ENDOGRADE: A four level classification to rate surgical complexity in endometriosis

OBJECTIVES

We studied a post operative classification of surgical complexity in endometriosis.

STUDY DESIGN

Retrospective monocentric observational study was conducted between January 2001 to December 2019 and included 764 women with DE that underwent surgery. We retrospectively graded surgical complexity through operative reports according to the ENDOGRADE classification, that grades the surgical complexity of DE in four progressive levels.

RESULTS

Operating time was longer for patients rated ENDOGRADE 3 (228±93 min) compared to patients rated ENDOGRADE 2 (120± 51 min) (p<10-3) and for patients rated ENDOGRADE 4 (301±99 min) compared to patients rated ENDOGRADE 3 (228±93 min), (p<10-3). Eighty percent (20/25) of peroperative complications were rated ENDOGRADE 3 or 4, 20% (5/25) were rated ENDOGRADE 1 or 2 (p = 0.01). Patients rated ENDOGRADE 2, 3 and 4 were 10.3 times (95CI=2.4-44.9, p = 2.10-3), 12.2 times (95CI=2.9-50.2, p = 5.10-4) and 38.3 times (95CI=9.1-162, p = 7.10-7) more likely to experience postoperative complications than those rated ENDOGRADE 1. According to multivariate analysis, only patients rated ENDOGRADE 2, 3, and 4 had a significantly higher risk of postoperative complications with an OR=16.0 (95CI=2.0-127.4, p = 9.10-3), OR=16.2 (95CI=1.6-159.7, p = 0.02) and OR=104.2 (95CI=24.6-440.5, p = 4.10-3), respectively.

CONCLUSION

ENDOGRADE classification of surgical complexity in DE is correlated to operating time, per- and post-operative complications.

[Préservation de la fertilité avant traitement d'un cancer de l'ovaire]

FERTILITY PRESERVATION BEFORE OVARIAN MALIGNANCY TREATMENT While most ovarian epithelial malignancies affect postmenopausal women, 12% occur in reproductive age patients. In addition, borderline ovarian tumors and rare non epithelial ovarian tumors are diagnosed in young patients as well. The prognosis of early-stage epithelial tumors, non-epithelial and frontier tumors is good. Increased knowledge in this specific field now allows the development of fertility preservation strategies. They include conservative surgery when applicable, associated with oocyte and / or ovarian tissue cryopreservation. Indications remain limited, and any decision must be validated by a multidisciplinary expert committee. The different strategies depend on specific tumoral or genetic context.

Unexplained recurrent miscarriages: predictive value of immune biomarkers and immunomodulatory therapies for live birth

INTRODUCTION

Recurrent miscarriages are defined as three or more early miscarriages before 12 weeks of gestation. The aim of this study was to describe a cohort of women with unexplained recurrent miscarriages, evaluate several potential biomarkers of immune origin, and describe the outcome of pregnancies under immunomodulatory therapies.

METHODS

Women having a history of at least 3 early miscarriages without any etiology were recruited from 3 university hospitals.

RESULTS

Among 101 women with recurrent miscarriages, overall, 652 pregnancies have been included in the analysis. Women which experienced miscarriages were older (33.3 ± 5.4 versus 31.9 ± 6.7; p = 0.03), with history of more pregnancies (4 (2-6) versus 3.5 (1-5.75); p 0.0008), and less frequently the same partner (406 (74%) versus 79 (86%); p=0.01). There was no difference in the level and frequencies of biomarkers of immune origin (NK, lymphocyte, gamma globulins and blood cytokine levels and endometrial uNK activation status), except the higher rates of positive antinuclear antibodies in women with live birth (12 (13%) versus 36 (7%); p=0.03). Among the 652 pregnancies, 215 (33%) have been treated and received either aspirin/low weighted molecular heparin (LMWH) and/or combined to different lines of immunomodulatory treatment. Patients with pregnancy under treatment had a significantly higher rate of cumulative live birth rate than those with untreated ones (43.0% vs 34.8%; p = 0.04). When compared to patients with untreated pregnancies, patients with steroids during the pregnancy had twice more chances to obtain live birth (OR 2.0, CI95% 1.1 - 3.7, p = 0.02).

CONCLUSIONS

Unexplained recurrent miscarriages could have improved obstetrical outcome under immunomodulatory therapies and in particular steroids.

Intralipid therapy for unexplained recurrent miscarriage and implantation failure: Case-series and literature review

INTRODUCTION

In retrospective cohort study of women with unexplained recurrent implantation failure (RIF) and miscarriage (RM), we analyzed the efficacy and safety of intralipid therapy to obtain a live birth.

PATIENTS AND METHODS

Women with unexplained RM and/or RIF were included from 2015 to 2018 from three French university hospitals.

RESULTS

Among 187 women treated for unexplained recurrent miscarriages and implantation failures, 26 women with median age of 36 years (29-43) received intralipid therapy. Among these 26 women, 10 women with a median age of 33 years (31-40) had a history of spontaneous recurrent miscarriages, with a median of 5 (4-8) previous miscarriages. Live births occurred in 7 (70 %) pregnancies under intralipids and were significantly more frequent than in women with recurrent miscarriages who did not receive intralipid therapy (n = 20, p = 0.02). Age, number of previous miscarriages, and additional therapies did not significantly differ between the two groups. Among the 26 included women, 16 had a history of recurrent implantation failures, with median age of 37 years (29-43) and median 9.5 (3-19) embryo transfers. Clinical pregnancy occurred in 9 (56 %) women receiving intralipids after embryo transfers under intralipids among which 5 (55 %) resulted in a live birth. Comparing successful pregnancies under intralipids with those with fetal loss, no significant differences have been noted.

CONCLUSION

Intralipids could be an effective and safe therapy in women with unexplained recurrent miscarriages and infertility.

A nomogram for predicting lymph node metastasis of presumed stage I and II endometrial cancer

OBJECTIVE

Our objective was to develop a nomogram based on pathological hysterectomy characteristics to provide a more individualized and accurate estimation of lymph node metastasis in endometrial cancer.

STUDY DESIGN

Data from the Surveillance, Epidemiology, and End Results database for 18,294 patients who underwent hysterectomy and lymphadenectomy were analyzed. A multivariate logistic regression analysis of selected prognostic features was performed, and a nomogram to predict lymph node metastasis was constructed. A cohort of 434 patients was used for the external validation.

RESULTS

The nomogram showed good discrimination with an area under the receiver operating characteristic curve of 0.80 (95% confidence interval, 0.79-0.81) in the training set and 0.79 (95% confidence interval, 0.78-0.80) in the validation set. The nomogram was well calibrated.

CONCLUSION

We developed a nomogram based on 5 clinical and pathological characteristics to predict lymph node metastasis with a high concordance probability.

The neuroendocrine regulation of the human ovarian cycle

The menstrual cycle is now thought to be mainly determined by the ovary itself, which sends various signals to the pituitary and the hypothalamus. The hypothalamus is an autonomous pacemaker, with a pulse frequency that is modulated by ovarian signals; in turn, it is indispensable to ovarian function. In women, the ovarian cycle produces a single mature oocyte each month from puberty to menopause. This follicle is rescued from atresia, the genetically controlled ovarian apoptosis (or "programmed cell death"), involving 99.9% of the follicles. Follicular growth and maturation are mostly independent of gonadotropins from the stage of primordial to antral follicles. A complete intraovarian paracrine system is implied in this gonadotropin-independent follicular growth and in the modulation of the action of gonadotropins in the ovary. Follicle-stimulating hormone (FSH) allows the rescue of a minority of follicles from atresia and is indispensable only for the final maturation of the preovulatory follicle during the follicular phase of the cycle. Luteinizing hormone (LH) is responsible for the final growth of the dominant follicle in the late follicular phase. the induction of ovulation during the LH peak, and the survival of the corpus luteum during the luteal phase. The cyclical variations of gonadotropins are under the control of ovarian steroids (estradiol and progesterone) and peptides (inhibins). The cycle length is determined by the duration of terminal follicular growth and by the fixed life span of the corpus luteum. The ovarian cycle can be monitored as well at the level of target tissues of steroids, such as the endometrium. In fact, the endometrial maturation is synchronized to follicular development, and this synchronization is indispensable for successful implantation of the embryo. The improving knowledge of follicular and endometrial physiology will allow the development of new treatments of infertility, the design of new contraceptive techniques, and a better tolerance of treatments using sex steroids.