Self-sampling versus physician-sampling for human papillomavirus testing

We evaluated the detection of human papillomavirus (HPV) infection using two sampling methods of cervical exfoliated cells, consisting of self-sampling of vaginal cells and cervical sampling performed by the physician. Women included were 379 patients of the general population attending outpatient clinics in Northern Greece for routine cytological cervical dysplasia screening. HPV DNA detection was similar with both sampling techniques. The HPV prevalences in self-collected samples were 4.7% and 3.7% in the physician-collected samples ( P>0.05). The Kappa statistic for HPV DNA agreement between the two methods was 0.54 (95% Confidence interval = 0.33–0.75). Self-sampling of cervico-vaginal exfoliated cells could be used as an alternative option to test for HPV infection.

Steroid receptor expression in human endometrium during the follicular phase of stimulated cycles

BACKGROUND

No data are currently available regarding kinetics of human endometrial steroid receptors in stimulated cycles.

METHODS

In 31 patients (age <39 years) stimulated with gonadotrophins and GnRH antagonists for intrauterine insemination (IUI) an endometrial biopsy was performed on the first day after the end of menstruation and a second biopsy was performed two (Group 0 + 2, n = 10) or four (Group 0 + 4, n = 11) days after the first biopsy, or on the day of hCG administration (Group 0 + hCG, n = 10). Expression of progesterone (PR) and estrogen (ER) receptor was investigated by immunohistochemistry using monoclonal antibodies.

RESULTS

PR and ER levels were significantly increased in the second versus the first biopsy, in all groups analyzed (P = 0.01), in both stromal and glandular cells. Between the three groups compared, a significant increase in PR expression was observed for glandular cells (P = 0.03), with the highest value observed in Group 0 + 4. Moreover, the increase in PR expression in stromal cells differed between groups (P = 0.01), with the highest value observed in the Group 0 + hCG.

CONCLUSIONS

In stimulated cycles for IUI, ER expression in both glandular and stromal endometrial cells, after an initial increase, does not appear to change significantly during the follicular phase. On the contrary, during the same period of time, following an initial rise, PR expression in glandular and stromal cells continues to increase.

KIT protein expression in uterine sarcomas: an immunohistochemical study and review of the literature

PURPOSE

The aim of the present study was to investigate the possibility of treating uterine sarcomas with imatinib mesylate. Imatinib mesylate, a selective tyrosine kinase inhibitor, is very efficient against mesenchymal tumors of the gastrointestinal tract, known as GISTs. Imatinib mesylate acts against a tyrosine kinase encoded by the KIT gene in GISTs, and is more effective in tumors expressing this protein.

METHODS

Expression of KIT was analyzed immunohistochemically (n = 12) in formalin-fixed paraffin-embedded primary uterine sarcomas.

RESULTS

Using a semi-quantitative immunohistochemical score we found that KIT expression was very weak in the majority of tumors, while none of the uterine sarcomas tested showed strong expression. Overall, published studies addressing this issue in small series of uterine sarcomas yielded similar results.

CONCLUSION

Current data suggest that it is unlikely that imatinib mesylate could be used effectively as a single agent in patients with uterine sarcomas.

The role of hysteroscopy in the current management of the cervical polyps

The current management of patients with cervical polyps may include different approaches and protocols, such as a simply removal of the polyp in most cases at an office setting, surgical dilatation and curettage, electrosurgical excision or hysteroscopic polypectomy. Exploration of the cervical canal and uterine cavity by hysteroscopy determines the exact origin of the polyp pedicle (cervical or endometrial) and if there is any concurrent endometrial pathology. The majority of cervical polyps are asymptomatic, and their incidence is increasing with age. Symptomatic cervical polyps may cause intermenstrual bleeding, postcoital bleeding, heavy menses, postmenopausal bleeding and vaginal discharge. Cervical polyps may be detected by routine gynaecological examination, colposcopy, filling defects on hysterosalpingogram, gynaecological ultrasound (abdominal, transvaginal or sonohysterography) or endometrial biopsy. The location, number, and size of cervical polyps are best determined with diagnostic hysteroscopy. In the past, simple twisting or avulsion of the polyp or blind curettage was the standard surgical treatment of choice. However, this treatment often leaves residual polyp fragments in the cervical canal. Difficulty may also occur in differentiating endocervical from endometrial lesions. In addition, up to 25% of patients who have cervical polyp, have also a coexisting endometrial polyp, so there is a need for evaluation of the endometrial cavity. It is important to note the usefulness of hysteroscopy to manage a patient with a cervical polyp, especially when she presents abnormal uterine bleeding, in order to make an accurate diagnosis and offer appropriate treatment.

Among patients treated with FSH and GnRH analogues for in vitro fertilization, is the addition of recombinant LH associated with the probability of live birth? A systematic review and meta-analysis

The aim of this systematic review and meta-analysis was to assess whether the addition of recombinant luteinizing hormone (LH) increases live birth rate, among patients treated with follicle stimulating hormone (FSH) and gonadotrophin-releasing hormone (GnRH) analogues for in vitro fertilization (IVF). Eligible studies were randomized controlled trials (RCTs) answering the research question that contained sufficient information to allow ascertainment of whether randomization was true and whether equality was present between the groups compared, regarding baseline demographic characteristics, gonadotrophin stimulation protocol, number of embryos transferred and luteal phase support administered. A literature search identified seven RCTs (701 patients) that provided the information of interest, among which five reported agonist and two antagonist cycles. The reported outcome measure, clinical pregnancy, was converted to live birth using published data in one study. No significant difference in the probability of live birth was present with or without rLH addition to FSH (odds ratio [OR]: 0.92, 95% confidence interval (CI): 0.65-1.31; P = 0.65). This finding remained stable in subgroup analyses that ordered the studies by dose of rLH added, the type of analogue used to inhibit premature LH surge, the time rLH was added during the follicular phase, the age of patients analysed, the presence of allocation concealment and by the way the information on live birth was retrieved. In conclusion, the available evidence does not support the hypothesis that the addition of recombinant LH increases the live birth rate in patients treated with FSH and GnRH analogues for IVF.

Is progesterone elevation on the day of human chorionic gonadotrophin administration associated with the probability of pregnancy in in vitro fertilization? A systematic review and meta-analysis

The role of progesterone elevation on in vitro fertilization (IVF) outcome has remained a debatable issue for several years. The aim of this systematic review and meta-analysis was to evaluate whether progesterone elevation on the day of human chorionic gonadotrophin (hCG) administration is associated with the probability of pregnancy. Eligible studies were considered those in which patients did not participate more than once. A literature search in MEDLINE, EMBASE and CENTRAL identified 12 eligible studies, 10 of which were retrospective. The majority (n = 10) of these studies did not detect a statistically significant association between progesterone elevation and the probability of pregnancy. Meta-analysis was performed only for the studies (n = 5) that provided data on clinical pregnancy per patient reaching hCG administration for final oocyte maturation. No statistically significant association between progesterone elevation and the probability of clinical pregnancy was detected (Odds ratio: 0.75, 95% confidence interval 0.53-1.06; P = 0.10). This finding persisted in the sensitivity analyses performed, which excluded the studies that did not report clearly that measurement of progesterone did not affect patients' management and those that did not report definition of clinical pregnancy. In addition, subgroup analyses were conducted on the basis of type of gonadotrophin-releasing hormone GnRH analogue used and on the value of serum threshold used to classify patients in those with or without progesterone elevation. These analyses, however, did not materially change the results obtained. In conclusion, the best available evidence does not support an association between progesterone elevation on the day of hCG administration and the probability of clinical pregnancy in women undergoing ovarian stimulation with GnRH analogues and gonadotrophins for IVF.

Prenatal Management and Postnatal Separation of Omphalopagus and Craniopagus Conjoined Twins

Two cases of prenatally diagnosed conjoined twins are presented: a set of omphalopagus twins sharing a common liver, and a set of craniopagus with involvement limited to the skull. In both cases, prenatal diagnosis allowed accurate planning of pre- and postnatal management. Prenatal management involved serial imaging and counseling with participation of different specialists according to imaging findings. In the rare case of conjoined twins, an interdisciplinary approach is required, with feto-maternal specialists playing a pivotal role in co-ordinating teamwork and planning successive stages of management.

Results after hysteroscopic management of premenopausal patients with dysfunctional uterine bleeding or intrauterine lesions

AIM

The purpose of this study was to evaluate the efficacy, safety and benefits of hysteroscopic surgery in the management of dysfunctional uterine bleeding or intrauterine lesions causing menstrual disorders in premenopausal women.

METHODS

We enrolled in this study 228 patients who underwent operative hysteroscopy because of metrorrhagia due to endometrial polyps or submucous myomas diagnosed by hysterosalpingography, transvaginal ultrasound and diagnostic hysteroscopy. In addition, the study population included 27 patients who presented dysfunctional uterine bleeding resistant to medical therapy. These patients underwent total or partial transcervical resection of endometrium (TCRE).

RESULTS

Operative hysteroscopy was a successful procedure in 250 of the 255 cases (98%) but it needed to be repeated in three cases with large submucous myomas of type I and II and after two polypectomies. Mean duration of the procedure was 26.1 min (range 4-58) and mean postoperative hospital stay was six hours (range 2-48 hours). There were two cases with fluid overload and five with postoperative uterine bleeding reported in this study. During postoperative follow-up (12-36 months) the majority of patients (246/255 or 96.5%) were free of symptoms. After total or partial TCRE, 23/27 patients (85.2%) reported eumenorrhea or hypomenorrhea, 2/27 (7.4%) amenorrhea and 2/27 (7.4%) metrorrhagia (due to adenomyosis).

CONCLUSION

Hysteroscopic surgery is an effective and safe method for the management of benign intracavitary pathology or the treatment of dysfunctional uterine bleeding. In addition, it has the advantages of quick recovery, early return to normal activities and reduced hospital stay for the patient. Careful monitoring of the patients avoids serious complications.

Fetal abdominal subcutaneous tissue thickness measured by ultrasound at term is associated with birth weight and mode of delivery

PURPOSE

To determine if measurement of fetal abdominal subcutaneous tissue thickness (FASTT) at term can predict birth weight, mode of delivery and perinatal outcome.

METHODS

A prospective study with 352 normal, singleton pregnancies in the vertex presentation examined with real-time ultrasound at 37-39 weeks' gestation.

RESULTS

FASTT was positively correlated with birth weight (Pearson's, r = 0.784, p < 0.001). Fetuses with low FASTT were more likely to be delivered through normal vaginal delivery (7.8 +/- 0.1 mm), while higher FASTT was correlated with operative vaginal delivery (7.9 +/- 0.2 mm) and cesarean section (8.6 +/- 0.3 mm) (ANOVA, p = 0.034). In contrast, FASTT was not correlated with intrapartum CTG, labor duration and Apgar scores.

CONCLUSIONS

In normal pregnancies, FASTT at term is positively associated with birth weight. With increasing FASTT the likelihood of operative vaginal and cesarean delivery increases. FASTT is not associated with perinatal outcome.

Nuchal cord detected by ultrasound at term is associated with mode of delivery and perinatal outcome

OBJECTIVES

To evaluate the clinical relevance of nuchal cord in normal, vertex, singleton pregnancies at term, and its effect on mode of delivery and perinatal outcome.

STUDY DESIGN

Prospective study with 352 normal, singleton pregnancies, with fetuses in the vertex presentation, examined with real-time ultrasound at 37-39 weeks. Health care workers at labour and delivery blinded to previous detection of nuchal cord.

RESULTS

Fetuses of nulliparous women with a nuchal cord were more likely to be delivered with operative vaginal or caesarean delivery (n = 153, p < 0.0001). This was not the case with higher parity (n = 199, p = 0.07). There was no difference between nuchal cord (n = 144) and control groups (n = 208) in amniotic fluid quantity at 37-39 weeks (p = 0.554) or intrapartum CTG (p = 0.9). On the other hand, nuchal cord group had lower Apgar scores at 1 and 5 min (p = 0.001 and 0.027 respectively); this difference remained significant when adjusted for birth weight (p = 0.001 and 0.016), but disappeared when adjusted for mode of delivery (p = 0.048 and 0.319).

CONCLUSIONS

Nuchal cord in normal pregnancies at term is associated with increased rate of operative vaginal and caesarean delivery in nulliparae. The presence of a nuchal cord results in slightly lower Apgar scores at 1 and 5 min, mainly as a consequence of higher operative delivery rates.

Endometrial lesions causing uterine bleeding in postmenopausal women receiving raloxifene

It is generally accepted, that raloxifene administration does not have adverse effects on the uterus. We report the cases of two relatively young postmenopausal patients, who presented with vaginal bleeding, due to endometrial pathology, approximately 1 year after the initiation of raloxifene administration. The women were 43 and 44 years old, and received 60 mg/day of oral raloxifene for 11.5 and 10.5 months, respectively. In both cases, raloxifene was given for osteoporosis prevention in the absence of vasomotor symptoms. The first patient underwent Pipelle-biopsy and hysteroscopy with histopathology revealing simple endometrial hyperplasia. The second patient underwent hysteroscopy with removal of an endometrial polyp, with no histopathological signs of malignancy. Continuation of raloxifene administration was decided in both cases, and follow-up did not reveal any sign of recurrence. Uterine bleeding may rarely occur in postmenopausal women under raloxifene therapy. Patients should be encouraged to report bleeding or spotting and appropriate diagnostic and therapeutic management should follow as in any other case.

Human papillomavirus testing for primary screening in women at low risk of developing cervical cancer. The Greek experience

OBJECTIVE

To compare the performance of human papillomavirus (HPV) DNA detection against routine Papanicolaou smear for the detection of low- and high-grade cervical intraepithelial neoplasia in a low-risk population.

MATERIALS AND METHODS

A cross-sectional study was performed involving 1296 women attending six outpatient clinics in Northern Greece (Thessaloniki, Thermi, Mihaniona, Corfu, Veria, and Serres). Women underwent a gynecological examination, including collection of exfoliated cervical cells for Papanicolaou cytology and HPV DNA detection. Cytology was processed according the conventional routine manner, and HPV DNA was determined using the polymerase chain reaction technique. In positive cases of either method, a complete colposcopic evaluation was performed with directed biopsies. Tests (HPV DNA, cytology, and colposcopy) performance characteristics were determined using the histopathologic diagnosis as the reference standard.

RESULTS

HPV DNA testing showed a significantly better sensitivity than the Papanicolaou smear in detecting cervical intraepithelial neoplasia (75% versus 50% for high-grade lesions and 81.2% versus 50% for lesions of any grade, respectively). Specificity, and positive and negative predictive values did not significantly differ. Even after dividing women in younger or older than 30 years, the sensitivity of the HPV DNA test was greater than cytology (100% and 70% versus 50% for cytology in both groups, respectively), with a 6.3% loss in specificity when performed in women younger than 30 years.

CONCLUSION

HPV testing could be useful in screening women at low risk for cervical cancer, either as an adjunct tool to augment existing cytology programs or as a unique test of its own.

Mucocele of the vermiform appendix with sonographic appearance of an adnexal mass

Mucocele of the vermiform appendix is caused by mucus retention in its lumen, due to obstruction or hyperproduction. Appendiceal malignancy can be the underlying cause, making accurate preoperative diagnosis imperative. In women, it can sometimes present as an adnexal mass. A rare case of an appendiceal mucocele is presented, mimicking a cystic tumor of the right adnexum, both clinically and ultrasonographically. In addition, serum levels of CA-125 were increased. This is the first case of a mucocele of the appendix simulating an adnexal mass on ultrasound with increased levels of CA-125 to be reported. This clinical entity should be considered in patients presenting on ultrasound with a right-sided adnexal mass as a rare potential diagnosis.

Endometriotic uterocutaneous fistula after cesarean section. A case report

Endometriosis outside the pelvis is rare and most cases occur in surgical scars after operations involving the female genital tract. Fistulae involving the uterus are also very rare, usually being the result of postpartum and postoperative complications. In the present report, a case of a 44-year-old patient with an endometriotic uterocutaneous fistula is described. The patient presented 6 years after her fourth cesarean section with a painful nodule on the cesarean scar, which was bleeding during menstruation. The lesion extended to the uterine fundus, connecting the endometrial cavity with the skin. This is merely the second case of a uterocutaneous fistula to be reported in the literature and the first case developed on grounds of endometriosis.

Caudal regression syndrome and sirenomelia in only one twin in two diabetic pregnancies

Many authors consider sirenomelia to be an extreme form of caudal regression syndrome (CRS), while others argue that they are two distinct entities. Maternal diabetes mellitus is considered to be an important predisposing factor for both CRS and sirenomelia. Two rare cases of diabetic, dizygotic twin pregnancies, each with one normal and one affected fetus are presented. In case 1 the affected fetus had CRS. In case 2 the affected fetus had sirenomelia. The present cases suggest that the pathogenesis of CRS and sirenomelia is more complex than previously thought, that maternal diabetes is not the only underlying pathogenetic mechanism and that genetic or epigenetic factors probably contribute to the formation of these conditions.

Cesarean section rates and indications in Greece: data from a 24-year period in a teaching hospital

OBJECTIVE

To assess the overall cesarean section rates and indications in a Greek teaching hospital over a period of 24 years.

METHOD

Data from 34,575 deliveries between 1977 and 2000 were reviewed. Analysis of cesarean section rates and indications followed.

RESULTS

The overall cesarean section rate increased progressively from 13.8% (1977-83) to 29.9% (1994-2000). Cesarean section rates due to previous cesarean delivery increased from 7.7% of all deliveries (1977-83) to 10.9% (1994-2000). Primary cesarean section rates increased more than three-fold from 6.1% (1977-83) to 19% (1994-2000). The main indications for primary cesarean section were: dystocia (including dysfunctional labor, cephalopelvic disproportion and malpresentations), fetal distress, breech presentation, and hypertensive disorders of pregnancy.

CONCLUSIONS

The overall cesarean section rate increased more than two-fold over the study period. Previous cesarean section was the most common indication. However, the overall increase is mainly to increase of primary cesarean section rates.

Expression of estrogen receptors alpha and beta in two uterine mesenchymal tumors after prolonged tamoxifen therapy. Report of two cases

INTRODUCTION

Tamoxifen therapy is associated with an increased risk of endometrial carcinoma, and possibly uterine sarcomas. Little is known about hormone receptor expression in mesenchymal tumors of the uterus after tamoxifen therapy.

CASES

The cases of two patients with uterine mesenchymal tumors after prolonged tamoxifen therapy due to breast cancer are presented. The expression of estrogen receptors alpha (ERalpha) and beta (ERbeta) and progesterone receptors (PR) was studied immunohistochemically in both cases. Both tumors were negative for ERalpha and positive for ERbeta. In the first case the tumor was negative for PR, while in the second only 20% of nuclei were PR-positive.

CONCLUSIONS

Consistent with previous studies, uterine mesenchymal tumors after tamoxifen therapy do not express ERalpha. The results of the present report provide for the first time evidence that tamoxifen might exert a stimulatory effect on the uterus, at least during tumor progression, through ERbeta but not through ERalpha.

Primitive neuroectodermal tumor (PNET) of the uterine isthmus

Primitive neuroectodermal tumors (PNETs) of the uterus are very rare. The histogenesis of these tumors is still unknown and the differential diagnosis includes a wide variety of tumor entities. We describe a rare case of a 68-year-old female who presented with persistent vaginal bleeding. Physical examination and CT-scan revealed a large tumor in the uterus. Macroscopically the tumor involved the uterine isthmus. Histological and immunohistochemical examination showed that the tumor fulfilled the diagnostic criteria set for PNET. Only a very small number of cases of PNETs of the uterus have been reported in the literature, thus no definitive conclusions concerning the therapeutic management and prognosis have been ascertained.

Synchronous primary neoplasms of the uterine corpus and the ovary: a case report

OBJECTIVE

To determine the frequency of synchronous primary neoplasia of the ovaries in patients with primary malignant neoplasia of the uterus, and to analyze the clinical and histological characteristics of these cases.

MATERIALS AND METHODS

Clinicopathological data from a series of patients treated for primary malignant neoplasia of the uterus between 1985 and November 2003 have been studied retrospectively.

RESULTS

Synchronous primary neoplasia of the ovaries was found in 13 out of 173 patients (7.5%) treated for primary malignant neoplasia of the uterus. In four patients (2.3%) the histological findings suggested ovarian metastases from primary endometrial adenocarcinoma. In four other cases (2.3%) there was extension of the primary uterine sarcoma to the ovaries. In the remaining five cases (2.9%) primary endometrial adenocarcinoma coexisted with: a) ovarian cystadenocarcinoma in two cases, b) ovarian fibromathecoma in two cases, and c) ovarian tumor of borderline malignancy in one case.

CONCLUSIONS

Coexistence of distinct primary neoplasias in the uterus and ovaries is rare. Diagnosis of two primary malignancies in the uterus and ovaries should be based on histological examination. Treatment should be appropriate for both tumors, taking into consideration that treatment of one tumor will not lead to subtreatment of the other.

Ovarian Sertoli-Leydig cell tumor with coexisting vaginal angiomyxoma: case report and review of the literature

An extremely rare case of a postmenopausal patient with an ovarian Sertoli-Leydig cell tumour and a coexistent vaginal angiomyxoma is reported. A 71-year-old patient was admitted complaining of abdominal distension. A thorough diagnostic evaluation revealed a large tumour of the right ovary, and an oval-shaped greyish-white polypoid vaginal lesion. Total hysterectomy with bilateral salpingooophorectomy and lymph node sampling was performed, followed by excision of the vaginal lesion. Histological examination showed a Sertoli-Leydig cell tumour of the right ovary, and a vaginal angiomyxoma. Twenty-six months after the operation the patient is well with no signs of recurrence. To the best of our knowledge, no case of coexistence of an ovarian Sertoli-Leydig cell tumour with a myxoma has been previously reported.

Fetal tachycardia: is digitalis still the first-line therapy?

Medical treatment of fetal tachycardias has substantially improved neonatal outcome over the past years. Digitalis has been often used as first-line therapy in these cases, and more recently the use of several newer agents have been reported. We present four cases of fetal tachycardia with a favorable neonatal outcome after successful treatment with digitalis. Rapid transplacental digitalization appears to be an effective and reliable treatment option for fetal tachycardia, particularly in non-hydropic fetuses. In hydropic fetuses, however, digitalis alone appears to be less effective and administration of a second drug is usually needed.

Pelvic echinococcus mimicking multicystic ovary

An unusual case of pelvic echinococcus cyst is presented, appearing initially on transvaginal ultrasound as a pelvic mass mimicking a multicystic ovary. A similar mass in the liver raised preoperatively the suspicion of echinococcosis, making an open surgical procedure preferable to laparoscopy. Diagnosis was confirmed pathologically after removal of the cyst. Though their location in the pelvis is rare, echinococcal cysts should be considered in the differential diagnosis of pelvic masses, especially in patients from endemic areas. Evaluation of previous medical history and current symptoms, together with the ultrasonographic findings, is important for correct diagnosis and appropriate management.

Methylenetetrahydrofolate reductase polymorphism C677T is not associated to the risk of cervical dysplasia

The aim of the study was to explore a possible association between methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism and cervical neoplasia. A total of 229 women were subjected to cytologic and colposcopic evaluation. Ninety-one of them were found to be normal, and served as the control group, while the other 138 of them had present or past histologically proven cervical pathology (patients group). All patients and controls were investigated for the MTHFR C677T polymorphism. Statistical analysis between the groups of cases with cervical intraepithelial neoplasia or invasive cervical cancer and the control group did not reveal any statistically significant difference in the frequency of the MTHFR C677T polymorphism.

Clinical management of low ovarian response to stimulation for IVF: a systematic review

Poor response is not a rare occurrence in ovarian stimulation. Although not fully accepted, the most dominant criteria for poor ovarian response are small numbers of follicles developed or oocytes retrieved, and low estradiol (E2) levels after the use of a standard stimulation protocol. There is no ideal predictive test as the poor responder is revealed only during ovulation induction; however, increased levels of day 3 FSH and E2 as well as decreased levels of inhibin B can be used to assess ovarian reserve. Several protocols have been proposed for clinical management of low ovarian response in IVF. Although high doses of gonadotrophins have been used by the vast majority of authors, results have been controversial and prospective randomized studies have shown little or no benefit. The few available relevant studies do not indicate that recombinant FSH improves outcome. Flare-up GnRH agonist protocols (including all dosage varieties) produce better results than standard long luteal protocols. Luteal initiation GnRH agonist 'stop' protocols were shown to improve ovarian response according to prospective studies with historical controls, but this was not confirmed by well-designed prospective, randomized, controlled studies. The few available data obtained with GnRH antagonists have not shown any benefits. Adjuvant therapy with growth hormone (GH) or GH-releasing factors results in no significant improvement. The use of corticosteroids reduces the incidence of poor ovarian response in women undergoing IVF treatment. The limited data obtained with nitric oxide donors are encouraging. Pretreatment with combined oral contraceptives prior to stimulation may help ovarian response. No benefit was observed with standard use of ICSI or assisted hatching of zona pellucida. Finally, natural cycle IVF has produced results which are comparable with those obtained with stimulated cycles in true poor responders. Well-designed, large-scale, randomized, controlled trials are needed to assess the efficacy of these different management strategies.

Factor V Leiden and prothrombin G20210A mutations in pregnancies with adverse outcome

BACKGROUND

Inherited thrombophilia has been associated with obstetric complications through mechanisms that are not yet fully elucidated. The aim of this study was to investigate the relationship between specific obstetric adverse outcomes and factor V Leiden and prothrombin G20210A mutations.

METHODS

Forty-five women with adverse pregnancy outcome defined as severe pre-eclampsia, abruptio placentae, intrauterine growth restriction and stillbirth, were tested for factor V Leiden and prothrombin G20210A mutations. The control group comprised 100 women with at least one normal pregnancy and no history of thrombosis.

RESULTS

Overall, 13 women with one or more of the above-mentioned pregnancy complications (28%) had either thrombophilic mutation, as compared with six in the control group (6%) (p < 0.001, odds ratio (OR) 6.1; 95% confidence interval (CI) 1.9-20). The factor V Leiden mutation was detected in ten of the women with complicated pregnancies (22%) and in four of the controls (4%) (p < 0.001, OR 6.6; 95% CI 1.7-27.2). The prothrombin G20210A mutation was detected in three women in the group with complications (6%) and in two of the controls (2%) (p = 0.17, OR 3.4; 95% CI 0.4-30.5). Compared to controls, the prevalence of the factor V Leiden mutation was significantly higher in the subgroups of severe pre-eclampsia, abruptio placentae and fetal growth restriction. The prevalence of the prothrombin G20210A mutation does not appear to be significantly different from that in the controls in any of the groups studied.

CONCLUSIONS

Our data suggest that inherited thrombophilia, and specifically the factor V Leiden mutation, may be associated with adverse pregnancy outcome. The role of the prothrombin G20210A mutation remains to be elucidated.

Association of oestrogen receptor alpha polymorphisms and androgen receptor CAG trinucleotide repeats with male infertility: a study in 109 Greek infertile men

This study was performed to examine the contribution of genetic polymorphism of oestrogen and androgen receptor (AR) genes in male infertility. We have studied in total 173 Greek men, 109 infertile patients and 64 controls (group A). Patients were divided in to three subgroups: group B (n=29) with idiopathic moderate oligospermia, group C (n=42) with azoospermia or idiopathic severe oligospermia and group D (n=38) with azoospermia or oligospermia of various known aetiologies. All patients and controls were genotyped for two polymorphisms of the oestrogen receptor alpha (ERalpha) gene and also for the (CAG)n repeat length polymorphism of the X-linked androgen receptor (AR)gene. The control group had statistically significant difference from group C regarding the XbaI polymorphism of ERalpha gene. Despite the fact that we did not observe any statistically significant differences in the mean and range of the CAG repeat number, the frequency of the higher repeats of the nucleotide repeat sequence (CAG)n of the AR gene was 2-4 times higher in groups B and C compared with the control group A. Our results indicate that both ERalpha and AR gene play significant role in male fertility. It is possible that a synergy may exist between unfavourable genotypes of these two genes in male infertility.

Congenital obstructive azoospermia in a man with Marfan syndrome

OBJECTIVE

To present a case of Marfan syndrome and concurrent congenital obstructive azoospermia.

DESIGN

Case report.

SETTING

Tertiary-care academic hospital.

PATIENT(S)

A man with Marfan syndrome and obstructive azoospermia.

INTERVENTION(S)

The patient was evaluated for azoospermia that was proved to be due to congenital absence of large segments of vas deferens and epididymis bilaterally.

MAIN OUTCOME MEASURE(S)

Evaluation for testicular sperm extraction and ICSI procedure.

RESULT(S)

The patient is a candidate for testicular sperm extraction and ICSI.

CONCLUSION(S)

The Marfan syndrome and azoospermia may be associated in sporadic cases.

Factor V leiden and prothrombin G20210A mutations, but not methylenetetrahydrofolate reductase C677T, are associated with recurrent miscarriages

The aim of this study was to investigate the relationship between recurrent miscarriages and factor V Leiden, prothrombin G20210A and C677T methylenetetrahydrofolate reductase (MTHFR) mutations. In this case-control study the prevalence of factor V Leiden, prothrombin G20210A and C677T methylenetetrahydrofolate reductase mutations was determined in a consecutive series of 80 recurrent miscarriage patients and 100 controls. Fifteen of 80 recurrent miscarriage patients and four out of 100 controls carried the factor V Leiden mutation (19 versus 4%, P = 0.003, odds ratio 5.5, 95% confidence interval (CI): 1.7-17). Seven of 80 recurrent miscarriage patients and two of 100 controls were carriers of the prothrombin G20210A mutation (9 versus 2%, P = 0.038, odds ratio 4.6, 95% CI: 0.9-23.2). Six of 80 recurrent miscarriage women and 15 of 100 controls were homozygotes for the C677T MTHFR mutation (8 versus 15%, P = 0.134, odds ratio: 0.4, 95% CI: 0.1-1.2). Our results suggest that the presence of factor V Leiden and prothrombin G20210A polymorphism, but not MTHFR C677T homozygosity, could be additional risk factors for recurrent miscarriages. Furthermore, it was suggested that the prevalence of factor V Leiden and prothrombin G20210A mutations is more prominent in second trimester, primary fetal losses and it is independent of the existence of additional pathology predisposing to recurrent fetal losses.

Growth hormone response to oral glucose tolerance and insulin tolerance tests in patients with PCOS

Polycystic ovary syndrome (PCOS) is characterized by its heterogeneity. This is the reason for the diversity in the clinical manifestations and laboratory findings. In this study we examined the serum levels of growth hormone (GH) in 15 women with PCOS and 5 healthy volunteers following oral administration of 75 gr glucose (OGTT) and intravenous administration of insulin (ITT). The OGTT produced no significant difference between the two groups of women, in the ITT there was a difference between the GH response of the women with PCOS and that of the healthy women. The group with PCOS showed a later, more prolonged, higher response, indicating that the hypothalamus is probably involved in PCOS.

Lead concentrations in early human milk of urban and rural mothers

The aim of this study was to determine and compare lead concentrations in breast milk between urban and rural women. Colostrum from 51 women living in the city of Thessaloniki (exposed to increased air lead concentration, 0.54 micrograms/m3) and from 40 women living in rural areas (exposed to significantly lower air lead concentrations) was analyzed by atomic absorption spectrometry. Urban women showed slightly higher lead concentrations (mean +/- SD: 0.090 +/- 0.029 micrograms/ml) than rural women (mean +/- SD: 0.084 +/- 0.024 micrograms/ml). This difference was not statistically significant. These results suggest that the lead content of human milk is not influenced by the concentrations of this environmental pollutant in the air.

Cytokines in the human ovary: presence in follicular fluid and correlation with leukotriene B4

PURPOSE

This study was undertaken to correlate the follicular levels of interleukin (IL)-1 alpha, IL-2, tumor necrosis factor-alpha (TNF-alpha), and leukotriene (LT) B4 with oocyte maturity, fertilization, and achievement of pregnancy.

METHODS

The material was obtained from 22 women undergoing IVF, 8 of whom became pregnant and 14 of whom did not.

RESULTS

All of the studied cytokines and LT B4 were found in follicular fluids, but there were no significant differences according to oocyte maturity, fertilization, embryo quality, and achievement of pregnancy. On the other hand, a significant positive correlation was found between IL-1 alpha and TNF-alpha, IL-1 alpha, and LT B4 as well as between TNF-alpha and LT B4 in follicular fluids with subsequently fertilized oocytes.

CONCLUSIONS

It seems that IL-1 alpha, TNF-alpha and LT B4 may take part in the process of follicle wall degradation, and their follicular correlations may suggest more optimal follicular and oocyte development and maturation.

Treatment of endometrial hyperplasias with gonadotropin-releasing hormone agonists: pathological, clinical, morphometric, and DNA-cytometric data

On the basis of the recently reported observation that gonadotropin-releasing hormone agonists (GnRH-a) can affect endometrial cell proliferation, both indirectly, through the hormonal axis, and directly, by acting on the GnRH-a receptors, we investigated how far GnRH-a can be used as a new treatment mode for endometrial hyperplasias. Forty-two women, aged 28-60 years, with histologically confirmed simple (n = 30) or complex (n = 12, 2 with atypias) hyperplasia of the endometrium were involved in the study. According to the protocol they were treated for 6 months with GnRH-a (leuprolide acetate or triptorelin), and each patient underwent uterine curettage in the third and the sixth month of treatment, and 6 and at least 12 months after cessation of the treatment, for histological examination and morphometric and DNA-cytometric evaluation of the endometrium (mean pathological follow-up, 19.2 months; mean clinical follow-up, 30.7 months). During treatment, most of the women first revealed endometrial atrophy, and, after cessation of the treatment, again an atrophic or mainly functional endometrium; in 7 women, all with initial diagnosis of simple hyperplasia, the endometrial hyperplasia reappeared, which led in all 7 cases to hysterectomy. The mean values of almost all morphometric and DNA-cytometric parameters during and after treatment showed statistically significant changes in relation to pretreatment values, indicating a decrease in the proliferative activity of the endometrial cells; the GnRH-a antiproliferative effect was still active for a long time after cessation of the therapy. Our results, based for the first time not only on histological but also on serial nuclear morphometric and DNA-cytometric examinations of the endometrial cells and on the longest follow-up time, support the view that in cases of endometrial hyperplasia, especially of complex type, the use of GnRH agonists, which decrease the proliferative tendency of endometrial cells, could represent an alternative conservative therapeutic approach, which, however, requires close monitoring of the endometrium.

Therapeutic approach of immotile cilia syndrome by intracytoplasmic sperm injection: a case report

OBJECTIVE

To present a case of immotile cilia syndrome, a very rare cause of male infertility and to evaluate the role of the recently suggested treatment by intracytoplasmic sperm injection (ICSI).

DESIGN

Case report.

SETTING

Tertiary-care academic hospital.

PATIENT(S)

One man with immotile cilia syndrome, showing no motile spermatozoa despite normal morphology and viability.

INTERVENTION(S)

The patient's partner underwent two cycles with IVF of the oocytes achieved by ICSI.

MAIN OUTCOME MEASURE(S)

Evaluation of ICSI procedure in cases of immotile cilia syndrome.

RESULT(S)

Thirty-three percent of the oocytes were fertilized and subsequently divided enabling ET in both cycles.

CONCLUSION(S)

Intracytoplasmic sperm injection seems to represent a promising approach to the problem of infertility in men with immotile cilia syndrome.

The effect of transdermal estradiol on the conjunctiva in postmenopausal women

OBJECTIVE

To evaluate the effect of hormonal replacement therapy on the conjunctiva in postmenopausal women.

STUDY DESIGN

A prospective clinical study in the setting of a tertiary-care university hospital. Eleven postmenopausal women received hormonal replacement therapy (transdermal estradiol or transdermal estradiol plus medroxyprogesterone acetate) for 4 months. Serum estradiol levels as well as vaginal and conjunctival maturation value (a cytological parameter) were measured before and after the treatment. Data were analysed using the Wilcoxon matched pairs signed-Rank test.

RESULTS

A significant increase of serum estradiol levels (P < 0.01) and of vaginal maturation value (P < 0.01) were found. Cytological maturation changes in conjunctival epithelium were also observed. These changes, although mild, were statistically significant (P < 0.01).

CONCLUSION

These data support the view that the hormonal replacement therapy induces cytological maturation changes in conjunctival epithelium in postmenopausal women.

Intrafollicular ovarian pregnancy after ovulation induction/intrauterine insemination: pathophysiological aspects and diagnostic problems

Ovarian pregnancy is a rare variant of ectopic implantation. A case of an intrafollicular ovarian pregnancy after ovulation induction/intrauterine insemination is presented. The woman had primary infertility of 4 years. Diagnostic laparoscopy revealed endometriosis and adhesions. After adhesiolysis and laser vaporization of endometriotic implants, the patient underwent ovulation induction with artificial insemination by husband/intrauterine insemination; she conceived at her second attempt. The pregnancy proved to be an ovarian intrafollicular one. She was treated by right partial ovariectomy. Three months later she conceived spontaneously with an intrauterine pregnancy which is still ongoing. The diagnostic problems resulting from the coexistence of ovarian hyperstimulation and the intrafollicular development of pregnancy are discussed. A re-evaluation of the criteria for the diagnosis of ovarian pregnancy based on the currently available diagnostic methods is proposed. Moreover, the pathophysiology of ovarian and especially intrafollicular implantation is reviewed.

Adenomyosis at hysterectomy: prevalence and relationship to operative findings and reproductive and menstrual factors

In order to estimate the frequency and risk factors for adenomyosis, the clinical records of 594 women undergoing hysterectomy were retrieved. Data were collected on indications for the intervention, age at surgery, age at menarche, parity, abortions, mode of delivery, abnormal uterine bleeding, dysmenorrhea, and menopausal status at surgery. Adenomyosis was found in 116 of the 594 patients (19.5%). A pathologic condition was present in 63 patients with fibroids (20.5%), 11 with genital prolapse (25.6%), 11 with benign ovarian tumors (17.8%), six with endometrial hyperplasia (13.6%), two with cervical cancer (18.2%), ten with endometrial cancer (16.1%), and 13 with ovarian cancer (21.3%). No relationship was found between adenomyosis and endometriosis. On the contrary, a strong relationship was found between adenomyosis and parity, cesarean section, induced abortions, dysmenorrhea, abnormal uterine bleeding, and late age at menarche. These results show that adenomyosis is a common pathologic finding, significantly related to reproductive and menstrual characteristics of the patients.

Application of image analysis cytometry in follicular fluid cells obtained from in-vitro fertilization cycles: relationships to patient's age, oocyte maturity, fertilizability and in-vitro fertilization outcome

In an in-vitro fertilization (IVF)/embryo transfer programme granulosa cells obtained from 59 individual preovulatory follicles were analysed using multiparameter image analysis cytometry, in an attempt to determine whether their morphometric and DNA-cytometric parameters could prove useful in assessing follicle and oocyte maturity and in predicting fertilizability and outcome of these IVF cycles. Almost all morphometric and DNA-cytometric parameters were not correlated with either the patient's age or oocyte maturity, and did not predict oocyte fertilization or occurrence of a clinical pregnancy. The only possible relevant parameter which, despite its inverse correlation to total luteinizing hormone administration, also proved to be inversely correlated to pregnancy outcome (in the seven cases in which a pregnancy occurred), was the percentage of granulosa cell nuclei with increased DNA content (> 5c). Finally, if granulosa cells do not reveal euploid polyploidization in spontaneous or induced ovulatory cycles, the detected cells with increased DNA content should be interpreted as aneuploid, i.e. with chromosomal aberrations, and so their presence could also be discussed in connection with the hypothetical risk of prospective neoplastic transformation of the tissue.

Azoospermia: clinical, hormonal, and biochemical investigation

The aim of this study was to evaluate the clinical, hormonal and biochemical characteristics of infertile men with azoospermia. A total of 187 azoospermic out of 2610 infertile men (7.2%) were studied. Mean testicular volume and basal plasma levels of FSH were the most useful parameters concerning the evaluation of azoospermia. Basal plasma levels of LH and T were useful only in azoospermic men with hypogonadism, whereas plasma PRL levels, semen volume, and seminal plasma fructose levels were not found to be of common use except in selected cases.