Chronic Stress in Pregnancy Is Associated with Low Birth Weight: A Meta-Analysis

BACKGROUND AND OBJECTIVES

Chronic activation of the stress system has cumulative effects on the body, and it places individuals at risk for adverse health outcomes. Chronic stress has been assessed by health questionnaires in pregnancy. During the perinatal period, mothers experience increased physical and emotional demands. Chronic stress interferes with hormonal functions in mothers and infants. This meta-analysis studies the effect of maternal chronic stress during pregnancy, as assessed by established stress questionnaires, on the birth weight of their full-term infants.

DESIGN AND METHODS

According to our criteria and after research collection, we obtained 107 studies and we conducted two types of analyses: a logistic (N = 22,342) and linear regression analysis (N = 7431).

RESULTS

Our results show that chronic stress is associated with a statistically significant risk of low birth weight (OR = 1.50, CI 95% = [1.13; 1.99], p ≤ 0.02).

CONCLUSIONS

Increased maternal chronic stress, as assessed by questionnaires, in pregnancy is associated with a low-birth-weight baby. The above meta-analysis indicates that maternal high chronic stress questionnaire scores could be used as a clinical tool in order to assess low-birth-weight risk.

Acute iv CRH administration significantly increases serum active ghrelin in postmenopausal PCOS women compared to postmenopausal controls

PURPOSE

In women with Polycystic Ovarian Syndrome (PCOS), an increased risk of disordered eating has been described. There is growing interest regarding a possible interconnection between psychological states and increased appetite in women with PCOS. Acute stress is characterized by increased Corticotropin Releasing Hormone (CRH) secretion. The aim was to estimate the ghrelin concentrations during CRH test.

METHODS

Twenty postmenopausal women with PCOS and twenty age- and BMI- matched postmenopausal control women were recruited at Aretaieion University Hospital. In the morning (9 am) all subjects had anthropometric measurements (weight, height, waist circumference) and a fasting sample for hormonal measurements. An intravenous (iv) CRH stimulation test conducted over 1 min. Serum active ghrelin levels were measured at 0, 15, 30, 60, 90, 120 min after iv CRH administration.

RESULTS

The postmenopausal PCOS group had a higher waist circumference compared to postmenopausal controls. Active ghrelin concentrations increased significantly from 0 to 15 min, to 30 min, to 60 min, to 90 min and then decreased to 120 min. However, within the postmenopausal control group there were no significant changes in serum active ghrelin levels. Serum active ghrelin concentrations were significantly greater in the postmenopausal control group at 0, 15 and 120 min compared to the postmenopausal PCOS group. At 90 min active ghrelin concentrations were significantly greater in the postmenopausal PCOS group. Delta Area Under the Curve of active ghrelin (ΔAUCghr) was significantly greater in the postmenopausal PCOS group compared to controls.

CONCLUSIONS

In postmenopausal PCOS, but not in postmenopausal controls, iv CRH administration induces increased serum active ghrelin secretion, suggesting a possible anti-stress adaptive mechanism. An increase in serum active ghrelin may induce hunger as a side-effect of this presumed adaptive mechanism.

Primary follicular lymphoma of the uterine cervix: A case report

Primary non-Hodgkin lymphoma of the uterine cervix is a rare clinical entity. The present case report describes an incidence of primary cervical follicular lymphoma, diagnosed during management of concurrent cervical intraepithelial neoplasia. The present case report outlines not only the necessity of adhering to guidelines regarding the management of abnormal cervical cytology, but also the importance of expert pathological review and the need for personalized management.

LBODP090 The Addition Of Anastrozole To Standard Testosterone Enanthate Treatment Significantly Improves Penile Size In Adolescent Boys With Micropenis

Background

Micropenis is treated preferably in infancy (≤ 2 yrs) or at the onset οf puberty, usually with 3 (2-4) monthly testosterone enanthate I. M. injections at the dose of 100 mg/m2. This short-term therapy may temporarily advance bone maturation but with a concomitant increase in height velocity and no apparent change in predicted adult height. Bone maturation depends on locally produced estrogens by aromatization. Third generation aromatase inhibitors (AIs) are used as an off-label treatment to improve predicted adult height (PAH) in boys as well as in girls, either as monotherapy or in combination with growth hormone and/or puberty inhibition. They induce reverse binding inhibiting the activity of aromatase (a cytochrome P450 enzyme), which catalyzes the conversion of androstenedione and testosterone to estrone and estradiol, respectively, resulting in a substantial increase of the circulating testosterone concentrations.

Aims

To compare the traditional treatment of isolated - idiopathic - relative micropenis in boys with testosterone enanthate monotherapy to its combination with anastrozole 1 mg×1 p. o.

Methods

164 boys with micropenis (stretched penile length ≤ -2 SD) received testosterone enanthate 100 mg/m2 I. M. /month either as monotherapy (n=63, mean age 10.8 yrs, group A) or in combination with anastrozole 1 mg/day (n=101, mean age 11 yrs, group B) for 3 months. Stretched penile length, bone maturation and auxological data were analyzed. All measurements were performed by the same examiner. The choice of therapeutic intervention was made randomly. Groups A and B did not differ in terms of age at intervention onset, bone age, target height or predicted adult height. They underwent a 6-month follow-up that included clinical examination, bone age X-ray evaluated by BoneXpert ver. 3.2. 0 (Visiana, Denmark), and laboratory tests at 8: 00hrs (LH, FSH, testosterone, estradiol, estrone), prior and under treatment.

Results

In both groups penile length normalized: for group A gain was +1.9 cm (+2. 08 SD) and for group B +2.24 cm (+2.3 SD), with group B attaining a greater length by +18% (p=0. 004) due to the higher testosterone concentrations attained by at least 50%. Group A presented a slight acceleration of height velocity with parallel advancement of their bone age maturation while group B with unchanged or lower estradiol and estrone concentrations maintained their height velocity with parallel movement of their bone age maturation.

Conclusions

Addition of anastrozole 1 mg/day p. o. in testosterone enanthate treatment for idiopathic-isolated-relative micropenis at the beginning of puberty significantly improves penile length by almost 20% while the tempo of height velocity and bone maturation continue their previous track.

Presentation: No date and time listed

Daughters of polycystic ovary syndrome pregnancies and androgen levels in puberty: a Meta-analysis

Purpose: To provide an overview and critical analysis of the literature related to the circulating androgen levels of daughters of PCOS mothers during prepubertal and pubertal stage who have not yet been diagnosed with PCOS or precocious puberty. Methods: We critically considered and meta-analyzed observational studies comparing androgens concentration in daughters of PCOS mothers compared to daughters of mothers without PCOS. A literature search was conducted in MEDLINE, Scopus and other sources from 01/09/2021 until 01/12/2021. The study followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). The primary outcome included total testosterone levels whereas the secondary outcomes included 17a-hydroxyprogesterone (17-OHP), androstenedione (Δ4Α) and Sex Hormone Binding Globulin (SHBG) levels respectively. Results: Our search yielded 1073 studies, 9 of which were included in our analysis. The results are presented differently according to pubertal stage. Pubertal daughters of PCOS mothers exhibited significantly higher total testosterone (pooled mean difference 14.95 (95%CI: 6.98 to 22.93), higher 17-OHP (pooled mean difference 0.11 (95%CI: 0.02 to 0.20) and lower SHBG levels (pooled mean difference -10.48 (95%CI: -16.46 to -4.61). Instead, prepubertal daughters of PCOS mothers presented greater SHBG levels (pooled mean difference 7.79 (95%CI: 0.03 to 15.54) compared to controls. No difference was found in Δ4Α levels in both groups. Conclusion: The onset of puberty is a critical point in the development of the disease and an early intervention may be imperative.

Presence of antiphospholipid antibodies is associated with increased implantation failure following in vitro fertilization technique and embryo transfer: A systematic review and meta-analysis

Purpose

A systematic review and meta-analysis was conducted comparing the presence of anti-phospholipid (anti-PL) antibodies between women of reproductive age, without diagnosis of antiphospholipid syndrome, who experienced at least two implantation failures following in vitro fertilization and embryo transfer (IVF-ET), and either women who had a successful implantation after IVF-ET or women with at least one successful spontaneous pregnancy or unselected healthy fertile women with no history of IVF-ET.

Methods

Systematic search of the literature and meta-analysis of the relevant studies studying presence of antiphospholipid antibodies in women experiencing at least two implantation failures in IVF-ET as compared to either women who had a successful implantation after IVF-ET or/and women with at least one successful spontaneous pregnancy or unselected healthy fertile women with no history of IVF-ET. Six hundred ninety-four published reports were retrieved; 17 of them fulfilled the inclusion criteria set.

Results

Presence of either any type of anti-phospholipid or anticardiolipin antibodies or lupus-anticoagulant in women experiencing at least two implantation failures in IVF-ET was associated with increased implantation failure compared to women who had a successful implantation after IVF-ET (relative risk, RR: 3.06, 5.06 and 5.81, respectively). Presence of either anticardiolipin or lupus-anticoagulant or anti-beta₂ glycoprotein-I or anti-phosphatidylserine antibodies in women experiencing at least two implantation failures in IVF-EΤ was associated with increased implantation failure compared to unselected healthy fertile women with no history of IVF-ET (RR:13.92, 6.37, 15.04 and 164.58, respectively).

Conclusion

The prevalence of antiphospholipid antibodies, particularly that of anti-beta₂ glycoprotein-I and anti-phosphatidylserine antibodies, in women experiencing at least two implantation failures in IVF-ET without diagnosis of antiphospholipid syndrome is significantly greater than either in women who had a successful implantation after IVF-ET or women with at least one successful spontaneous pregnancy or unselected healthy fertile women with no history of IVF-ET.

Trial registration number

PROSPERO ID: CRD42018081458

Relationship Between Maternal Bone Biomarkers and Fetal Adiposity Through Normal Pregnancy

PURPOSE

To examine the association of maternal bone markers [sclerostin, soluble receptor activator of nuclear factor-κB ligand (sRANKL), osteocalcin, 25-hydroxyvitamin D3] with fetal intra-abdominal and subcutaneous adipose tissue deposition and birthweight during normal pregnancy.

METHODS

One hundred pregnant women (aged 30.4 ± 5.6 years, mean ± SD) with prepregnancy body mass index = 24.1 ± 4.6 kg/m2 were seen prospectively during each trimester. At each visit they were submitted to anthropometric measurements, a fasting blood sampling, a 75-g oral glucose tolerance test, and a fetal ultrasonogram. At birth, neonates had birth weight measurement.

RESULTS

In the second trimester, maternal sclerostin concentrations correlated positively with fetal abdominal circumference and birth weight; maternal sRANKL concentrations correlated positively with fetal abdominal subcutaneous fat thickness, sagittal abdominal diameter, and abdominal circumference. Fetuses born to mothers with greater (>254 ng/mL), compared to fetuses born to mothers with lower (≤254ng/mL), sRANKL concentrations had greater abdominal circumference, sagittal diameter, and abdominal subcutaneous fat thickness. Maternal serum sclerostin concentrations were the best positive predictors of birth weight. In the third trimester maternal sclerostin concentrations correlated positively with fetal sagittal abdominal diameter; maternal sRANKL concentrations positively correlated with fetal abdominal circumference and fetal abdominal sagittal diameter.

CONCLUSIONS

Maternal bone markers sclerostin and sRANKL may relate to fetal intra-abdominal adipose tissue deposition through as yet unknown direct or indirect mechanisms, thus contributing to birthweight.

Low versus high volume of culture medium during embryo transfer: a randomized clinical trial

PURPOSE

The aim of this prospective randomized control trial was to evaluate if the use of two different volumes (20-25 vs 40-45 μl) of media used for embryo transfer affects the clinical outcomes in fresh in vitro fertilization (IVF) cycles.

METHODS

In total, 236 patients were randomized in two groups, i.e., "low volume" group (n = 118) transferring the embryos with 20-25 μl of medium and "high volume" group (n = 118) transferring the embryos with 40-45 μl of medium. The clinical pregnancy, implantation, and ongoing pregnancy rates were compared between the two groups.

RESULTS

No statistically significant differences were observed in clinical pregnancy (46.8 vs 54.3%, p = 0.27), implantation (23.7 vs 27.8%, p = 0.30), and ongoing pregnancy (33.3 vs 40.0%, p = 0.31) rates between low and high volume group, respectively.

CONCLUSION

Higher volume of culture medium to load the embryo into the catheter during embryo transfer does not influence the clinical outcome in fresh IVF cycles.

TRIAL REGISTRATION NUMBER

NCT03350646.

Myomas and Adenomyosis: Impact on Reproductive Outcome

Among uterine structural abnormalities, myomas and adenomyosis represent two distinct, though frequently coexistent entities, with a remarkable prevalence in women of reproductive age. Various mechanisms have been proposed to explain the impact of each of them on reproductive outcome. In respect to myomas, current evidence implies that submucosal ones have an adverse effect on conception and early pregnancy. A similar effect yet is not quite clear and has been suggested for intramural myomas. Still, it seems reasonable that intramural myomas greater than 4 cm in diameter may negatively impair reproductive outcome. On the contrary, subserosal myomas do not seem to have a significant impact, if any, on reproduction. The presence of submucosal and/or large intramural myomas has also been linked to adverse pregnancy outcomes. In particular increased risk for miscarriage, fetal malpresentation, placenta previa, preterm birth, placenta abruption, postpartum hemorrhage, and cesarean section has been reported. With regard to adenomyosis, besides the tentative coexistence of adenomyosis and infertility, to date a causal relationship among these conditions has not been fully confirmed. Preterm birth and preterm premature rupture of membranes, uterine rupture, postpartum hemorrhage due to uterine atony, and ectopic pregnancy have all been reported in association with adenomyosis. Further research on the impact of adenomyosis on reproductive outcome is welcome.

Laparoscopic excision of rectosigmoid endometriotic plaque and cul de sac obliteration in deeply infiltrating endometriosis: a case report

Endometriosis represents a main cause of infertility and pelvic pain affecting 3-43% among reproductive age women. Deep pelvic endometriosis is defined as subperitoneal infiltration of endometrial implants in the uterosacral ligaments, rectum, rectovaginal septum, vagina or bladder. The authors present a case of a 29-year-old patient who underwent laparoscopic excision of extensive endometriotic plaque in rectovaginal septum accompanied with deeply infiltrating endometriosis (DIE) and chronic pelvic pain (CPP).

Endometriosis and ovarian cancer: clinical and molecular aspects

Endometriosis is one of the most commonly encountered benign problems in gynecology. Even though endometriosis appears to predispose to ovarian cancer the progression from atypical epithelial proliferation (atypical endometriosis and metaplasia), to the formation of well-defined borderline tumors and finally to endometrioid ovarian cancer will take several years. To elaborate on the concept of endometriosis as a precursor of some types of ovarian cancer, we present an overview of the pathophysiological and genetic characteristics, common in those two conditions. Furthermore, we present the genetic mutations found in ovarian cancers and we outline the common genetic alterations of endometriosis and ovarian cancer, focusing on the PI3K/Akt/mTOR-signaling pathway.

Successful management of evisceration occurred after exploratory laparotomy for bilateral ovarian micropapillary serous borderline tumors

Micropapillary serous borderline tumor of the ovary is characterized by a more frequent association with extraovarian, especially invasive, implants. The aim of this study was to report the clinicopathological findings of a rare case of micropapillary serous borderline tumor of the ovary since there are less than 100 similar cases in the published literature. Additionally, the successful management of evisceration that complicated the postoperative stay of the patient is analyzed. The incidence of this severe complication is estimated between 0.29-2.3%. There are four main causes: suture tearing through the fascia, knot failure, suture failure, and extrusion of abdominal contents between sutures placed too far apart. At least 50% of the cases are due to technical error with a potentially lethal result.

Effect of luteal-phase support on endometrial microRNA expression following controlled ovarian stimulation

BACKGROUND

Studies suggested that microRNAs influence cellular activities in the uterus including cell differentiation and embryo implantation. In assisted reproduction cycles, luteal phase support, given to improve endometrial characteristics and to facilitate the implantation process, has been a standard practice. The effect of different types of luteal phase support using steroid hormones in relation to endometrial miRNA profiles during the peri-implantation period has not seen described. This study was designed to evaluate the expression of miRNAs during the luteal phase following controlled ovarian stimulation for IVF and the influence of different luteal phase support protocols on miRNA profiles.

METHODS

The study was approved by the Johns Hopkins Hospital Institutional Review Board. Endometrial biopsies were obtained on the day of oocyte retrieval from 9 oocyte donors (group I). An additional endometrial biopsy was obtained 3-5 days later (Group II) after the donors were randomized into three groups. Group IIa had no luteal-phase support, group IIb had luteal support with micronized progesterone (P), and Group IIc had luteal support with progesterone plus 17-beta-estradiol (P + E). Total RNA was isolated and microarray analysis was performed using an Illumina miRNA expression panel.

RESULTS

A total of 526 miRNAs were identified. Out of those, 216 miRNAs were differentially regulated (p < 0.05) between the comparison groups. As compared to the day of retrieval, 19, 11 and 6 miRNAs were differentially regulated more than 2 fold in the groups of no support, in the P support only, and in the P + E support respectively, 3-5 days after retrieval. During the peri-implantation period (3-5 days after retrieval) the expression of 33 and 6 miRNAs increased, while the expression of 3 and 0 miRNAs decreased, in the P alone and in the P + E group respectively as compared to the no steroid supplementation group.

CONCLUSION

Luteal support following COS has a profound influence on miRNA profiles. Up or down regulation of miRNAs after P or P + E support suggest a role(s) of luteal support in the peri-implantation uterus in IVF cycles through the regulation of associated target genes.

Cytochrome P450 1A1 (CYP1A1) gene polymorphisms and cervical cancer risk: a meta-analysis

This meta-analysis aims to examine whether the genotype status of MspI and Ile462Val polymorphisms in Cytochrome-P450 1A1 (CYP1A1) is associated with cervical cancer risk. Eligible case-control studies were identified through search in MEDLINE (end of search: October 2010). Pooled odds ratios (ORs) were appropriately derived from fixed-effects or random effects models. Concerning MspI polymorphism, six studies were eligible (722 cases and 770 controls); four studies were eligible (350 cases and 519 controls) for Ile462Val. MspI polymorphism was associated with elevated cervical cancer risk (for heterozygous TC vs. TT carriers OR = 1.50, 95% CI: 0.93-2.42, random effects; for homozygous CC vs. TT carriers OR = 2.66, 95% CI: 1.14-6.19, random effects). Similarly, Ile462Val polymorphism was associated with elevated cervical cancer risk (for heterozygous Ile/Val vs. Ile/Ile carriers OR = 2.36, 95% CI: 1.10-5.08, random effects; for homozygous Val/Val vs. Ile/Ile carriers OR = 2.73, 95% CI: 1.21-6.15, fixed effects). The results were replicated upon Caucasian subjects, who represented the majority of existing data. The two examined CYP1A1 genotype polymorphisms seem to confer additional risk for cervical cancer. Accumulation of further data seems mandatory for future race-specific analyses and for the demonstration of CYP1A1-smoking interactions.

The impact of luteal phase support on endometrial estrogen and progesterone receptor expression: a randomized control trial

BACKGROUND

To assess the impact of luteal phase support on the expression of estrogen receptor (ER) alpha and progesterone receptors B (PR-B) on the endometrium of oocyte donors undergoing controlled ovarian hyperstimulation (COH).

METHODS

A prospective, randomized study was conducted in women undergoing controlled ovarian hyperstimulation for oocyte donation. Participants were randomized to receive no luteal support, vaginal progesterone alone, or vaginal progesterone plus orally administered 17 Beta estradiol. Endometrial biopsies were obtained at 4 time points in the luteal phase and evaluated by tissue microarray for expression of ER alpha and PR-B.

RESULTS

One-hundred and eight endometrial tissue samples were obtained from 12 patients. No differences were found in expression of ER alpha and PR-B among all the specimens with the exception of one sample value.

CONCLUSIONS

The administration of progesterone during the luteal phase of COH for oocyte donor cycles, either with or without estrogen, does not significantly affect the endometrial expression of ER alpha and PR.

GSTM1 polymorphism, GSTT1 polymorphism, and cervical cancer risk: a meta-analysis

INTRODUCTION

A debate exists about whether glutathione S-transferase (GST) polymorphisms (GST mu-1 [GSTM1] null/present genotype and GST theta-1 [GSTT1] null/present genotype) confer additional risk for cervical cancer. This meta-analysis was aimed to examine the associations between the aforementioned polymorphisms and cervical cancer risk.

METHODS

Thirteen studies were eligible for GSTM1 (1616 cervical cancer cases and 1970 controls), and 12 studies were eligible for GSTT1 (1393 cases and 1766 controls). Pooled odds ratios (OR) were appropriately derived from fixed effects or random effects models. Separate analyses were conducted on Chinese and non-Chinese populations. Metaregression with publication year was also performed.

RESULTS

At the overall analysis, the GSTM1 null genotype was associated with increased cervical cancer risk (pooled OR = 1.272; 95% confidence interval [CI], 1.014-1.597, random effects). The association seemed confined to non-Chinese populations (pooled OR = 1.392; 95% CI, 1.003-1.932, random effects) given that the association was not significant in the subset of Chinese studies (pooled OR = 1.080; 95% CI, 0.870-1.340, fixed effects). On the other hand, at the overall analysis, the GSTT1 null genotype was not associated with increased cervical cancer risk (pooled OR = 1.301; 95% CI, 0.948-1.787, random effects). Similarly, no significant associations were detected in either non-Chinese or Chinese populations concerning the GSTT1 null genotype.

CONCLUSIONS

The GSTM1 null genotype confers additional risk for cervical cancer in non-Chinese populations. The trend concerning GSTT1 has not reached significance.

Changes in maternal serum thioredoxin (TRX) levels after delivery in preeclamptic and normotensive pregnant women

OBJECTIVE

To investigate changes of maternal plasma thioredoxin (TRX) levels after delivery in preeclamptic and normotensive pregnant women.

METHODS

Ten normotensive women (group A) were compared to 17 women with severe preeclampsia (group B). TRX levels were assessed in maternal plasma, immediately after delivery and 12-16 weeks postpartum.

RESULTS

There were no differences in plasma TRX levels between the two groups immediately antepartum (p = 0.095). A significant reduction in plasma TRX levels was found immediately following delivery only in normotensive group (117.76 ± 37.19 ng/mL vs. 43.45 ± 21.11 ng/mL, p = 0.002), but not in women with preeclampsia (80.42 ± 59.95 ng/mL vs. 53.82 ± 44.34 ng/mL, p = 0.12). Plasma TRX levels remained unchanged in women with preeclampsia (80.42 ± 59.95 ng/mL vs. 55.37 ± 52.23 ng/mL, p = 0.2) at 12-14 weeks postpartum.

Glutathione S-transferase M1, T1, and P1 polymorphisms and ovarian cancer risk: a meta-analysis

INTRODUCTION

Cytosolic glutathione S-transferase (GST) comprises multiple isoenzymes that catalyze reactions between glutathione and lipophilic compounds with electrophilic centers, resulting in the neutralization of toxic compounds, xenobiotics, and products of oxidative stress. Several studies have examined whether GST polymorphisms (GSTM1 null/present genotype, GSTT1 null/present genotype, and GSTP1 Ile105Val) represent risk factors for ovarian cancer, as they all may denote reduced enzyme activity. This meta-analysis aimed to examine the associations between the aforementioned polymorphisms and ovarian cancer risk.

METHODS

The MEDLINE database was searched up to September 2009 using the appropriate terms. Case-control studies with no mutually overlapping populations were selected. Pooled odds ratios (ORs) were appropriately derived from fixed-effects or random-effects models. Meta-regression with publication year was also performed.

RESULTS

Eight studies regarding GSTM1 null polymorphism status (2357 cases and 3044 controls), 6 studies concerning GSTT1 null polymorphism (1923 cases and 2759 controls), and 3 studies on GSTP1 Ile105Val were included in the meta-analysis. The GSTM1 null genotype was not associated with an increased risk for ovarian cancer (pooled OR, 1.031; 95% confidence interval, 0.867-1.226; random effects). The GSTT1 null genotype was not associated with an increased ovarian cancer risk (pooled OR, 0.934; 95% confidence interval, 0.804-1.086; random effects); similarly, no significant associations were demonstrated for GSTP1 Ile105Val.

CONCLUSIONS

The examined GSTM1, GSTT1, and GSTP1 genotype polymorphisms do not seem to confer any additional risk for ovarian cancer. Given that the studies included in this meta-analysis involve mainly white populations, these results cannot be extrapolated on other populations, and additional data are needed for future race-specific analyses.

Fertility drugs and ovarian cancer risk: a critical review of the literature

There is evidence that medications used for ovarian stimulation and in vitro fertilization may be associated with ovarian cancer. In this review, we attempt to describe this relationship according to the most recent epidemiologic data and to present the possible mechanisms on the molecular level that could potentially explain this correlation. Currently there is no proven relationship between any type of ovarian cancer and drugs used for infertility treatment. Overall, infertile women have increased risk for ovarian malignancies. Nulligravidas that received treatment are at increased risk for ovarian malignancy as compared to women that conceived after treatment. More studies with the appropriate statistical power and follow-up time, as well as with better adjustment for confounding factors, which coexist in infertile patients, are required to evaluate accurately the long-term effects of these drugs and procedures.

Endometriosis and ovarian cancer: a review

OBJECTIVES

To describe the relationship between endometriosis and ovarian cancer.

SEARCH STRATEGY

Review of the relevant clinical, epidemiologic, and molecular biology literature.

SELECTION CRITERIA

Studies published in the English language using the MEDLINE database.

DATA COLLECTION AND ANALYSIS

Relevant studies were reviewed by the three authors and those that seem to be of significant scientific value, based on the methodology and statistical power, were included.

MAIN RESULTS

Endometriosis and ovarian cancer share many common predisposing factors. Both conditions demonstrate similar patterns regarding local invasion and distal spread they respond similarly to estrogen-induced growth signaling, they express resistance to apoptotic mechanisms and they are characterized by genomic instability. Endometrioid and clear-cell are the most frequent types of ovarian cancer associated with endometriosis. Tubal ligation, in women with endometriosis, seems to prevent retrograde menstruation but it has also been shown to be protective from these types of ovarian cancer.

CONCLUSION

There is evidence to support that endometriosis (by definition a benign process), could simultaneously have the potential for malignant transformation. More studies are needed to establish risk factors that may lead to malignant transformation of this condition and to identify predisposed individuals who may require closer surveillance.

Effect of pentoxifylline on vascular endothelial growth factor C and flk-1 expression on endometrial implants in the rat endometriosis model

OBJECTIVE

To investigate the effects of pentoxifylline, on vascular endothelial growth factor (VEGF)-C and flk-1 expression in the rat endometriosis model.

DESIGN

Prospective, randomized, placebo-controlled study.

SETTING

Academic institution.

ANIMAL(S)

Twenty Wistar rats with surgically induced endometriosis.

INTERVENTION(S)

Animals were evaluated after surgical induction of endometriosis and random allocation to a group that received pentoxifylline and a control group that received NaCl 0.9%, for 3 weeks. At the end of the treatment period the animals were killed and the implants evaluated macroscopically as well as by immunohistochemistry.

MAIN OUTCOME MEASURE(S)

Morphologic changes of the endometriotic implants; and evaluation of VEGF-C and flk-1 expression by a semiquantitative analysis (HSCORE) for the intensity of immunohistochemical reactivity.

RESULT(S)

A significant reduction was observed in the mean volume of the endometriotic implants per animal in the treatment group as compared with the control group. There was a significant reduction not only in the mean volume of implants per animal but also in the mean number of implants per animal after treatment. By immunohistochemical evaluation (HSCORE), there was a significant reduction in VEGF-C expression after treatment in all areas examined. A significant reduction of flk-1 expression was also noted in the glandular compartment after treatment but not in the epithelial surface or stroma.

CONCLUSION(S)

Pentoxifylline may cause suppression of endometriotic lesions by suppressing angiogenesis through VEGF-C and flk-1 expression.

Serum adiponectin during pregnancy and postpartum in women with gestational diabetes and normal controls

AIMS

To investigate changes in serum adiponectin during pregnancy and postpartum and assess its relationship with insulin resistance as measured by homeostasis model assessment (HOMA-IR).

METHODS

Twenty-two normal pregnant women were compared with 22 women diagnosed with gestational diabetes mellitus (GDM). Serum adiponectin levels were measured at the time of the glucose challenge test as well as in the immediate postpartum period and the correlation of adiponectin to HOMA-IR was performed.

RESULTS

Adiponectin was significantly lower in women with GDM than in controls during pregnancy (5381 vs. 8449 ng/dl, p = 0.004), as well as postpartum (3278 vs. 6958 ng/ml, p = 0.002). A significant reduction in adiponectin (3278 vs. 5381 ng/ml, p = 0.002) was observed postpartum in GDM women but not in controls. Using a lower cut-off value of 5253 ng/ml, maternal adiponectin could exclude GDM with a sensitivity of 86.4% and a specificity of 59.1% (area under the curve = 0.752, standard error = 0.77, 95% confidence interval 0.601-0.903, p = 0.004). Adiponectin levels during pregnancy were negatively correlated with HOMA-IR (r = -0.375, p = 0.012).

CONCLUSION

GDM is associated with decreased serum adiponectin levels both in pregnancy as well as postpartum. Adiponectin is negatively correlated to HOMA-IR. A reduction in maternal adiponectin after delivery indicates a significant placental contribution to adiponectin production.

Randomized controlled trial comparing superovulation with letrozole versus recombinant follicle-stimulating hormone combined with intrauterine insemination for couples with unexplained infertility who had failed clomiphene citrate stimulation and intrauterine insemination

OBJECTIVE

To compare the efficacy of letrozole to recombinant FSH for ovarian stimulation combined with IUI in a group of patients that had failed to conceive after clomiphene citrate (CC) and IUI.

DESIGN

Prospective randomized trial with human subjects.

SETTING

University-based fertility center.

PATIENT(S)

Fifty couples with unexplained infertility that failed to conceive after three cycles of CC combined to IUI.

INTERVENTION(S)

Couples were randomized to undergo superovulation either with letrozole or with recombinant FSH combined to IUI.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy per cycle of treatment and clinical pregnancy per couple.

RESULT(S)

Pregnancy rate (PR) per cycle was 8.9% in the letrozole group as compared with 14% in the gonadotropin IUI group. This resulted in a cumulative PR per couple of 24% versus 36% and a take home baby rate of 20% versus 28%. Endometrial thickness was significantly lower in the letrozole group (7.1 +/- 2.3 vs 8.6 +/- 1.8).

CONCLUSION(S)

Ovarian stimulation with letrozole is associated with acceptable PRs compared with gonadotropin with significant less cost, risks, and patient inconvenience.

Laparoscopic tubal reanastomosis using robotics: experience from a teaching institution

PURPOSE

Tubal reanastomosis typically requires a laparotomy and in the past few years has been performed much less frequently due to the development and success of in vitro fertilization. Laparoscopic tubal anastomosis eliminates the need for laparotomy and can be performed in an out-patient setting.

MATERIALS AND METHODS

From October 2003 to September 2004, five patients who had previous tubal sterilization and requested tubal reanastomosis underwent laparoscopic tubal reanastomosis with the use of the da Vinci surgical system (Intuitive Surgical, Mountain View, CA).

RESULTS

Ten fallopian tubes were successfully reconstructed, as confirmed by chromopertubation at the end of the procedure. Patency was confirmed by hysterosalpingogram in seven out of eight tubes. The mean (+/- standard deviation) time of the procedure was 172 +/- 53 min. The mean time for docking the robotic arms to the patient was 62 +/- 16.8 min and the mean robotic time was 97 +/- 36 min. There were two live births, one ectopic pregnancy, and one biochemical pregnancy. The mean time to conception was 5.5 +/- 2 months.

CONCLUSION

Laparoscopic microsurgical tubal reanastomosis after tubal sterilization can be performed using a remote-controlled robotic system. Systematization of the operative steps allowed for operative times that compare favorably with the time needed for open microsurgical techniques. Larger series are needed to standardize the procedure and confirm postoperative fecundity rates.

Prevention and management of ovarian hyperstimulation syndrome

The Ovarian Hyperstimulation Syndrome (OHSS) represents one of the biggest nightmares of all physicians involved in Assisted Reproductive Technologies (ART). Every year, several hundreds of women are hospitalized and to date several deaths have been reported. The pivotal event in the development of OHSS is the disruption of capillary integrity that results in leakage of intravascular fluid and proteins into third space. On the molecular level, human chorionic godadotropin (HCG) either exogenous or endogenous, functions as the triggering point for the production of vascular endothelial growth factor (VEGF) that is the main mediator to increase permeability on the vascular bed. Spontaneous OHSS has also been reported, either due to inappropriate activation of a mutant FSH receptor or due to very high levels of HCG during pregnancy. The available evidence on the several preventive and therapeutic approaches with special attention to level 1 evidence when available is also presented. OHSS is a self-resolving condition and the main role of the physician is to correct and maintain the intravascular volume, to support renal function and respiration and prevent thrombotic events. An algorithm on the management of OHSS on an outpatient basis and in the hospital is based on the previous mentioned principles.

Immunological localization of syndecan-1 in human endometrium throughout the menstrual cycle

OBJECTIVE

To examine the expression of syndecan-1 in the endometrium during the menstrual cycle.

DESIGN

The expression of syndecan-1 was determined by tissue microarray and immunohistochemistry.

SETTING

Academic clinical and research laboratories.

PATIENT(S)

Seventy-one regularly cycling women who underwent endometrial biopsy.

INTERVENTION(S)

Endometrial samples representing five stages of the menstrual cycle were used for the study.

MAIN OUTCOME MEASURE(S)

Semiquantitative analysis by evaluating the intensity of immunohistochemical reactivity of syndecan-1 by using a modified HSCORE.

RESULT(S)

Endometrial syndecan-1 was expressed in the luminal and glandular epithelium as well as in the stroma throughout the menstrual cycle in a nonsynchronized fashion. In the luminal epithelium, the expression of syndecan-1 was statistically significantly higher in the mid-secretory phase when compared with the proliferative phase. In the stroma, however, the expression of syndecan-1 was down-regulated after ovulation and remained at a low level through the secretory phases. Differences between the proliferative and mid secretory, as well as between the ovulatory and the early, mid, and late secretory phases, all were statistically significant.

CONCLUSION(S)

Syndecan-1 is up-regulated in luminal epithelial cells during the mid-secretory phase and is down-regulated in the stroma during the early to late secretory phases. The differential expression of syndecan-1 coincides with the endometrial remodeling throughout the menstrual cycle.

Effect of luteal-phase support on endometrial L-selectin ligand expression after recombinant follicle-stimulating hormone and ganirelix acetate for in vitro fertilization

CONTEXT

The impact of different types of luteal phase support on endometrial receptivity after ovarian stimulation has not been investigated.

OBJECTIVE

Our objective was to evaluate the impact of different luteal-phase support protocols on sex steroid levels and on endometrial expression of L-selectin ligand after ovarian hyperstimulation with a GnRH antagonist protocol.

PATIENTS AND DESIGN

Seventeen oocyte donors who underwent ovarian stimulation with a recombinant FSH/ganirelix acetate protocol were randomized into three groups: group I had no luteal-phase support; group II had luteal support with micronized progesterone; and group III had luteal support with progesterone plus 17beta-estradiol. All donors had endometrial biopsies on the day of retrieval, and then 3, 5, and 10 d after retrieval. In addition, they had serum estradiol and progesterone measurements on d 3, 5, and 10.

MAIN OUTCOME MEASURES

Endometrial L-selectin ligand expression was detected by immunohistochemical staining in the luminal and glandular epithelium. A histological score was used for the quantification of the immunostaining. Sex steroid levels were measured during the luteal phase.

RESULTS

By d 10 after retrieval, there was a significant decrease in mean progesterone levels in group I compared with the other two groups that may reflect the expected demise of the corpus luteum. There was also a significant increase in the presence of L-selectin ligands in the luminal epithelium in group III.

CONCLUSIONS

During controlled ovarian stimulation with a GnRH antagonist protocol, luteal-phase support with micronized progesterone and 17beta-estradiol seem to increase endometrial L-selectin ligand expression in the luminal endothelium.

Hysteroscopic resection of a large submucosal fibroid using intermittent bimanual uterine massage and a bipolar resectoscope: a case report

BACKGROUND

Hysteroscopic resection of large sub-mucosal myomas embedded deep in the myometrium is often unsuccessful due to absorption of large amounts of nonionic fluid that may result in water intoxication or incomplete resection of the intramural portion of the tumor, which later protrudes within the cavity.

CASE

A 35-year-old woman with a large, sessile, sub-mucosal leiomyoma underwent hysteroscopic resection using a bipolar resectoscope under laparoscopic monitoring with intermittent uterine massage. An isotonic electrolyte solution was used for uterine distention and visualization. Frequent massaging of the uterus during the procedure resulted in the expulsion of the fibroid into the endometrial cavity and facilitated complete resection.

CONCLUSION

A bipolar resectoscope, which can be used with electrolyte solutions, such as 0.9% NaCl, combined with uterine massage, allows complete removal of large leiomyomas without adverse electrolyte imbalances.

Women with ovulatory dysfunction undergoing ovarian stimulation with clomiphene citrate for intrauterine insemination may benefit from administration of human chorionic gonadotropin

OBJECTIVE

To investigate factors that may affect pregnancy outcome following ovarian stimulation with clomiphene citrate (CC) combined with intrauterine insemination (IUI).

DESIGN

Retrospective cohort study.

SETTING

University teaching hospital.

PATIENT(S)

Three hundred and twenty women who underwent 691 ovarian stimulation cycles with CC for IUI.

INTERVENTION(S)

Ovarian stimulation with CC followed by a single IUI either 24 hours after a spontaneous serum LH surge (>25 mIU/mL) or 36 hours after intramuscular human chorionic gonadotropin (hCG) administration (10,000 IU) when the largest follicle had reached a diameter of 17 mm.

MAIN OUTCOME MEASURE(S)

Clinical pregnancies.

RESULT(S)

Women with ovulatory dysfunction who received hCG had significantly higher pregnancy rates (24.6%) compared with women with other types of infertility. There were no differences in pregnancy rates between the LH surge group and the hCG group (14.3% vs 12.4%). A spontaneous LH surge was noted in a variety of follicular sizes (14 to 35 mm). There was no correlation for age, body mass index, follicular diameter, number of mature follicles, other sperm characteristics, and pregnancy outcome in either group.

CONCLUSION(S)

After ovarian stimulation with CC, IUI is equally effective 24 hours after a spontaneous LH surge or 36 hours after administration of hCG. Spontaneous LH surges were observed at a variety of follicular sizes with comparable pregnancy rates. In women with ovulatory dysfunction, hCG administration before insemination may be beneficial.

An oocyte donation protocol using the GnRH antagonist ganirelix acetate, does not compromise embryo quality and is associated with high pregnancy rates

PURPOSE

To evaluate the effect of the GnRH antagonist, ganirelix acetate, on oocyte quality.

METHODS

Stimulation characteristics, implantation rates and clinical pregnancy rates were compared between 29 oocyte donors 21-31 years of age who underwent 31 cycles of ovarian stimulation with gonadotropins and ganirelix acetate, and 36 infertile couples of similar age range who underwent 51 cycles of ovarian stimulation using the same protocol.

RESULTS

A significantly lower number of embryos were transferred in the donor/recipient group as compared to the infertile group (2.32+/-0.54 vs. 2.82+/-0.71, P<0.05). In contrast, implantation and clinical pregnancy rates per transfer, were significantly higher in the donor/recipient group (38.1% vs. 10.4%, P<0.01) and (61.3% vs. 23.1%, P<0.05) respectively, as compared to the infertile group.

CONCLUSIONS

Incorporation of ganirelix acetate for pituitary suppression in stimulation protocols for oocyte donation is associated with high pregnancy rates suggesting that ganirelix acetate does not exert an adverse effect on oocyte or embryo quality.

Uterine myomas: an overview of development, clinical features, and management

OBJECTIVE

To review the biology and the pathophysiology of uterine myomas, focus on options for management, and emphasize principles that will render the decision-making process as logical as possible.

DESIGN

Literature review and synthesis of the authors' experience and philosophy.

RESULTS

Uterine myomas are the most common solid pelvic tumors in women. There is increasing evidence that they have a genetic basis and that their growth is related to genetic predisposition, hormonal influences, and various growth factors. Treatment choices are wide and include pharmacologic, surgical, and radiographically directed intervention. Most myomas can be followed serially with surveillance for development of symptoms or progressive growth.

CONCLUSION

The past century has witnessed development of highly sophisticated diagnostic and therapeutic technology for myomas. The tools currently at our disposal permit greater management flexibility with safe options, which must be tailored to the individual clinical situation.

The ovarian hyperstimulation syndrome

OBJECTIVE

To review the up-to-date literature concerning the pathogenesis of, risk factors for, prevention of, and therapy for the ovarian hyperstimulation syndrome, and to provide suggestions for management of this syndrome.

DESIGN

Literature review combined with on-site clinical experiences at the authors' institution of practice.

PATIENT(S)

Women who have risk factors for or manifest the ovarian hyperstimulation syndrome.

INTERVENTION(S)

Intravenous fluid management, thrombosis prevention techniques, paracentesis techniques, and critical care management protocols.

MAIN OUTCOME MEASURE(S)

Staging system of the ovarian hyperstimulation syndrome, criteria for outpatient versus hospitalization management, and indications for varying levels of interventional management.

RESULT(S)

The ovarian hyperstimulation syndrome, unique to the field of assisted reproductive technology, remains a largely elusive and unpredictable iatrogenic physiologic complication in the course of pharmacologic ovarian stimulation. Reliable information on risk factors, possible physiologic mechanisms, prevention techniques, and management is fortunately progressing, and overall advances are being made in this field. The present review is an attempt to summarize the modern literature regarding this syndrome and to use this current knowledge to provide a basis for acceptable management regimens.

CONCLUSION(S)

Ovarian hyperstimulation syndrome is a serious complication of assisted reproductive technology, with potential for critical morbidity and death. Physicians who prescribe medications known to be associated with this syndrome should be familiar with identifiable risk factors, means of prevention, and a system for staging and treating the disease and have a current knowledge base for putative models of pathogenesis.