJ, Rio de Janeiro 20261-243, RJ, Brazil
| | - Nash S. Moawad
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics & Gynecology, P.O. Box 100294, Gainesville, FL 32610, USA
- UF Health COEMIG, P.O. Box 100294, Gainesville, FL 32610, USA
- University of Florida College of Medicine, P.O. Box 100294, Gainesville, FL 32610, USA
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16
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Uterine disorders and iron deficiency anemia. Fertil Steril 2022; 118:615-624. [PMID: 36182260 DOI: 10.1016/j.fertnstert.2022.08.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/18/2022] [Accepted: 08/08/2022] [Indexed: 02/07/2023]
Abstract
Abnormal uterine bleeding (AUB) is a clinical entity which can lead to iron deficiency anemia. Classification according to the acronym PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy, and hyperplasia; coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not otherwise classified) provides a structured approach to establish the cause of AUB. The goal of this review is to discuss the different mechanisms and the relationship between uterine disorders and AUB. Heavy menstrual bleeding, a subgroup of AUB, is more closely related to the presence of uterine fibroids. The relationship between heavy menstrual bleeding and uterine fibroids remains poorly characterized, particularly the understanding of endometrial function in women with structural myometrial features such as leiomyomas. A number of theories have been proposed in the literature and are discussed in this review. Uterine adenomyosis is also a frequent cause of AUB, and its pathogenesis is still far from being fully elucidated. The mechanisms contributing to its development are multifactorial. Many theories lean toward invasion of the myometrium by endometrial cells. Both clinical and basic studies favor the theory of direct invasion, although de novo development of adenomyosis from Müllerian rests or stem cells has not been ruled out. Development of adenomyotic lesions involves repeated tissue injury and repair. In addition, this review describes the other causes of AUB such as endometrial polyps, cesarean scar defects, and uterine vascular abnormalities. Endometrial polyps are often asymptomatic, but approximately 68% of women have concomitant AUB. Histologic alterations in the lower uterine segment in patients who had undergone cesarean sections were identified and may explain the cause of AUB.
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Moawad NS, Palin H. Hysteroscopic Myomectomy. Obstet Gynecol Clin North Am 2022; 49:329-353. [DOI: 10.1016/j.ogc.2022.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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A review of the pathophysiology of recurrent implantation failure. Fertil Steril 2021; 116:1436-1448. [PMID: 34674825 DOI: 10.1016/j.fertnstert.2021.09.014] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 09/06/2021] [Accepted: 09/14/2021] [Indexed: 11/20/2022]
Abstract
Implantation is a critical step in human reproduction. The success of this step is dependent on a competent blastocyst, receptive endometrium, and successful cross talk between the embryonic and maternal interfaces. Recurrent implantation failure is the lack of implantation after the transfer of several embryo transfers. As the success of in vitro fertilization has increased and failures have become more unacceptable for patients and providers, the literature on recurrent implantation failure has increased. While this clinical phenomenon is often encountered, there is not a universally agreed-on definition-something addressed in an earlier portion of this Views and Reviews. Implantation failure can result from several different factors. In this review, we discuss factors including the maternal immune system, genetics of the embryo and parents, anatomic factors, hematologic factors, reproductive tract microbiome, and endocrine milieu, which factors into embryo and endometrial synchrony. These potential causes are at various stages of research and not all have clear implications or immediately apparent treatment.
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Wei J, Ma X, Wang W, Zhang M, Yu Z, Zhang W, Hong L, Li Z, Li L, Du X, Feng Y, Guo R, Zhang C, Yue Q, Wang W, Wang S. Gonadotropin-releasing hormone agonist versus expectant management for treating multiple leiomyomas after myomectomy: the study protocol for a multicentre, prospective, randomised controlled clinical trial. BMJ Open 2021; 11:e044347. [PMID: 34663648 PMCID: PMC8524271 DOI: 10.1136/bmjopen-2020-044347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Leiomyoma recurrence is a major concern for long-term myomectomy management, especially for multiple leiomyomas. Gonadotropin-releasing hormone agonist (GnRHa) is one of the most effective medications to reduce the volume of fibroids and the uterus. However, its role in preventing recurrence after conservative surgery remains unclear. At present, there is no randomised clinical trial determining the efficacy of GnRHa treatment for preventing multiple leiomyomas recurrence after myomectomy. METHODS AND ANALYSIS We are conducting a phase IV randomised controlled trial in women aged 18-45 undergoing myomectomy for multiple leiomyomas. After surgery, women whose pathological result confirms multiple leiomyomas are randomised in a 1:1 ratio into an observation or GnRHa group. The primary outcome is the recurrence of either clinical symptoms or fibroids on imaging. Patients will be assessed for adverse events during the follow-up. ETHICS AND DISSEMINATION The study was approved by the Medical Ethics Committee of the Tongji Hospital Affiliated with the Tongji Medical College of Huazhong University of Science and Technology (TJ-IRB20180311) according to the submitted study protocol (V.1.0, 10 November 2017) and informed consent (V.1.0, 10 November 2017). The results will be presented at domestic and international conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER ChiCTR-IPR-17012992.
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Affiliation(s)
- Jia Wei
- Obstetrics and Gynaecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiangyi Ma
- Obstetrics and Gynaecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Wenwen Wang
- Obstetrics and Gynaecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Minli Zhang
- Obstetrics and Gynaecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Zhiying Yu
- Obstetrics and Gynaecology, Shenzhen Second People's Hospital, Shenzhen, Guangdong, China
| | - Wei Zhang
- Obstetrics and Gynaecology, Wuhan University Zhongnan Hospital, Wuhan, Hubei, China
| | - Li Hong
- Obstetrics and Gynaecology, Wuhan University Renmin Hospital, Wuhan, Hubei, China
| | - Zhiying Li
- Obstetrics and Gynaecology, Three Gorges University Renhe Hospital, Yichang, Hubei, China
| | - Lin Li
- Obstetrics and Gynaecology, Xiangyang Central Hospital, Xiangyang, Hubei, China
| | - Xin Du
- Obstetrics and Gynaecology, Maternal and Child Hospital of Hubei Province, Wuhan, Hubei, China
| | - Yun Feng
- Obstetrics and Gynaecology, First People's Hospital of Yunnan, Kunming, Yunnan, China
| | - Ruixia Guo
- Obstetrics and Gynaecology, Zhengzhou University First Affiliated Hospital, Zhengzhou, Henan, China
| | - Chunlian Zhang
- Obstetrics and Gynaecology, Taihe Hospital, Shiyan, Hubei, China
| | - Qingfen Yue
- Obstetrics and Gynaecology, Luoyang Central Hospital Affiliated to Zhengzhou University, Luoyang, Henan, China
| | - Wuliang Wang
- Obstetrics and Gynaecology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Shixuan Wang
- Obstetrics and Gynaecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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Hysteroscopy as a Primary Tool in Exploration and Treatment of Infertility: Single Center Experience in Western Romania. Diagnostics (Basel) 2021; 11:diagnostics11101917. [PMID: 34679615 PMCID: PMC8535164 DOI: 10.3390/diagnostics11101917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/01/2021] [Accepted: 10/13/2021] [Indexed: 11/23/2022] Open
Abstract
(1) Background: Infertility is a disease that affects millions of individuals worldwide. Intrauterine lesions are common in infertile women, hysteroscopy being considered the gold standard for assessing them, even if in routine clinical practice indirect imaging techniques are the first-line investigative tools. The aim of the study was to evaluate hysteroscopic findings among women with unexplained infertility and to analyze fertility outcomes after operative hysteroscopy; (2) Methods: a retrospective cohort study was conducted among 198 women with infertility that had undergone hysteroscopy as the first step of their infertility workup. (3) Results: The median age of the participants was 34 years, 67.7% of them being diagnosed with primary infertility. The most common abnormalities were endometrial polyps, uterine synechiae and uterine fibroids. In addition, pregnancy rates were 23.1% after hysteroscopic polypectomy, 11.1% after hysteroscopic myomectomy and 23.8% after uterine synechiae resection; (4) Conclusions: Endometrial polyps were the most common uterine abnormality found in women with infertility. Hysteroscopic interventions appeared to increase pregnancy rates and outcomes among these women.
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Intramural myomas more than 3-4 centimeters should be surgically removed before in vitro fertilization. Fertil Steril 2021; 116:945-958. [PMID: 34579828 DOI: 10.1016/j.fertnstert.2021.08.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 08/06/2021] [Indexed: 12/29/2022]
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Dolmans MM, Cacciottola L, Donnez J. Conservative Management of Uterine Fibroid-Related Heavy Menstrual Bleeding and Infertility: Time for a Deeper Mechanistic Understanding and an Individualized Approach. J Clin Med 2021; 10:4389. [PMID: 34640407 PMCID: PMC8509802 DOI: 10.3390/jcm10194389] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/22/2021] [Accepted: 09/23/2021] [Indexed: 12/17/2022] Open
Abstract
(1) Background: Uterine fibroids are the most common form of benign uterine tumors, causing heavy menstrual bleeding (HMB), pelvic pain, infertility and pressure symptoms. Almost a third of women with uterine fibroids seek treatment. The objective of this review is to understand the mechanisms linking fibroids to these symptoms and evaluate different options for their management, particularly the place of gonadotropin-releasing hormone (GnRH) antagonist. (2) Methods: We gathered the most recent and relevant papers on the main fibroid-related symptoms and medical and surgical therapy for their treatment. Those reporting use of oral GnRH antagonists were investigated in detail. (3) Results: The mechanisms explaining myoma-related HMB and infertility were reviewed, as they are essential to a deeper mechanistic understanding and oriented approach. The choice of treatment depends on the number, size, and location of fibroids, and is guided by the patient's age and desire to preserve her fertility. Economic impacts of myomas in terms of direct costs, lost workdays, and complications were found to be significant. Medical, surgical, and non-surgical strategies were analyzed in this context. Novel medical approaches with GnRH antagonist were explored and found to represent an effective new option. (4) Conclusion: The need for alternatives to surgical intervention is very real, especially for women seeking to preserve their fertility. New options now exist, with GnRH antagonists proven to treat fibroid symptoms effectively, opening the door to novel strategies for the management of myomas.
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Affiliation(s)
- Marie-Madeleine Dolmans
- Gynecology Department, Cliniques Universitaires St-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium;
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Avenue Mounier 52, 1200 Brussels, Belgium;
| | - Luciana Cacciottola
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Avenue Mounier 52, 1200 Brussels, Belgium;
| | - Jacques Donnez
- Université Catholique de Louvain, 1200 Brussels, Belgium
- Société de Recherche pour l’Infertilité (SRI), 143 Avenue Grandchamp, 1150 Brussels, Belgium
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Uterine Fibroids and Infertility. Diagnostics (Basel) 2021; 11:diagnostics11081455. [PMID: 34441389 PMCID: PMC8391505 DOI: 10.3390/diagnostics11081455] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 07/29/2021] [Accepted: 08/10/2021] [Indexed: 02/01/2023] Open
Abstract
Infertility is a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse. Uterine fibroids are the most common tumor in women, and their prevalence is high in patients with infertility. Fibroids may be the sole cause of infertility in 2–3% of women. Depending on their location in the uterus, fibroids have been implicated in recurrent pregnancy loss as well as infertility. Pregnancy and live birth rates appear to be low in women with submucosal fibroids; their resection has been shown to improve pregnancy rates. In contrast, subserosal fibroids do not affect fertility outcomes and their removal does not confer any benefit. Intramural fibroids appear to reduce fertility, but recommendations concerning their treatment remain unclear. Myomectomy should be discussed individually with the patient; other potential symptoms such as dysmenorrhea or bleeding disorders should be included in the indication for surgery.
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DE Angelis MC, DI Spiezio Sardo A, Carugno J, Manzi A, Sorrentino F, Nappi L. Fertility outcomes after hysteroscopic removal of intrauterine leiomyomas and polyps. Minerva Obstet Gynecol 2021; 74:3-11. [PMID: 33876900 DOI: 10.23736/s2724-606x.21.04739-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Thanks to the progress of science, it is now understood that a successful implantation not only depends on the quality of the embryo, but also on having a receptive endometrium. During the years, several authors have reviewed the important role of the uterine factor, ranging from the congenital anomalies, such as uterine septa and subsepta, and acquired conditions such as endometrial polyps and submucous myomas. Currently, hysteroscopy has proved to be a powerful and accurate tool for visualizing the uterine cavity and treating intrauterine pathologies. EVIDENCE ACQUISITION This review of the literature aims to report the current available data on the effects of the two most common endouterine pathologies (i.e. endometrial polyps and submucous myomas) and the impact of hysteroscopic removal on fertility outcomes. EVIDENCE SYNTHESIS To date, the low number of randomized controlled trials available does not yet make it possible to give a definitive answer on what are the reproductive outcomes following treatment of endometrial polyps and leiomyomas. Nevertheless, existing evidence points to a benefit of removal of this two pathologies in infertile women, mostly when they have a history of recurrent pregnancy loss. CONCLUSIONS Further studies are needed to demonstrate that surgical treatments of endometrial polyps and myomas could improve not only the morphology but also the function of the uterine cavity before undergoing any assisted fertility treatment.
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Affiliation(s)
| | | | - Jose Carugno
- Obstetrics, Gynecology and Reproductive Sciences Department, University of Miami, Miami, FL, USA
| | - Alfonso Manzi
- Department of Neurologic, Reproductive, and Odontostomatologic Sciences, Federico II University, Naples, Italy
| | - Felice Sorrentino
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
| | - Luigi Nappi
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
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Plöger TA, Koep S, Militzer HC, Göller AH. Combined experimental and quantum mechanical elucidation of the synthetically accessible stereoisomers of Hydroxyestradienone (HED), the starting material for vilaprisan synthesis. J Comput Aided Mol Des 2020; 35:505-516. [PMID: 33094408 DOI: 10.1007/s10822-020-00353-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/10/2020] [Indexed: 10/23/2022]
Abstract
Selective progesterone receptor modulators are promising therapeutic options for the treatment of uterine fibroids. Vilaprisan, a new chemical entity that was discovered at Bayer is currently in clinical development. In this study we provide a combined experimental and quantum chemical approach providing the data that allowed to present hydroxyestradienone as an acceptable starting material for drug substance synthesis. Hydroxyestradienone has four stereogenic centers leading to 8 diastereomers and 16 enantiomers of which only six diastereomers were synthetically accessible but two not. A computational multistep protocol resulting in density functional P2PLYP-D3(BJ)/dev2-TZVPP Gibbs free energies and SMD solvation free energies led to a clear separation between the existing and the synthetically not accessible enantiomers, whereas multiple geometry-based and cheminformatic descriptors were not able to explain experimental findings.
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Affiliation(s)
- Tobias A Plöger
- Product Supply, Pharmaceuticals, Bayer AG, 59192, Bergkamen, Germany
| | - Stefan Koep
- Product Supply, Pharmaceuticals, Bayer AG, 42096, Wuppertal, Germany
| | | | - Andreas H Göller
- Computational Molecular Design, Digital Technologies, Pharmaceuticals, Bayer AG, 42096, Wuppertal, Germany.
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Ierardi AM, Carnevale A, Pellegrino F, Stefano GD, Bonelli C, Renzulli M, Giganti M, Carrafiello G. Uterine Myomas: Extravascular Treatment. Semin Ultrasound CT MR 2020; 42:56-74. [PMID: 33541590 DOI: 10.1053/j.sult.2020.08.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Uterine fibroids are common benign tumors that affect the female reproductive tract. They are responsible for considerable morbidity and deterioration of life quality. The main advantages offered by mini invasive techniques are low grade of invasiveness and short times of hospitalization. The most diffuse technique is uterine artery embolization (UAE). Common concerns with UAE include postprocedural pain, postembolization syndrome, and risk of infection. Image-guided thermal ablation techniques like radiofrequency ablation, percutaneous microwave ablation, and imaging-guided high-intensity focused ultrasound were introduced to overcome the side effects related to UAE and surgery. The aim of this review is to briefly analyze the ablative procedures and their role in the management of symptomatic fibroids, and to describe the safety profile and outcomes of these modalities.
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Affiliation(s)
- Anna Maria Ierardi
- Radiology Unit, Foundation IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Aldo Carnevale
- Department of Morphology, Surgery and Experimental Medicine, Section of Radiology, University of Ferrara, Ferrara, Italy
| | - Fabio Pellegrino
- Department of Morphology, Surgery and Experimental Medicine, Section of Radiology, University of Ferrara, Ferrara, Italy
| | - Giuseppina Di Stefano
- Department of Morphology, Surgery and Experimental Medicine, Section of Radiology, University of Ferrara, Ferrara, Italy
| | - Cristian Bonelli
- Healthcare Professional Department, Foundation IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Matteo Renzulli
- Radiology Unit, Department of Experimental, Diagnostic and Speciality Medicine, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Melchiore Giganti
- Department of Morphology, Surgery and Experimental Medicine, Section of Radiology, University of Ferrara, Ferrara, Italy
| | - Gianpaolo Carrafiello
- Radiology Unit, Foundation IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
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Impact of intramural non-cavity-distorting leiomyoma on placental histopathology and perinatal outcome in singleton live births resulting from in vitro fertilization treatment. J Assist Reprod Genet 2020; 37:1963-1974. [PMID: 32572673 DOI: 10.1007/s10815-020-01867-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/17/2020] [Indexed: 10/24/2022] Open
Abstract
PURPOSE To evaluate the effect of non-cavity-distorting intramural leiomyomas on the placental histopathology pattern and perinatal outcome in singleton live births resulting from in vitro fertilization treatment. METHODS The study population included all singleton live births following in vitro fertilization treatment with autologous oocytes during the period from 2009 to 2017. Primary outcomes included anatomical, inflammation, vascular malperfusion, and villous maturation placental features. Secondary outcomes included fetal, maternal, delivery, and perinatal complications. RESULTS A total of 1119 live births were included in the final analysis and were allocated to the group of pregnancies with non-cavity-distorting intramural myomas (n = 101) and without myomas (n = 1018). After the adjustment for confounding factors, the non-cavity-distorting intramural myomas were found to be significantly associated with assisted placental delivery (OR 2.4; 95% CI 1.5-3.9), furcate cord insertion (OR 3.6; 95% CI 1.4-9.3), circumvallate membranes insertion (OR 5.2; 95% CI 1.4-19.3), chronic deciduitis (OR 8.2; 95% CI 1.6-42.2), focal intramural fibrin deposition (OR 25.1; 95% CI 2.1-306.2), subchorionic thrombi (OR 3.6; 95% CI 1.7-7.6), maternal vasculopathy (OR 2.5; 95% CI 1.2-5.5), and chorangioma (OR 5.9; 95% CI 1.4-25.2) as well as with the failure of labor progress (OR 2.4; 95% CI 1.3-4.4) and induction (OR 3.2; 95% CI 1.2-9.0). CONCLUSION Intramural non-cavity-distorting myomas have a significant impact on the placental histopathology with a higher incidence of dysfunctional labor.
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Donnez J, Dolmans MM. Hormone therapy for intramural myoma-related infertility from ulipristal acetate to GnRH antagonist: a review. Reprod Biomed Online 2020; 41:431-442. [PMID: 32703756 DOI: 10.1016/j.rbmo.2020.05.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 05/15/2020] [Accepted: 05/29/2020] [Indexed: 12/30/2022]
Abstract
Uterine fibroids may cause infertility, depending on their size and location according to the International Federation of Gynecology and Obstetrics classification. In this review, infertility relating to intramural myomas is evaluated. The mechanisms linking uterine fibroids and infertility are numerous: uterine cavity distortion (fibroids types 0, 1, 2, 2-5); impaired endometrial and myometrial blood supply; increased uterine contractility; hormonal, paracrine and molecular changes; impaired endometrial receptivity in gene expression (decrease in homeobox 10 [HOXA-10] expression); and thicker capsule. The negative effect of intramural myoma is related to myoma size and proximity of the uterine cavity. Therefore, a medical approach could be proposed to reduce the size of the myoma and push it back deep into the myometrium. The relevant medical treatments, including selective progesterone receptor modulator and gonadotrophin releasing hormone antagonist are reviewed. Even if the mystery surrounding intramural myomas remains, the development of new algorithms for intramural myoma-related infertility, and evaluation of the place of medical treatment as a primary approach are urgently needed. An algorithm, taking into account the mechanisms linking uterine fibroids and infertility, is proposed.
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Affiliation(s)
- Jacques Donnez
- Catholic University of Louvain and Société de Recherche pour l'Infertilité (SRI) 143 Avenue Grandchamp, Brussels B-1150, Belgium.
| | - Marie-Madeleine Dolmans
- Gynecology Department, Cliniques Universitaires St-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium: Pôle de Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Avenue Mounier 52, bte B1.52.02, Brussels 1200, Belgium
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Etiology and management of recurrent implantation failure: A focus on intra-uterine PBMC-therapy for RIF. J Reprod Immunol 2020; 139:103121. [DOI: 10.1016/j.jri.2020.103121] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 03/12/2020] [Accepted: 03/13/2020] [Indexed: 01/11/2023]
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Morgante G, Centini G, Troìa L, Orvieto R, De Leo V. Ulipristal acetate before in vitro fertilization: efficacy in infertile women with submucous fibroids. Reprod Biol Endocrinol 2020; 18:50. [PMID: 32430027 PMCID: PMC7236938 DOI: 10.1186/s12958-020-00611-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 05/12/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The presence of submucous fibroids strongly impacts on IVF results, therefore, these patients should be considered for surgical or medical treatment. The aim of this study was to assess the role of Ulipristal acetate (UPA), a selective progesterone receptor modulator, in restoring uterine cavity deformation due to submucous fibroids, in infertile patients attempting an IVF treatment. The secondary study outcome was to evaluate the impact of preconception UPA treatment on rate of biochemical pregnancy, ongoing pregnancy, and live birth compared to a control group without fibroids. METHODS Infertile patients with submucosal fibroid (Type 1 and Type 2 according to FIGO classification) were enrolled in the study as fibroids group and received 1 to 3 treatment cycles of UPA, according to their response, as reflected by fibroid volume reduction and restoration of normal uterine cavity. Patients in control group were randomly selected from a general IVF cohort by a ratio of 2:1 with fibroids group, matched by age, BMI, type and cause of infertility and antral follicle count. The impact of UPA on fibroids volume reduction was evaluated. IVF outcome was compared between groups. RESULTS Twenty-six patients underwent UPA treatment revealed a mean volume reduction of their fibroids of 41%. A total of 15 (57.6%) biochemical pregnancy were obtained, resulting in 13 (50%) ongoing pregnancy and 9 (34.6%) healthy babies were already delivered. Similar results were obtained in control group. CONCLUSION Restoration of normal uterine cavity by UPA treatment prior to IVF treatment avoids surgery and establishes a pregnancy rate comparable to a control group without fibroids.
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Affiliation(s)
- Giuseppe Morgante
- Obstetrics and Gynecology Unit, Department of Molecular and Developmental Medicine, University of Siena, Policlinico "Le Scotte" Viale Bracci, 53100, Siena, Italy.
| | - Gabriele Centini
- Obstetrics and Gynecology Unit, Department of Molecular and Developmental Medicine, University of Siena, Policlinico "Le Scotte" Viale Bracci, 53100, Siena, Italy
| | - Libera Troìa
- Obstetrics and Gynecology Unit, Department of Molecular and Developmental Medicine, University of Siena, Policlinico "Le Scotte" Viale Bracci, 53100, Siena, Italy
| | - Raoul Orvieto
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel-Hashomer, 52621, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, 39040, Tel Aviv, Israel
- The Tarnesby-Tarnowski Chair for Family Planning and Fertility Regulation, Sackler Faculty of Medicine, Tel-Aviv University, 39040, Tel Aviv, Israel
| | - Vincenzo De Leo
- Obstetrics and Gynecology Unit, Department of Molecular and Developmental Medicine, University of Siena, Policlinico "Le Scotte" Viale Bracci, 53100, Siena, Italy
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Rikhraj K, Tan J, Taskin O, Albert AY, Yong P, Bedaiwy MA. The Impact of Noncavity-Distorting Intramural Fibroids on Live Birth Rate in In Vitro Fertilization Cycles: A Systematic Review and Meta-Analysis. J Womens Health (Larchmt) 2020; 29:210-219. [DOI: 10.1089/jwh.2019.7813] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Kiran Rikhraj
- Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver General Hospital, Vancouver BC, Canada
| | - Justin Tan
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of British Columbia, BC Women's Hospital, Vancouver, BC, Canada
| | - Omur Taskin
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of British Columbia, BC Women's Hospital, Vancouver, BC, Canada
| | - Arianne Y. Albert
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of British Columbia, BC Women's Hospital, Vancouver, BC, Canada
| | - Paul Yong
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of British Columbia, BC Women's Hospital, Vancouver, BC, Canada
| | - Mohamed A. Bedaiwy
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of British Columbia, BC Women's Hospital, Vancouver, BC, Canada
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Pier B, Crellin C, Katre A, Conner MG, Novak L, Young SL, Arend R. Large, Non-Cavity Distorting Intramural Leiomyomas Decrease Leukemia Inhibitory Factor in the Secretory Phase Endometrium. Reprod Sci 2020; 27:569-574. [PMID: 32046421 PMCID: PMC7539805 DOI: 10.1007/s43032-019-00056-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 06/07/2019] [Indexed: 12/11/2022]
Abstract
Despite mounting evidence that large intramural leiomyomas decrease fecundity during in vitro fertilization cycles, few studies have demonstrated a mechanism for this impact. We hypothesize that large intramural leiomyomas (IM) decrease the expression of endometrial implantation factors during the window of implantation. We prospectively recruited sub-fertile patients with IM 3 cm or greater in size planning myomectomy and performed endometrial biopsies the day of planned myomectomy (n = 9). Preoperative screening demonstrated no intercavitary lesions. Control endometrial samples were obtained from young, normally menstruating women free of uterine leiomyomas (n = 8). Endometrial samples were obtained in the mid-secretory phase (average cycle day for control patients and intramural leiomyoma patients were 24.5 and 21.3, respectively). Expression of implantation markers HOXA10, leukemia inhibitory factor (LIF), ER-α, and PR was compared using quantitative immunohistochemistry. Standard descriptive statistics were used to compare H-scores between the cohorts. Patients with intramural leiomyomas were found to have decreased LIF compared to controls (p value < 0.001). Expressions of HOXA10 and PR were no different between cohorts; however, ER-α showed a trend toward increased expression in the fibroid cohort (p value 0.07). LIF is downregulated in the endometrium of patients with large IM. This study is among the first to show decreased LIF expression in patients with uterine leiomyomas. We hypothesize that this difference from previously published work is due to sampling the endometrium at the height of LIF expression. Further work is needed to show if LIF downregulation is corrected with leiomyoma resection.
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Affiliation(s)
- Bruce Pier
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Tripler Army Medical Center, Jarrett White Road, Honolulu, Hawaii 96859 USA
| | - Christopher Crellin
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Tripler Army Medical Center, Jarrett White Road, Honolulu, Hawaii 96859 USA
| | - Ashwini Katre
- Department of Cell, Developmental and Integrative Biology, University of Alabama at Birmingham, Birmingham, USA
| | - Michael G. Conner
- Department of Pathology, University of Alabama at Birmingham, Birmingham, USA
| | - Lea Novak
- Department of Pathology, University of Alabama at Birmingham, Birmingham, USA
| | - Steven L Young
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, University of North Carolina at Chapel Hill, North Carolina, USA
| | - Rebecca Arend
- Department of Cell, Developmental and Integrative Biology, University of Alabama at Birmingham, Birmingham, USA
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Chiofalo B, Palmara V, Vilos GA, Pacheco LA, Lasmar RB, Shawki O, Giacobbe V, Alibrandi A, Di Guardo F, Vitale SG. Reproductive outcomes of infertile women undergoing "see and treat" office hysteroscopy: a retrospective observational study. MINIM INVASIV THER 2019; 30:147-153. [PMID: 31855088 DOI: 10.1080/13645706.2019.1705352] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION This study aimed to assess the feasibility and efficacy of office hysteroscopy to diagnose and treat the specific uterine pathologies frequently diagnosed and thought to be associated with female infertility. MATERIAL AND METHODS Using office hysteroscopy, we examined the uterine cavity in women with primary or secondary infertility and evaluated the reproductive outcomes of those affected by one or more pathologies, including cervico-isthmic adhesions, intrauterine polyps and intrauterine adhesions. Additional patient characteristics considered were age and parity, uterine pathology, pain during hysteroscopy, and outcomes including spontaneous pregnancies achieved and time between treatment and pregnancy. RESULTS Reproductive outcomes of 200 patients affected by one or more uterine pathologies were evaluated. Cervico-isthmic adhesions were the most frequent findings in older women, with nearly 80% of them achieving pregnancy sooner than the others in our study. Spontaneous pregnancy rates following office hysteroscopy were 76%, 53% and 22% in women with cervico-isthmic adhesions, polyps (< 5 mm) and intrauterine adhesions, respectively. CONCLUSIONS Office hysteroscopy is a feasible and highly effective diagnostic and therapeutic procedure for cervico-isthmic and intrauterine adhesions, as well as for small polyps, allowing the resolution of female infertility related to these pathologies, without trauma and with only minimal discomfort.
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Affiliation(s)
- Benito Chiofalo
- Unit of Gynecology and Obstetrics, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Vittorio Palmara
- Unit of Gynecology and Obstetrics, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - George Angelos Vilos
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Western University, London, Canada
| | | | | | - Osama Shawki
- Department of Obstetrics and Gyneacology, School of Medicine, Cairo University, Cairo, Egypt
| | - Valentina Giacobbe
- Unit of Gynecology and Obstetrics, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Angela Alibrandi
- Department of Economics, Unit of Statistical and Mathematical Sciences, University of Messina, Messina, Italy
| | - Federica Di Guardo
- Obstetrics and Gynecology Unit, Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Salvatore Giovanni Vitale
- Obstetrics and Gynecology Unit, Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
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Karlsen K, Mogensen O, Humaidana P, Kesmodel US, Ravn P. Uterine fibroids increase time to pregnancy: a cohort study. EUR J CONTRACEP REPR 2019; 25:37-42. [PMID: 31821047 DOI: 10.1080/13625187.2019.1699047] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objectives: The primary purpose of the study was to investigate a possible association between uterine fibroids and time to pregnancy (TTP), and, secondly, to explore the effect of myomectomy on TTP.Methods: This historical cohort study used data from the Danish National Birth Cohort and the Danish National Patient Registry. The study population consisted of 86,323 women with 92,696 pregnancies. The main outcome was TTP; groups were compared using a binary outcome: TTP >12 months or TTP ≤12 months.Results: Women who had a fibroid diagnosis code before attempting to conceive (n = 92) had an increased risk of TTP >12 months compared with women without a fibroid diagnosis code (n = 87,358) (adjusted odds ratio [OR] 1.67; 95% confidence interval [CI] 1.05, 6.68). Women who had a fibroid diagnosis code after pregnancy (n = 963) also had an increased risk of TTP >12 months compared with women without a fibroid diagnosis code (adjusted OR 1.24; 95% CI 1.04, 1.47).Conclusion: We found an association between having a uterine fibroid diagnosis code and TTP >12 months. We were not able to make a valid assessment of the effect of myomectomy on TTP.
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Affiliation(s)
- Kamilla Karlsen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Gynaecology and Obstetrics, Odense University Hospital, Odense, Denmark
| | - Ole Mogensen
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Research, Aarhus University, Aarhus, Denmark
| | - Peter Humaidana
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,The Fertility Clinic, Skive Regional Hospital, Skive, Denmark.,Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Ulrik S Kesmodel
- Department of Obstetrics and Gynaecology, Aalborg University Hospital, Aalborg, Denmark.,Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Pernille Ravn
- Department of Gynaecology and Obstetrics, Odense University Hospital, Odense, Denmark
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Lebovitz O, Orvieto R, James KE, Styer AK, Brown DN. Predictors of reproductive outcomes following myomectomy for intramural fibroids. Reprod Biomed Online 2019; 39:484-491. [DOI: 10.1016/j.rbmo.2019.04.130] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 04/24/2019] [Accepted: 04/30/2019] [Indexed: 10/26/2022]
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Łoziński T, Filipowska J, Gurynowicz G, Zgliczyńska M, Kluz T, Jędra R, Skowyra A, Ciebiera M. The effect of high-intensity focused ultrasound guided by magnetic resonance therapy on obstetrical outcomes in patients with uterine fibroids – experiences from the main Polish center and a review of current data. Int J Hyperthermia 2019; 36:582-590. [DOI: 10.1080/02656736.2019.1616117] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Tomasz Łoziński
- Department of Obstetrics and Gynecology, Pro-Familia Hospital, Rzeszów, Poland
| | - Justyna Filipowska
- Department of Obstetrics and Gynecology, Pro-Familia Hospital, Rzeszów, Poland
- Faculty of Medicine, Institute of Nursing and Health Sciences, University of Rzeszów, Rzeszów, Poland
| | - Grzegorz Gurynowicz
- Division of Perinatology and Women’s Diseases, Poznań University of Medical Sciences, Poznań, Poland
| | - Magdalena Zgliczyńska
- Students’ Scientific Association at the First Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Tomasz Kluz
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Rzeszów, Poland
| | - Robert Jędra
- Second Department of Obstetrics and Gynecology, The Center of Postgraduate Medical Education, Warsaw, Poland
| | - Artur Skowyra
- Second Department of Obstetrics and Gynecology, The Center of Postgraduate Medical Education, Warsaw, Poland
| | - Michał Ciebiera
- Second Department of Obstetrics and Gynecology, The Center of Postgraduate Medical Education, Warsaw, Poland
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Dolmans MM, Donnez J, Fellah L. Uterine fibroid management: Today and tomorrow. J Obstet Gynaecol Res 2019; 45:1222-1229. [PMID: 31141843 DOI: 10.1111/jog.14002] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 04/28/2019] [Indexed: 12/11/2022]
Abstract
Current treatments for fibroids are mainly surgical and expensive, so alternatives need to be found. It is, therefore, vital to develop and evaluate alternatives to surgical procedures, especially when fertility preservation is the goal. Selective progesterone receptor modulators (SPRMs) are synthetic compounds that have either an agonistic or antagonistic impact on target tissues determined by their binding to progesterone receptors. Their mixed activity depends on recruitment of cofactors that regulate transcription along so-called genomic pathways, as well as nongenomic interactions with other signaling pathways. There is no doubt that surgery remains indicated in some instances, but we must now establish whether use of SPRMs (notably ulipristal acetate) allows less invasive surgery or even complete avoidance of surgery. Long-term intermittent administration of ulipristal acetate will undoubtedly change our approach to the management of uterine fibroids according to the International Federation of Gynecology and Obstetrics classification, which provides a comprehensive basis for different treatment options. When considering less invasive techniques (uterus-sparing options like myomectomy), the choice is guided by the size, number and location of fibroids, as well as the personal experience of the gynecologist and available equipment. There is now a growing body of evidence pointing to the crucial role of progesterone pathways in the pathophysiology of uterine fibroids. SPRMs should, therefore, be considered an alternative to surgical therapy, or at least an adjunct to surgery, as illustrated in the algorithms. © 2019 Japan Society of Obstetrics and Gynecology.
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Affiliation(s)
- Marie-Madeleine Dolmans
- Gynecology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium.,Pôle de Gynécologie, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium
| | - Jacques Donnez
- Université Catholique de Louvain, Société de Recherche pour l'Infertilité (SRI), Brussels, Belgium
| | - Latifa Fellah
- Radiology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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Pathologic Changes in Uterine Leiomyomas After Extended Treatment With Ulipristal Acetate. Int J Gynecol Pathol 2019; 39:146-151. [PMID: 30702466 DOI: 10.1097/pgp.0000000000000581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Ulipristal acetate is a selective progesterone receptor modulator that acts on progesterone receptors in uterine muscle and endometrium. It is effective in reducing the size of uterine leiomyomas (fibroids) and in managing associated menorrhagia. Although ulipristal acetate-associated pathologic changes have been previously documented in the endometrium, it is unclear what morphology can be expected in posttreatment fibroids. We herein report 2 cases in which patients underwent hysterectomy, after at least two 3-mo courses of ulipristal acetate. The fibroids demonstrated some pathologic changes that have previously been described associated with gonadotropin-releasing hormone agonist treatment and other progestogens. In addition, both cases demonstrated plexiform/"patchwork" fibrosis and vascular medial myxoid degeneration. Mitotic activity was absent; however, the presence of ischemic necrosis and mild nuclear atypia may mimic a more aggressive neoplasm in some areas. Awareness of these histopathologic patterns is important in the setting of ulipristal acetate treatment, to avoid over-diagnosis of "uncertain malignant potential" or malignant smooth muscle tumors.
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Abstract
Uterine fibroids are the most common tumors affecting premenopausal women, responsible for bleeding, pain, and reduced quality of life. When symptomatic, their management mainly involves surgery, which is all too often radical (hysterectomy). While surgical options sparing the uterus (hysteroscopic and laparoscopic myomectomy) and other non-surgical approaches do indeed exist, drug-based therapies are associated with lower costs and morbidity rates. Since progesterone is required for fibroid growth, gonadotropin agonists have been used to control bleeding and decrease fibroid volume, but they only represent a temporary remedy due to adverse events. Ulipristal acetate (UPA), a selective progesterone receptor modulator, is indicated for fibroid management. It is safe, provides fast control of bleeding, and causes sustained fibroid volume reduction in the vast majority of cases (80%). Indeed, UPA-treated fibroids shrink by a combination of inhibition of cell proliferation, stimulation of cell death, and fibrosis resorption. In the case of symptom recurrence, repeated intermittent 3-month courses of daily UPA considerably maximize the impact of treatment, sometimes resulting in complete disappearance of treated fibroids. Despite the therapeutic dose of UPA being very well tolerated, patients with liver anomalies or disorders should be excluded at screening according to European Medicines Agency-Pharmacovigilance Risk Assessment Committee (PRAC) recommendations. We therefore propose new algorithms for fibroid management in premenopausal women with symptomatic fibroids, depending on their localization, the patient's wishes, and clinical response, while monitoring liver enzymes and bilirubin, as recommended by the PRAC, in order to minimize the risks of possible liver toxicity.
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Affiliation(s)
- J Donnez
- a Société de Recherches pour l'Infertilité , Professor Emeritus, Université Catholique de Louvain , Brussels , Belgium
| | - G E Courtoy
- b Pôle de Gynécologie, Institut de Recherche Expérimentale et Clinique , Université Catholique de Louvain , Brussels , Belgium
| | - M-M Dolmans
- b Pôle de Gynécologie, Institut de Recherche Expérimentale et Clinique , Université Catholique de Louvain , Brussels , Belgium.,c Gynecology Department , Cliniques Universitaires St-Luc , Brussels , Belgium
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Yang JH, Chen MJ, Yang PK. Factors increasing the detection rate of intrauterine lesions on hysteroscopy in infertile women with sonographically normal uterine cavities. J Formos Med Assoc 2019; 118:488-493. [DOI: 10.1016/j.jfma.2018.08.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 08/09/2018] [Accepted: 08/17/2018] [Indexed: 11/28/2022] Open
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41
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Bosteels J, van Wessel S, Weyers S, Broekmans FJ, D'Hooghe TM, Bongers MY, Mol BWJ. Hysteroscopy for treating subfertility associated with suspected major uterine cavity abnormalities. Cochrane Database Syst Rev 2018; 12:CD009461. [PMID: 30521679 PMCID: PMC6517267 DOI: 10.1002/14651858.cd009461.pub4] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Observational studies suggest higher pregnancy rates after the hysteroscopic removal of endometrial polyps, submucous fibroids, uterine septum or intrauterine adhesions, which are present in 10% to 15% of women seeking treatment for subfertility. OBJECTIVES To assess the effects of the hysteroscopic removal of endometrial polyps, submucous fibroids, uterine septum or intrauterine adhesions suspected on ultrasound, hysterosalpingography, diagnostic hysteroscopy or any combination of these methods in women with otherwise unexplained subfertility or prior to intrauterine insemination (IUI), in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI). SEARCH METHODS We searched the following databases from their inception to 16 April 2018; The Cochrane Gynaecology and Fertility Group Specialised Register, the Cochrane Central Register of Studies Online, ; MEDLINE, Embase , CINAHL , and other electronic sources of trials including trial registers, sources of unpublished literature, and reference lists. We handsearched the American Society for Reproductive Medicine (ASRM) conference abstracts and proceedings (from 1 January 2014 to 12 May 2018) and we contacted experts in the field. SELECTION CRITERIA Randomised comparison between operative hysteroscopy versus control for unexplained subfertility associated with suspected major uterine cavity abnormalities.Randomised comparison between operative hysteroscopy versus control for suspected major uterine cavity abnormalities prior to medically assisted reproduction.Primary outcomes were live birth and hysteroscopy complications. Secondary outcomes were pregnancy and miscarriage. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion and risk of bias, and extracted data. We contacted study authors for additional information. MAIN RESULTS Two studies met the inclusion criteria.1. Randomised comparison between operative hysteroscopy versus control for unexplained subfertility associated with suspected major uterine cavity abnormalities.In women with otherwise unexplained subfertility and submucous fibroids, we were uncertain whether hysteroscopic myomectomy improved the clinical pregnancy rate compared to expectant management (odds ratio (OR) 2.44, 95% confidence interval (CI) 0.97 to 6.17; P = 0.06, 94 women; very low-quality evidence). We are uncertain whether hysteroscopic myomectomy improves the miscarriage rate compared to expectant management (OR 1.54, 95% CI 0.47 to 5.00; P = 0.47, 94 women; very low-quality evidence). We found no data on live birth or hysteroscopy complication rates. We found no studies in women with endometrial polyps, intrauterine adhesions or uterine septum for this randomised comparison.2. Randomised comparison between operative hysteroscopy versus control for suspected major uterine cavity abnormalities prior to medically assisted reproduction.The hysteroscopic removal of polyps prior to IUI may have improved the clinical pregnancy rate compared to diagnostic hysteroscopy only: if 28% of women achieved a clinical pregnancy without polyp removal, the evidence suggested that 63% of women (95% CI 45% to 89%) achieved a clinical pregnancy after the hysteroscopic removal of the endometrial polyps (OR 4.41, 95% CI 2.45 to 7.96; P < 0.00001, 204 women; low-quality evidence). We found no data on live birth, hysteroscopy complication or miscarriage rates in women with endometrial polyps prior to IUI. We found no studies in women with submucous fibroids, intrauterine adhesions or uterine septum prior to IUI or in women with all types of suspected uterine cavity abnormalities prior to IVF/ICSI. AUTHORS' CONCLUSIONS Uncertainty remains concerning an important benefit with the hysteroscopic removal of submucous fibroids for improving the clinical pregnancy rates in women with otherwise unexplained subfertility. The available low-quality evidence suggests that the hysteroscopic removal of endometrial polyps suspected on ultrasound in women prior to IUI may improve the clinical pregnancy rate compared to simple diagnostic hysteroscopy. More research is needed to measure the effectiveness of the hysteroscopic treatment of suspected major uterine cavity abnormalities in women with unexplained subfertility or prior to IUI, IVF or ICSI.
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Affiliation(s)
- Jan Bosteels
- Cochrane BelgiumAcademic Centre for General PracticeKapucijnenvoer 33blok J bus 7001LeuvenBelgium3000
| | - Steffi van Wessel
- Ghent University HospitalWomen’s ClinicCorneel Heymanslaan 10GhentBelgium9000
| | - Steven Weyers
- University Hospital GhentObstetrics and GynaecologyDe Pintelaan 185GhentBelgium
| | - Frank J Broekmans
- University Medical CenterDepartment of Reproductive Medicine and GynecologyHeidelberglaan 100UtrechtNetherlands3584 CX
| | - Thomas M D'Hooghe
- University Hospital GasthuisbergLeuven University Fertility CentreHerestraat 49LeuvenBelgium3000
| | - M Y Bongers
- Máxima Medisch CentrumDepartment of Obstetrics and GynaecologyVeldhovenNetherlands
| | - Ben Willem J Mol
- Monash UniversityDepartment of Obstetrics and Gynaecology246 Clayton RoadClaytonVictoriaAustralia3168
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Do Women over 35 Years Old Who Have Undergone a Myomectomy Require More Acupuncture Sessions to Become Pregnant? JOURNAL OF ACUPUNCTURE RESEARCH 2018. [DOI: 10.13045/jar.2018.00213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Kara M, Sabah Ozcan S, Aran T, Kara O, Yilmaz N. Decreased expression of LIF mRNA in patients withmyoma uteri. J Cell Biochem 2018; 120:3423-3427. [PMID: 30242886 DOI: 10.1002/jcb.27613] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 08/09/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate endometrial receptivity by measuring HOXA-10, HOXA-11, and LIF gene expressions in women with polycystic ovary syndrome. METHODS A total of 48 women were included in this clinical study. Thepatients were allocated to two groups: study group consisted of 28 patients with myoma uteri and control group consisted of 20 patients without myoma uteri. Endometrial sampling was performed during the proliferative phase. The biopsies obtained from the patients with myoma uteri were taken from the place where the fibroids were localized. HOXA-10, HOXA-11, and LIF expressions were measured in the endometrial sampling material. Demographic data of the patients such as age, obstetric and gynecologic history, medical conditions, medications, surgical history, last menstrual period were recorded. Also, the number, size, localization, and type of the myoma were registered. RESULTS The mean age of the patients was 42.07 and 38.17, respectively. HOXA-11 levels in the study and control groups were 0.004 ± 0.001 and 0.010 ± 0.001, respectively ( P < 0.90). Paradoxically, HOXA-10 levels were found to be higher in the study group than the control group, but the difference was not statistically significant ( P < 0.25). LIF levels were significantly lower in the study group ( P < 0.05). CONCLUSION Our results showed that myoma uteri might lead to a decrease in implantation rate by diminishing LIF gene expressions. However, there were no differences between the two groups in terms of HOXA-10 and HOXA-11 levels.
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Affiliation(s)
- Mustafa Kara
- Department of Gynecology and Obstetrics, Bozok University School of Medicine, Yozgat, Turkey
| | - Seda Sabah Ozcan
- Department of Medical Biology, Bozok University School of Medicine, Yozgat, Turkey
| | - Turhan Aran
- Department of Gynecology and Obstetrics, Karadeniz Technical University School of Medicine, Trabzon, Turkey
| | - Ozlem Kara
- Department of Histology and Embryology, Erciyes University, Institute of Health Sciences, Kayseri, Turkey
| | - Neziha Yilmaz
- Department of Infection Disease and Medical Microbiology, Bozok University School of Medicine, Yozgat, Turkey
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Ali M, Al-Hendy A. Selective progesterone receptor modulators for fertility preservation in women with symptomatic uterine fibroids. Biol Reprod 2018; 97:337-352. [PMID: 29025038 PMCID: PMC5803778 DOI: 10.1093/biolre/iox094] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 08/23/2017] [Indexed: 12/15/2022] Open
Abstract
Uterine fibroids (UFs, AKA leiomyoma) are the most important benign neoplastic threat to women's health, with costs up to hundreds of billions of health care dollars worldwide. Uterine fibroids caused morbidities exert a tremendous health toll, impacting the quality of life of women of all ethnicities, especially women of color. Clinical presentations include heavy vaginal bleeding, pelvic pain, bulk symptoms, subfertility, and obstetric complications. Current management strategies heavily lean toward surgical procedures; nonetheless, the choice of treatment is generally subject to patient's age and her desire to preserve future fertility. Women with UF who desire to maintain future fertility potential face a dilemma because of the limited treatment choices that are currently available to help them achieve that goal. Recently, ulipristal acetate the first of the promising family of oral selective progesterone receptor modulators has been approved for UF treatment in Europe, Canada, and several other countries and is under review for possible approval in the USA. In this review article, we discuss recent advances in the management options against UF with a bend toward oral effective long-term treatment alternatives who are particularly suited for those seeking to preserve their future fertility potential. We also explore the transformative concept of primary and secondary UF prevention using these new anti-UF agents. We envision a remarkable shift in the management of UF in future years from surgical/invasive treatment to orally administrated options; clearly, this potential shift will require additional intense clinical research.
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Affiliation(s)
- Mohamed Ali
- Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta University, Augusta, Georgia, USA.,Clinical Pharmacy department, Faculty of pharmacy, Ain Shams University, Cairo, Egypt
| | - Ayman Al-Hendy
- Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
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Melis GB, Neri M, Piras B, Paoletti AM, Ajossa S, Pilloni M, Marotto MF, Corda V, Saba A, Giancane E, Mais V. Vilaprisan for treating uterine fibroids. Expert Opin Investig Drugs 2018; 27:497-505. [DOI: 10.1080/13543784.2018.1471134] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Gian Benedetto Melis
- Dipartimento di Scienze Chirurgiche, Clinica Ostetrica e Ginecologica, Azienda Ospedaliero Universitaria di Cagliari, Policlinico Universitario Duilio Casula, University of Cagliari, Italy
| | - Manuela Neri
- Dipartimento di Scienze Chirurgiche, Clinica Ostetrica e Ginecologica, Azienda Ospedaliero Universitaria di Cagliari, Policlinico Universitario Duilio Casula, University of Cagliari, Italy
| | - Bruno Piras
- Dipartimento Materno Infantile, clinica ostetrica e ginecologica, policlinico universitario Duilio Casula, Azienda Ospedaliero Universitaria di Cagliari, Cagliari, Italy
| | - Anna Maria Paoletti
- Dipartimento di Scienze Chirurgiche, Clinica Ostetrica e Ginecologica, Azienda Ospedaliero Universitaria di Cagliari, Policlinico Universitario Duilio Casula, University of Cagliari, Italy
| | - Silvia Ajossa
- Dipartimento Materno Infantile, clinica ostetrica e ginecologica, policlinico universitario Duilio Casula, Azienda Ospedaliero Universitaria di Cagliari, Cagliari, Italy
| | - Monica Pilloni
- Dipartimento Materno Infantile, clinica ostetrica e ginecologica, policlinico universitario Duilio Casula, Azienda Ospedaliero Universitaria di Cagliari, Cagliari, Italy
| | - Maria Francesca Marotto
- Dipartimento Materno Infantile, clinica ostetrica e ginecologica, policlinico universitario Duilio Casula, Azienda Ospedaliero Universitaria di Cagliari, Cagliari, Italy
| | - Valentina Corda
- Dipartimento di Scienze Chirurgiche, Clinica Ostetrica e Ginecologica, Azienda Ospedaliero Universitaria di Cagliari, Policlinico Universitario Duilio Casula, University of Cagliari, Italy
| | - Alessandra Saba
- Dipartimento di Scienze Chirurgiche, Clinica Ostetrica e Ginecologica, Azienda Ospedaliero Universitaria di Cagliari, Policlinico Universitario Duilio Casula, University of Cagliari, Italy
| | - Elena Giancane
- Dipartimento di Scienze Chirurgiche, Clinica Ostetrica e Ginecologica, Azienda Ospedaliero Universitaria di Cagliari, Policlinico Universitario Duilio Casula, University of Cagliari, Italy
| | - Valerio Mais
- Dipartimento di Scienze Chirurgiche, Clinica Ostetrica e Ginecologica, Azienda Ospedaliero Universitaria di Cagliari, Policlinico Universitario Duilio Casula, University of Cagliari, Italy
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Tian YC, Wu JH, Wang HM, Dai YM. Improved Fertility Following Enucleation of Intramural Myomas in Infertile Women. Chin Med J (Engl) 2018; 130:1648-1653. [PMID: 28685713 PMCID: PMC5520550 DOI: 10.4103/0366-6999.209900] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: The relationship between intramural myomas and fertility remains unclear. The main debate rests on whether cavity-distorting intramural myomas (CDMs) adversely affect fertility more than non-CDMs. We aimed to compare the effects of enucleating non-CDMs and CDMs on fertility improvement in females with unexplained infertility. Methods: We prospectively recruited 83 women undergoing myomectomy for unexplained infertility with intramural myomas between June 2008 and November 2012 and classified them into non-CDMs group (n = 45) and CDMs group (n = 38). We then compared postoperative infertility rates, spontaneous pregnancy rates, pregnancy outcomes, live birth rates, and obstetric complications. For continuous variables, we calculated the mean ± standard deviation, median and interquartile range, and analyzed the data using Student's t-test and the Mann-Whitney U-test. For categorical variables, the Pearson's Chi-square test, the continuity correction test, and Fisher's exact test were used. Results: Patients’ demographics and myoma characteristics were comparable between the two groups. The overall spontaneous pregnancy rate increased from 0% to 68.42% following myomectomy. The postoperative infertility rate was significantly higher in the non-CDMs group than that in the CDMs group (50.00% vs. 23.53%, t = 5.579, P = 0.018), whereas the postoperative spontaneous pregnancy rate was significantly lower in the non-CDMs group than that in the CDMs group (47.62% vs. 70.59%, t = 4.067, P = 0.044). Compared with the enucleation of non-CDM, the enucleation of CDM patients was a protective factor for the fertility restoration (risk ratio [RR] = 3.717, 95% confidence interval [CI]: 1.284–10.753, P = 0.015), although postoperative fertility restoration declined with age (RR = 1.141, 95% CI: 1.005–1.295, P = 0.041). Conclusions: Intramural myomas are associated with impaired fertility. Women experiencing unexplained infertility, and possessing intramural myomas, have a better chance of conception following myomectomy, and these benefits are more obvious for younger patients and patients with CDM.
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Affiliation(s)
- Yu-Cui Tian
- Department of Perinatal Medicine, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing 100026, China
| | - Jian-Hong Wu
- Department of Gynecology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing 100026, China
| | - Hong-Mei Wang
- Department of Perinatal Medicine, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing 100026, China
| | - Yin-Mei Dai
- Department of Minimal Invasive Gynecology Center, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing 100026, China
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Morbidity, fertility and pregnancy outcomes after myoma enucleation by laparoscopy versus laparotomy. Arch Gynecol Obstet 2018; 297:969-976. [PMID: 29417281 DOI: 10.1007/s00404-018-4697-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 01/30/2018] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Myomas are defined as benign tumours that arise from smooth muscle cells of the uterus. Clinically, they are found in 5-77% of women of reproductive age. The prevalence rate varies considerably in the literature and a large number of fibroids do not cause symptoms. The lifetime risk of acquiring myomas is 70% for Caucasian women and ≥ 80% for African American women. MATERIALS/METHODS The data of 265 patients undergoing surgery for symptomatic myomas by laparoscopy or laparotomy, performed in the gynaecological department of Hannover Medical School, Hannover, Germany, between 2009 and 2013, were retrospectively analysed in this retrospective design study. RESULTS High pregnancy rates (up to 70%) and birth rates (up to 86%) after myomectomy, regardless of the surgical approach adopted, were found in the current study. The trend was that ≥ 3 myomas and those that were ≥ 6 cm in size were almost always removed by laparotomy in our clinic. It was possible to remove up to 42 myomas without having to perform a hysterectomy. A statistically significant negative correlation was observed in relation to the association between the size of the largest myoma extracted and the pregnancy rate (p = 0.02). A statistically significant correlation between the number of removed myomas and the pregnancy rate was observed for patients who wished to bear children (p = 0.010). Elevated complication rates (of up to 50%) were reported for more than three extracted myomas with a statistically significance (p = 0.0471). CONCLUSIONS It is necessary to ensure sound preoperative selection of the surgical approach in order to achieve the most optimal results, especially for those patients who wished to bear children.
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Lee SR, Kim YJ, Kim KG. A Fast 3-Dimensional Magnetic Resonance Imaging Reconstruction for Surgical Planning of Uterine Myomectomy. J Korean Med Sci 2018; 33:e12. [PMID: 29215821 PMCID: PMC5729653 DOI: 10.3346/jkms.2018.33.e12] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 10/14/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Uterine myoma is the most common benign gynecologic tumor in reproductive-aged women. During myomectomy for women who want to preserve fertility, it is advisable to detect and remove all myomas to decrease the risk of additional surgery. However, finding myomas during surgery is often challenging, especially for deep-seated myomas. Therefore, three-dimensional (3D) preoperative localization of myomas can be helpful for the surgical planning for myomectomy. However, the previously reported manual 3D segmenting method takes too much time and effort for clinical use. The objective of this study was to propose a new method of rapid 3D visualization of uterine myoma using a uterine template. METHODS Magnetic resonance images were listed according to the slide spacing on each plane of the multiplanar reconstruction, and images that were determined to be myomas were selected by simply scrolling the mouse down. By using the selected images, a 3D grid with a slide spacing interval was constructed and filled on its plane and finally registered to a uterine template. RESULTS The location of multiple myomas in the uterus was visualized in 3D and this proposed method is over 95% faster than the existing manual-segmentation method. Not only the size and location of the myomas, but also the shortest distance between the uterine surface and the myomas, can be calculated. This technique also enables the surgeon to know the number of total, removed, and remaining myomas on the 3D image. CONCLUSION This proposed 3D reconstruction method with a uterine template enables faster 3D visualization of myomas.
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Affiliation(s)
- Sa Ra Lee
- Department of Obstetrics and Gynecology, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Young Jae Kim
- Department of Biomedical Engineering, Gachon University, Incheon, Korea
| | - Kwang Gi Kim
- Department of Biomedical Engineering, Gachon University, Incheon, Korea.
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Percutaneous High Frequency Microwave Ablation of Uterine Fibroids: Systematic Review. BIOMED RESEARCH INTERNATIONAL 2018; 2018:2360107. [PMID: 29511672 PMCID: PMC5817312 DOI: 10.1155/2018/2360107] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 11/29/2017] [Indexed: 01/20/2023]
Abstract
Uterine fibroids are the most common benign pelvic tumor of the female genital tract and tend to increase with age; they cause menorrhagia, dysmenorrhea, pelvic pressure symptoms, back pain, and subfertility. Currently, the management is based mainly on medical or surgical approaches. The nonsurgical and minimally invasive therapies are emerging approaches that to the state of the art include uterine artery embolization (UAE), image-guided thermal ablation techniques like magnetic resonance-guided focused ultrasound surgery (MRgFUS) or radiofrequency ablation (RF), and percutaneous microwave ablation (PMWA). The purpose of the present review is to describe feasibility results and safety of PMWA according to largest studies available in current literature. Moreover technical aspects of the procedure were analyzed providing important data on large scale about potential efficacy of PMWA in clinical setting. However larger studies with international registries and randomized, prospective trials are still needed to better demonstrate the expanding benefits of PMWA in the management of uterine fibroids.
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The current place of medical therapy in uterine fibroid management. Best Pract Res Clin Obstet Gynaecol 2018; 46:57-65. [DOI: 10.1016/j.bpobgyn.2017.10.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 10/10/2017] [Accepted: 10/10/2017] [Indexed: 12/26/2022]
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