[Prevention of postoperative abdominal adhesions in gynecological surgery. Consensus paper of an Italian gynecologists' task force on adhesions]

Adhesions are the most frequent complication of abdominopelvic surgery, causing important short- and long-term problems, including infertility, chronic pelvic pain and a lifetime risk of small bowel obstruction. They also complicate future surgery with considerable morbidity and expense, and an important mortality risk. They pose serious quality of life issues for many patients with associated social and healthcare costs. Despite advances in surgical techniques, the healthcare burden of adhesion-related complications has not changed in recent years. Adhesiolysis remains the main treatment although adhesions reform in most patients. There is rising evidence, however, that surgeons can take important steps to reduce the impact of adhesions. A task force of Italian gynecologists with a specialist interest in adhesions having reviewed the current evidence on adhesions and considered the opportunities to reduce adhesions in Italy, have approved a collective consensus position. This consensus paper provides a comprehensive overview of adhesions and their consequences and practical proposals for actions that gynecological surgeons in Italy should take. As well as improvements in surgical technique, developments in adhesion-reduction strategies and new agents offer a realistic possibility of reducing adhesion formation and improving outcomes for patients. They should be adopted particularly in high risk surgery and in patients with adhesiogenic conditions. Patients also need to be better informed of the risks of adhesions.

Efficacy of an alpha-hydroxy acid (AHA)-based cream, even in monotherapy, in patients with mild-moderate acne

AIM AND METHODS

The treatment of mild-moderate acne with topical drugs in association with appropriate cosmetics is currently the golden standard. The tolerability and efficacy of a cream formulated with a new mix of alpha-hydroxy acids (Hyseac AHA cream) in 248 patients with mild-moderate acne (comedonic, inflammatory, or mixed) have been investigated in a multicenter, non-randomized, open study by 10 dermatologists from different Italian areas during their routine practice. The medication with Hyseac AHA cream was prescribed at first consultation for 60 days, twice a day, either as a monotherapy (49.2% patients) or in association with a pharmacological treatment (50.2%).

RESULTS

The tolerability was good to excellent in 92.3% patients, without significant differences between patients using AHA cream in monotherapy (90.0%) or associated with concomitant pharmacological treatment (97.6%). The efficacy was overall high in 64.2% patients, again without significant differences related to concomitant pharmacological treatment or not (64.8% vs. 63.3%) and/or the acne clinical type (comedonic vs. inflammatory vs. mixed: 69.2% vs. 66.7% vs. 58%).

CONCLUSION

The results of this study, while confirming the high tolerability and efficacy of this AHA cream in the treatment of mild/moderate acne, reasonably suggest its possible use also in monotherapy. Furthermore, its use can be reasonably hypothesized as a maintenance treatment after specific pharmacological treatment even in more severe acne types.

Ovarian endometrioma: postoperative adhesions following bipolar coagulation and suture

OBJECTIVE

To compare bipolar coagulation and suturing of the ovary in terms of postoperative ovarian adhesions after laparoscopic ovarian cystectomy for endometriosis.

DESIGN

Prospective, randomized, controlled study.

SETTING

Department of Obstetrics and Gynecology, University of Naples "Federico II."

PATIENT(S)

Thirty-two women with a single endometriotic cyst were randomly divided into two groups of 16 women each (groups A and B).

INTERVENTION(S)

All patients underwent laparoscopic ovarian cystectomy for endometriosis. In group A, hemostasis was performed by closure of the ovary with an intraovarian suture. In group B, complete hemostasis was achieved only with bipolar coagulation on the internal face of the ovary.

MAIN OUTCOME MEASURE(S)

Rate and extension of postsurgical ovarian adhesions at 60-90 days follow-up.

RESULT(S)

At follow-up, a significantly lower rate of postsurgical ovarian adhesions was observed in group A than in group B (30.8% vs. 57.1%). The extension of ovarian adhesions was significantly higher in group B than in group A.

CONCLUSION(S)

The use of sutures on ovaries treated for endometrioma is associated with a lower rate of postoperative ovarian adhesion formation compared with bipolar coagulation.

[Diagnostic and operative fertiloscopy]

In the last decade, ''fertiloscopy'', a new mini-invasive diagnostic technique, is becoming more and more popular: it is a good alternative to the diagnostic laparoscopy, a standard procedure but surely not harmless, very often capable to discover pathologies in asymptomatic patients. Fertiloscopy allows the visualization of the posterior pelvis (posterior face of the uterus, ovaries, tubes and intestinal ansae with the rectum), with a technique of introducing an optical device in the pouch of Douglas, through the posterior vaginal fornix, under previous general or local anesthesia. When fertiloscopy is performed under local anesthesia, it can comfortably be carried out in out-patient departments and it is generally well tolerated by patients, who follow the whole procedure on the monitor. Moreover, it is possible to perform small interventions, such as adhesiolysis, ovarian drilling, coagulation of endometriosis spots and to perform chromosalpingoscopy and salpingoscopy, important investigations in the diagnostic iter of unexplained female infertility. With fertiloscopy, the patient, therefore, can avoid a real surgical intervention, such as diagnostic laparoscopy, and also uncomfortable examinations, such as hysterosalpingography.

Vaginoscopic versus traditional office hysteroscopy: a randomized controlled study

BACKGROUND

A randomized, controlled study was performed to compare vaginoscopic versus traditional (speculum with or without tenaculum) hysteroscopy in terms of pain score and procedure time.

METHODS

Three hundred patients were randomized in two groups: Group A, diagnostic hysteroscopy with vaginoscopic approach (150 patients) and Group B, diagnostic hysteroscopy with traditional approach (150 patients). All procedures were performed using a semi-rigid 3.5-mm minihysteroscope with a 0 degrees grade optic. Patients of each group were divided into three subgroups according to their reproductive status: fertile nulliparous (FN), fertile multiparous (FM) and post-menopausal (MEN) women. Women were asked to rate their degree of pain during four phases of the procedure: introduction of hysteroscope (Group A) or speculum (Group B) into the vagina (Phase I) and progression through cervical canal up to internal uterine orifice (IUO) (Phase II), inspection of uterine cavity (Phase III) and performing of endometrial biopsy (Phase IV). A total pain score was calculated for each group. For each patient, the duration of hysteroscopy was recorded from the introduction to the extraction of the scope (Group A) or of the speculum (Group B).

RESULTS

Although the median total pain scores were 2 in each group, the 95% confidence interval for vaginoscopic hysteroscopy (1.86-2.01) was significantly (P < 0.05) lower than that for traditional hysteroscopy (2.10-2.26). Comparison between the corresponding phases of the procedure showed the only significant difference during Phase I of the procedure [Group A: 1 (95% CI 1.0-1.18) versus Group B: 2 (95% CI 2.3-2.8); P < 0.05]. No significant differences in terms of duration of the procedure were observed between the two approaches.

CONCLUSIONS

When surgeons using vaginoscopic hysteroscopy with a semi-rigid minihysteroscope were compared with those using traditional approach and the same instrumentation, the operating times and the patients' pain scores were similar.

[Voluminous ectopic polycystic ovaries in Mayer-Rokitansky-Küster-Hauser syndrome]

We report the case of a 20-year-old woman with primary amenorrhea, normally developed sexual characteristics, infantile external genitals and absence of vaginal orifice. Blood chemistry studies showed elevated serum levels of gonadotropin, estrogens, testosterone, 17OH-progesterone, prolactin and TSH and low concentrations of FT(3) and FT(4). Cytogenetic karyotyping and in situ fluorescence hybridization revealed a 46,XX karyotype and the presence of Barr chromatin body. Laparoscopy disclosed absence of a vagina, apparently normal, enlarged tubes, multifolicular ectopic gonads and symmetric bilateral uterine buds. Diagnostic work-up included skeletal radiography, renal ultrasonography, intravenous pyelography, pelvic echography, pelvic phlebography and magnetic resonance imaging studies to demonstrate possible associations between the genitourinary and skeletal anomalies. Based on the clinical and laboratory findings, a diagnosis of Mayer-Rokitansky-Küster-Hauser syndrome was established, associated with the presence of enlarged ectopic polycystic ovaries in the abdominal cavity.

[Etiopathogenesis of endometriosis related infertility]

In the last years the entire scientific community has devoted remarkable resources to the understanding of endometriosis. In spite of this, endometriosis remains one of the most complex gynecological diseases, in nearly all of its physiopathological aspects and implications. In particular, the association between endometriosis and infertility has proven to be complex and it has been widely discussed. It is generally accepted that moderate/severe endometriosis related sterility is due to mechanical factors, namely to the distortion/subversion of the regular pelvic anatomy. On the contrary, the factors behind infertility/subfertility related to minimal/mild endometriosis are less clear. None of the hypothesized mechanisms exhaustively explained the infertility related to endometriosis, while it is possible that such disease is caused by multiple factors altogether. The aim of this thorough review of the international literature is to analyze the main etiological factors (i.e. alterations in oocyte maturation and/or growth, defects of fertilization, impairments of implantation or aberrant immunological mechanisms) that are potentially involved, as well as the role that each of the above mentioned factors has in determining the endometriosis related infertility/subinfertility.

Molecular mechanisms involved in GnRH analogue-related apoptosis for uterine leiomyomas

GnRH agonist therapy is known to reduce uterine leiomyoma volume, although the molecular mechanisms responsible for this effect remain poorly understood. In this study, we have investigated the molecular mechanisms involved in the anti-proliferative effect of a GnRH agonist, leuprolide acetate (LA), in uterine leiomyomas obtained from six patients treated with LA for 3 months before surgery (group B), compared with tumours from six untreated patients (group A). To this end, we have evaluated the expression and the activity of molecules involved in the regulation of cell survival and proliferation. In group B, the total activity of PI3K was reduced by 60% compared with control samples. Furthermore, LA caused a reduction of PKB activation of approximately 50%, measured as serine 473 phosphorylation. In parallel with PKB reduction in LA samples, we observed a 60% reduction in the phosphorylation of its substrate BAD. While Bcl-xL/BAD association was not significantly modified in LA-treated leiomyomas, BAD/14.3.3 interaction was reduced, due to a 50% decreased 14.3.3 expression. In addition, LA was able to reduce the expression of the antiapoptotic proteins FLIP and PED/PEA15 by 70 and 50% respectively, compared with control samples. We next evaluated the activation of MAP kinases in leiomyomas. Activation of p42 and p44 MAP kinase isoforms was increased by 30% in group B. However, the phosphorylation of the transcription factor Elk1 was not increased in a similar fashion in LA-treated leiomyomas compared with group A. Thus, these data suggest that LA reduction of leiomyoma volume is mediated at least in part by a decreased activation of the PI3K/PKB survival pathway and by the suppression of antiapoptotic factors.

Adrenal adenoma and normal androgen levels in a young woman with polycystic ovaries: a case of idiopathic hirsutism?

A case of unusual combination of polycystic ovaries (PCO), adrenal non-functioning adenoma and severe hirsutism in a young woman from Southern Italy is reported here. A 18-yr-old woman was referred to our Department because of oligomenhorrea, acne and severe hirsutism. During evaluation of the cause of her symptoms, PCO and small left adrenal adenoma were revealed. Although adrenal androgen excess has been shown to dysregulate the hypothalamic-pituitary-gonadal axis, causing PCO-like syndrome, normal circulating androgen values were found. Androgens and cortisol levels were completely suppressed by low-dose dexamethasone test, excluding autonomous steroid secretion by the adrenal mass. Normal response of cortisol and adrenal androgens to corticotropin stimulation test permitted the exclusion of functional adrenal hyperandrogenism. Despite normal LH/FSH ratio, anovulatory cycles were revealed by persistently low progesterone values. Glucose and insulin response to oral glucose tolerance test did not differ from those of normal population. The patient showed an improvement of acne and hirsutism on therapy with estro-progestins (EP). In conclusion, despite normal pattern of serum androgens and LH/FSH ratio, this patient had anovulatory cycles and good response to the EP treatment. These findings suggest that ultrasonography evidence of PCO together with anovulatory cycles contributed to her clinical picture whereas adrenal adenoma seemed to have no relevant role. This case report underlines the need of cautious interpretation of imaging results and clinical signs of severe hirsutism, reminding one that the true cause of a medical problem may not be the most evident.

[Hysteroscopy in the diagnosis of endometrial carcinoma]

OBJECTIVE

To determine the diagnostic value of hysteroscopy in endometrial cancer.

METHODS

216 patients underwent hysteroscopy and endometrial biopsy. A comparison was made between hysteroscopic impression and histological examination.

RESULTS

Sensitivity of hysteroscopy for diagnosing of endometrial cancer was 83.33%, specificity was 99.04%, positive predictive value was 71.42% and negative predictive value was 99.52%.

CONCLUSION

Hysteroscopy was found to have a very important role in the diagnosis of endometrial cancer.

Vanadate regulates the insulin mitogenic effect by modulating SHP-2 association with insulin receptor substrate 1 in JAr human choriocarcinoma cells

Maternal hyperglycemia alters placental glucose metabolism and induces placental hypercellularity. In this study we investigated, in JAr cells, the effect of a protein tyrosine phosphatase inhibitor, vanadate, on the insulin receptor substrate 1 (IRS1)-mitogen-activated protein kinase (MAPK) pathway and on cell proliferation in the presence of normal or high glucose concentration. When JAr cells were cultured in the presence of 25 mmol/l glucose, treatment with vanadate completely prevented SHP-2 association with IRS1. However, vanadate treatment reverted the effect of high glucose on basal and insulin-stimulated insulin receptor and IRS1 phosphorylation. Similar effects were observed on MAPK activation. These events determined a related modification in cell proliferation. Indeed, after high glucose and vanadate treatment, thymidine incorporation levels were comparable to those observed in the presence of normal glucose concentration and in the absence of vanadate. Therefore, in JAr cells, vanadate exerts an inhibitory effect on cell proliferation. This action is related to a modulation of the SHP-2 association with IRS1 that in turn might regulate the phosphorylation state of the main substrates involved in mitogenesic signaling of the insulin receptor.

[Diagnosis of fertility with a personal hormonal evaluation test]

BACKGROUND

To evaluate the efficacy of the urinary test "Persona" in the recognition of the fertile period comparing hormonal assay and monitoring the follicular growth by ultrasonography.

METHODS

Twenty women have used "Persona" for 13 cycles (200 cycles). This device evaluates changes in E-3-G and LH concentrations and estimates the fertile days which are displayed by a red light. Inclusion criteria were: age 22-45, regular menstrual cycles (23-35 days), absence of the polycystic ovary syndrome. The participants underwent vaginal ultrasonography in several days (one of the first 7 "green days", the first "red day", the ovulation day "O", and the first "green day" after ovulation) and determination of blood concentration of LH, in the ovulation day, and progesterone, in the 21st day of cycle.

RESULTS

Vaginal ultrasonography was in agreement with predictions of "Persona" in 96% in the first "green days", in 94% in the first "red day", in 95,8% in the ovulation day and in 97,5% in the first "green day" after ovulation. All participants with ultrasonographic evidence of ovulation had a concentration of LH included in 13-71 mUI/ml range and of progesterone included in 12-50 ng/ml range.

CONCLUSIONS

These results suggest that the "Persona" test is effective in the recognition of the fertile period, but a correct maintenance of the microcomputer is important for the best reliability of method. The method seems to be a wellcome alternative for couples who want to use natural family planning.

[Options for uterine distension during hysteroscopy]

BACKGROUND

This comparative study evaluated effectiveness, complications and patient satisfaction following the use of carbon dioxide (CO2) compared with physiological solution for uterine distension during hysteroscopy. The study was motivated by doubts concerning the choice of distension methods and the implications of their use.

METHODS

The study population included 189 patients attending the outpatient services of the Obstetrics/Gynecological Clinic of the University of Naples for sterility/infertility disorders. Patients were randomly assigned by computer to either of two treatment groups. Both groups underwent hysteroscopy. In Group A (92 patients), uterine distension was performed using carbon dioxide (CO2), while in Group B (97 patients) physiological solution was used. Treatment was assessed for effectiveness, causes of discomfort, patient compliance and satisfaction rate.

RESULTS

Compared with carbon dioxide (CO2), the use of physiological solution as a means of uterine distension was demonstrated certain advantages that were statistically significantly for the parameters of operating time, onset of vagal reactions, causes of discomfort, compliance and satisfaction rate, and cost-effectiveness of equipment.

CONCLUSIONS

The use of physiological solution for uterine distension was observed to enhance patient compliance with hysteroscopy, because the method was better tolerated, more rapid and involved fewer failures.

[Hormone therapies in pregnancy]

Maternal endocrine disorders can have detrimental effects on the fetus and the pregnancy can affect the course of a pre-exisiting endocrinopathy or induce the onset of one of these disorders. Therapies for endocrine disorders are not always safe to administer during pregnancy. Before administering any therapy to the mother, the effects on the fetus, the degree of placental trespassing as well as the potential damaging effects must be assessed. An accurate evaluation of the risks/benefits of any drug to be used on the mother is needed, assessing above all a potential theratogenic effect. In this review, the incidence of the main endocrine disorders, their evolution during pregnancy, their effects on mothers and fetuses and new acquisition on the treatment during pregnancy are discussed.

Conscious sedation versus general anaesthesia for minilaparoscopic gamete intra-Fallopian transfer: a prospective randomized study

BACKGROUND

Gamete intra-Fallopian transfer (GIFT) is a successful technique for infertile women, and is performed almost exclusively by laparoscopy under general anaesthesia.

METHODS

We performed a prospective randomized study of 67 infertile patients to assess the efficacy of minilaparoscopic GIFT under conscious sedation/local anaesthesia (group A) compared with general anaesthesia (group B). Operative and discharge times and pregnancy outcome were evaluated in both groups.

RESULTS

Operative time was similar in both groups. The rate of patients discharged 2 h after surgery was significantly higher in group A. The necessity for postoperative analgesics was significantly higher in group B. No significant differences were noted between the two study groups in terms of pregnancy outcome.

CONCLUSIONS

Conscious sedation and local anaesthesia will allow us to perform an outpatient minilaparoscopic GIFT without the need for general anaesthesia. The simplicity of the method, and the quicker discharge time in comparison with general anaesthesia, offer a detectable benefit for patients.

[Effects of gonadotropins on oocyte maturation]

The use of exogenous gonadotropins, alone or in association with other drugs, is a useful tool in the treatment of anovulation. The first stages of the follicologenesis are gonadotropin independent up to the preantral stage. The final phase of this process begins when follicles grow faster during the luteal phase of the preceding cycle, the so-called gonadotropin-dependent phase. Recent studies confirmed the central role of FSH in follicular and oocyte maturation, but also re-evaluated the actions of LH, in particular during the first phases of these processes. LH induces the physiological development of the follicle, acting only on a limited number of follicles, while FSH protects against atresia. In the absence of FSH the development will be delayed. It seems obvious that both hormones are necessary, that a stimulation protocol may rely only on FSH, but the addition of LH will render it more physiological.

[Changes of leptin levels in menopause]

One of the main advances in the field of metabolic control of body weight and obesity treatment was the identification of the OB protein or leptin, that plays an important role in controlling body weight, signalling to the CNS the amount of body fat. Indeed, leptin levels are positively correlated to indices of body fat, namely total fat mass, percent body fat and body mass index (BMI). This protein may be also the signal that indicates the nutritional status to the reproductive axis. Whether this signal is exerted directly on the gonads or through the neuroendocrine axis is still to be determined. A sexual dimorphism between male and female in serum leptin levels has been observed, with the latter showing higher serum leptin levels. This evidence has led to the hypothesis that estrogens might have a stimulatory role in leptin secretion. To evaluate this hypothesis, several authors have determined serum leptin levels in postmenopausal women that have estrogen levels comparable to those present in men. The results of these studies are contradictory and the aim of this article has been the revision of data present in the literature regarding serum leptin levels in menopause and to correlate them to body composition changes taking place during menopause.

Effectiveness of short-term administration of tibolone plus gonadotropin-releasing hormone analogue on the surgical outcome of laparoscopic myomectomy

OBJECTIVE

To evaluate whether administration of tibolone changes the effectiveness of GnRH analogue administered before laparoscopic myomectomy.

DESIGN

Prospective, randomized, open, placebo-controlled clinical trial.

SETTING

Department of Gynecology and Obstetrics, University of Naples Federico II, Naples, Italy.

PATIENT(S)

66 women with symptomatic uterine leiomyomas.

INTERVENTION(S)

Treatment for 2 months with leuprolide acetate and iron tablets, plus tibolone (group A) or placebo tablets (group B); or with leuprolide acetate and iron tablets (group C).

MAIN OUTCOME MEASURE(S)

Laparoscopic myomectomy at the end of treatment. Operative time and blood loss during surgery were recorded. Uterine volume, volume and number of uterine leiomyomas, volume and echogenicity of the largest uterine leiomyomas, hematologic data, and myoma-related symptoms were evaluated at baseline and 1 week before and after surgery.

RESULT(S)

Uterine and leiomyomata volume and myoma-related symptoms were significantly reduced and hematologic variables improved significantly in groups A and B, compared with baseline values and with group C. Operative time and blood loss were significantly less in groups A and B than in group C. After surgery, hematologic variables were significantly worse in group C compared with groups A and B. During the study no significant difference was detected between groups A and B.

CONCLUSIONS

Administration of tibolone administration in patients treated with GnRH analogue before laparoscopic myomectomy does not change the effectiveness of the analogue administered alone.

Minilaparoscopic ovarian biopsy performed under conscious sedation in women with premature ovarian failure

OBJECTIVE

To evaluate the feasibility of a bilateral multiple ovarian biopsy through minilaparoscopy under local anesthesia and conscious sedation and to assess the efficacy of this technique as compared to the traditional laparoscopic approach.

STUDY DESIGN

Twenty-five infertile women with premature ovarian failure underwent bilateral ovarian biopsy plus chromoperturbation. Twelve patients were treated with minilaparoscopy (minilap group) and preoperatively received mepivacaine for subcutaneous local anesthesia and midazolam plus fentanyl for conscious sedation. Following minilaparoscopy, 40 mL of 0.5% intraperitoneal subdiaphragmatic lidocaine and 5 mL of ropivacaine, 7.5 mg/mL, for infiltration of the trocar insertion sites were administered. Thirteen women (control group) were treated with the traditional laparoscopic approach under general anesthesia. If necessary, ketoprofene or intramuscular ketorolac was administered following surgery. Postoperative pain score was evaluated by a 1-10 visual analogic scale immediately after surgery and in the following 24 hours; in addition, the quantity of ovarian biopsy material for the pathologist and the discharge and operative times were evaluated.

RESULTS

The minilap group had lower postoperative pain scores postoperatively. Operative time was similar in both groups. The rate of discharge two hours after surgery was significantly higher in the minilap group. In all cases the amount of ovarian tissue was sufficient for diagnosis. Twenty-one patients were affected by premature menopause and four by resistant ovary syndrome. The need for postoperative analgesics was significantly higher in the control group.

CONCLUSION

Minilap allows the performance of bilateral, multiple ovarian biopsy under local anesthesia and conscious sedation in association with chromoperturbation and the obtaining a sufficient amount of ovarian tissue for histopathologic diagnosis. Intraperitoneal lidocaine administration and ropivacaine infiltration of the trocar sites were beneficial for patients undergoing operative minilap in a day-surgery setting. The effect of these drugs was obviously temporary; however, low postoperative pain scores and low additional analgesic requirement permitted early discharge, within two hours after surgery.

Minilaparoscopic ovarian drilling under local anesthesia in patients with polycystic ovary syndrome

OBJECTIVE

To assess pain control in patients with polycystic ovary syndrome (PCOS) who are undergoing ovarian drilling during minilaparoscopy under local anesthesia and conscious sedation and to evaluate the efficacy of this protocol compared with the traditional approach in terms of operative and discharge times, subsequent ovulation, and pregnancy.

DESIGN

Prospective randomized study.

SETTING

University hospitals and private day-surgery unit.

PATIENT(S)

Sixty-two infertile women with PCOS.

INTERVENTION(S)

Group A underwent minilaparoscopic ovarian drilling under local anesthesia and conscious sedation. Group B (control group) was treated with traditional ovarian drilling by laparoscopy under general anesthesia.

MAIN OUTCOME MEASURE(S)

Intraoperative pain score in group A. Hormonal profile before and after surgery, operative and discharge times, postoperative analgesic requirements, and reproductive follow-up in both groups.

RESULT(S)

Group A showed a good intraoperative pain score. The hormonal profile after surgery did not differ between groups A and B. Operative times were also similar for both groups. The number of patients discharged within 2 hours after surgery was significantly higher in group A. The need for postoperative analgesics was significantly higher in group B. No statistically significant differences were noted between the groups in terms of pregnancy and ovulation rates.

CONCLUSION(S)

Intraoperative and postoperative local anesthesia plus conscious sedation allows outpatient bilateral ovarian drilling by minilaparoscopy to be performed without general anesthesia. The high pregnancy rates, the simplicity of the method, and the faster discharge time offer a new option for patients with PCOS who are resistant to clomiphene citrate. Moreover, ovarian cauterization can be performed simultaneously with a diagnostic minilaparoscopy and integrated into the infertility workup of these patients.

[Ovarian drilling in minilaroscopy and local anesthesia in the therapy of polycystic ovarian syndrome]

BACKGROUND

To evaluate the feasibility of ovarian drilling using minilaparoscopy under local anesthesia and to determine its efficacy in the surgical treatment of polycystic ovarian syndrome.

METHODS

Prospective randomized study carried out in an out patient service on 62 women affected by PCOS divided into two groups: 32 patients (group A) underwent bilateral ovarian drilling by minilaparoscopy under local anesthesia and 30 patients (group B) underwent bilateral ovarian drilling by traditional laparoscopy under general anesthesia.

RESULTS

Operation times were not different between the two groups. Discharge time was significantly lower in group A in comparison to group B. The rate of patients discharged after 2 hours was significantly higher in group A. The need for additional analgesia was lower in group A in comparison to group B. Serum LH, A and T levels were significantly reduced after surgery in both groups. Pregnancy rate after 1-year follow-up was higher, although not significantly in group A. Ovulation and abortion rates were not different between the two groups.

CONCLUSIONS

Ovarian drilling in minilaparoscopy under local anesthesia is a new option for gynecologists, allowing similar therapeutical results to those achieved by traditional laparoscopy, but with the benefits of a less invasive technique that can be carried out in an outpatient service without the need for general anesthesia.

The importance of user compliance on the effectiveness of natural family planning programs

Nowadays, there is an increasing interest in natural family planning methods. The biological basis for the application of natural family planning methods is the recognition of ovulation and, more extensively, of the fertile period. Several studies in the past decade have shown the efficacy of these methods and that the main cause of failure was either a conscious departure from the rules of the method or erroneous application of the method. Another problem affecting natural family planning that has been highlighted is the relatively high discontinuation rate. These features are probably due to low compliance in applying the natural family planning rules, which may be too demanding for a number of couples. In this review, there are comments on the application of natural family planning methods, the discontinuation rates and the failure of the method due to mistakes in the studies carried out in the past 15 years. Steps that can be taken to limit mistakes and discontinuity are also addressed.

Efficacy of methods for determining ovulation in a natural family planning program

OBJECTIVE

To evaluate the efficacy in ovulation detection of methods used in natural family planning in comparison with pelvic ultrasonography.

DESIGN

Prospective analysis of ovulation detection by natural family planning methods and ultrasonography.

SETTING

Natural family planning clinic, Department of Obstetrics and Gynecology, University of Naples "Federico II".

PATIENT(S)

Forty healthy women who were highly motivated to use natural family planning.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Transvaginal ultrasonographic findings, urinary LH levels, salivary beta-glucuronidase activity, salivary ferning levels and characteristics of cervical mucus, and BBT.

RESULT(S)

Urinary LH level determination yielded a 100% correlation with the simultaneous ultrasonographic diagnosis of ovulation. Mucus sensations and characteristics yielded a 48.3% correlation when simultaneously evaluated with ovulation. Beta-glucuronidase levels yielded a 27.7% correlation. The salivary ferning test had a 36.8% ovulation-detection rate the day of ovulation, but 58.7% of results were uninterpretable. Body temperature measurements yielded a 30.4% correlation with the simultaneous ultrasonographic diagnosis of ovulation.

CONCLUSION(S)

Measuring urinary LH levels is an excellent method for determining ovulation. Although variations in mucus characteristics and basal body temperature correlate somewhat with ovulation, the length of the fertile period is overestimated with these methods. The salivary ferning test and measurement of beta-glucuronidase levels are not good methods for home ovulation testing.

Topical anesthesia for office hysteroscopy. A prospective, randomized study comparing two modalities

OBJECTIVE

To compare the efficacy of two modalities of local anesthesia for diagnostic hysteroscopy in different steps of the procedure in terms of pain control and time required for the examination.

STUDY DESIGN

One hundred eighty women undergoing diagnostic hysteroscopy were included in the study and randomly allocated to one of two groups. Group A (n = 88), treated with prilocaine plus lidocaine cream, and group B (n = 92), treated with lidocaine spray, were compared with group C, a control group (n = 165), including all the hysteroscopies performed without anesthesia in the same period. Duration of the hysteroscopic examination was recorded; intensity of pain induced by the procedure and shoulder pain 10 minutes after the end of the examination were recorded for all patients on the basis of a four-point pain scale.

RESULTS

Duration of the procedure required was two minutes in a significantly lower percentage of patients in group A as compared to groups B and C. Furthermore, in group A we found a significant reduction in pain at placement of the tenaculum in comparison to groups B and C. In groups A and B, no patient experienced a "very painful" grade of pain versus 4.8% in group C. The vasovagal reaction rate was also significantly lower in both treated groups in comparison to the control group. Furthermore, the intensity of shoulder pain was significantly lower in the group receiving prilocaine plus lidocaine cream as compared to the other two groups.

CONCLUSION

Local anesthesia has a beneficial effect, at least in those hysteroscopies presumed to be, for whatever reasons, more cumbersome to perform. Prilocaine plus lidocaine cream was more effective than lidocaine spray in decreasing pain at placement of the tenaculum and shoulder pain after the procedure.

Ultrasonographic prediction of the efficacy of GnRH agonist therapy before laparoscopic myomectomy

STUDY OBJECTIVE

To assess ultrasonographic prediction of the efficacy of administration of a gonadotropin-releasing hormone (GnRH) analog before laparoscopic myomectomy.

DESIGN

Prospective, randomized study of women treated consecutively from September 1994 to July 1996 (Canadian Task Force classification I).

SETTING

Endogyn Service, Private Endoscopic Associates, Naples, and Department of Gynecologic and Pediatric Sciences, Reggio Calabria University, Catanzaro, Italy.

PATIENTS

Sixty-seven infertile women with symptomatic uterine myomata, mainly intramural, undergoing laparoscopic myomectomy.

INTERVENTIONS

Patients were prospectively randomized in two groups. Group A received preoperative administration of two injections of a depot formulation of leuprolide acetate 28 days apart, and group B underwent direct surgery. In each group we studied the number, diameter, and echogenicity of larger fibroids; resistance index of uterine arteries and myoma vessels; operating time; and blood loss.

MEASUREMENTS AND MAIN RESULTS

The two groups did not significantly differ in baseline ultrasonographic parameters. Both blood loss (p <0.01) and operating time (p <0.05) were significantly lower in group A. However, operating time was significantly longer when the main myoma was markedly hypoechoic.

CONCLUSION

Our data confirm the therapeutic efficacy of administration of a GnRH analog before laparoscopic myomectomy in reducing blood loss and decreasing operating time in all cases except those with markedly hypoechoic fibroids.

Postoperative pain control after microlaparoscopy in patients with infertility: a prospective randomized study

OBJECTIVE

To evaluate the efficacy of intraperitoneal subdiaphragmatic instillation of lidocaine and trocar site infiltration of bupivacaine to minimize postoperative pain after diagnostic microlaparoscopy performed under local anesthesia with conscious sedation.

DESIGN

Prospective randomized study.

SETTING

Day-surgery unit of Endogyn Service, Naples, and Department of Gynecologic and Pediatric Sciences, Reggio Calabria University, Catanzaro, Italy.

PATIENT(S)

Sixty-one women with infertility.

INTERVENTION(S)

All patients received local anesthesia and conscious sedation before surgery. After the microlaparoscopy, the treatment group was given 40 mL of intraperitoneal subdiaphragmatic 0.5% lidocaine and 5 mL of 0.5% bupivacaine that was infiltrated into the trocar insertion sites. The control group received no treatment. When necessary, ketoprofene or ketorolac were administered IM after surgery.

MAIN OUTCOME MEASURE(S)

Postoperative pain was evaluated with the use of a visual analog scale with scores ranging from 1-10 immediately after surgery and over the next 48 hours. The rate at which patients were discharged from the hospital 2 hours after surgery also was recorded.

RESULT(S)

The treatment group had significantly lower pain scores both immediately after surgery and 1, 3, and 6 hours afterward. The need for postoperative analgesics also was significantly lower in the treatment group. The rate at which patients were discharged 2 hours after surgery was significantly higher in the treatment group.

CONCLUSION(S)

Postoperative intraperitoneal lidocaine administration and bupivacaine infiltration of the trocar sites is beneficial for patients undergoing microlaparoscopy. The effect of these drugs is temporary, but they can significantly decrease postoperative pain for approximately 6 hours and reduce the need for additional analgesics. Most important, the rate at which patients can be discharged from the hospital only 2 hours after surgery is increased significantly.

Ultrasonographic measurement of endometrial thickness during hormonal replacement therapy in postmenopausal women

The objective of this study was to measure endometrial thickness by transvaginal ultrasonography during two regimens of hormonal replacement therapy (HRT) in postmenopausal women and to compare these data with endometrial histology. Transvaginal ultrasonographic evaluation of endometrial thickness and endometrial biopsy were performed in 80 postmenopausal women before and after 6 months of HRT (between the 24th and the 28th day of the cycle). The group was randomized so that 40 women (Group A) were treated with a continuous sequential regimen consisting of 5 micrograms/day of estradiol continuously and 5 mg/day of medrogestone from the 17th to the 28th day of the cycle; and 40 women (Group B) were given continuous administration of 50 micrograms/day estradiol and 5 mg/day medrogestone. Prior to therapy, there was no significant difference in mean endometrial thickness between the groups. After 6 months of therapy, endometrial thickness was significantly increased in comparison with basal values in both groups. The mean value was significantly higher (p < 0.001) in Group A (8.5 +/- 3.7 mm) than in Group B (3.6 +/- 1.3 mm). In Group A, endometrial thickness was < or = 4 mm in 16.7% of patients and < or = 8 mm in 69.5% of patients. In Group B, 91% of patients had an endometrium of < or = 4 mm. In both groups, the thickness of the atrophic endometrium was less than that of the other histological types of endometrium (4.1 +/- 0.3 mm for Group A and 3.5 +/- 1.2 mm for Group B). In Group A, the difference in mean endometrial thickness between the proliferative and secretory endometrium was not statistically significant. In both groups, the transvaginal ultrasonographic measurement of endometrial thickness of < or = 4 mm had a high sensitivity for detecting atrophic endometrium (83.3% for Group A and 93.7% for Group B).

Pain control after microlaparoscopy

STUDY OBJECTIVE

To evaluate the efficacy of intraperitoneal subdiaphragmatic instillation of 0.5% lidocaine and 0.5% bupivacaine infiltration of cannula sites to control pain after diagnostic microlaparoscopy.

DESIGN

Prospective, randomized study. (Canadian Task Force classification I).

SETTING

Day surgery unit of Endogyn Service, Private Endoscopic Associates, Naples, and Department of Gynecologic and Pediatric Sciences, Reggio Calabria University, Catanzaro, Italy.

PATIENTS

Forty women treated for infertility.

INTERVENTIONS

The treated group received 0.5% intraperitoneal subdiaphragmatic lidocaine 40 ml and 0.5% bupivacaine 5 ml infiltration of cannula insertion sites. The control group received no treatment. In all patients the procedure was performed with atropine 0.5 mg, fentanyl 0.1 mg, droperidol 5 mg, and local anesthesia. Postoperatively, depending on the need, ketoprofene 100 mg or ketorolac 30 mg was administered intramuscularly.

MEASUREMENTS AND MAIN RESULTS

Postoperative pain score was evaluated by visual analog scale immediately postoperatively and 1, 3, 6, 12, 24, 36, and 48 hours afterward. The treated group had significantly lower pain scores at the end of surgery and at 1-, 3-, (p <0.01), and 6-hour intervals (p <0.05). No significant differences in scores between groups were observed starting from 6 hours postoperatively.

CONCLUSION

Postoperative intraperitoneal lidocaine and bupivacaine infiltration of cannula sites offered a detectable benefit to women undergoing diagnostic microlaparoscopy. The effect was temporary, but induced a significant decrease in the postoperative pain for approximately 6 hours.

Prenatal diagnosis of congenital granular cell epulis

Congenital granular epulis is a benign tumor that has rarely been diagnosed prenatally, although there have been numerous reports on its postnatal diagnosis. We report a case of large granular epulis diagnosed at 31 weeks' gestation in a woman whose previous anomaly scan had been normal. The lesion was 2.5 cm in diameter, pedunculated, and arose from the maxilla. It was completely surgically removed following preterm vaginal birth and histologically examined. The tumor did not prevent deglutition of the amniotic fluid and did not interfere with feeding or respiration, but prevented complete closure of the lips. We discuss the fetal management and the theories of histogenesis, and highlight the importance of early diagnosis and treatment.

A prospective randomized study to evaluate leuprolide acetate treatment before laparoscopic myomectomy: efficacy and ultrasonographic predictors

OBJECTIVE

Aims of our study were as follows: (1) to evaluate the therapeutic efficacy of the preoperative administration of a gonadotropin-releasing hormone analog before laparoscopic myomectomy and (2) to assess whether any ultrasonographic parameter of the fibroids (number, size, Doppler velocimetry, or echogenicity) was of prognostic value.

STUDY DESIGN

A prospective randomized study was performed on 67 patients with symptomatic uterine fibroids that were mainly intramural; these patients were undergoing laparoscopic myomectomy. Patients were randomized either to preoperative administration of two injections of a depot formulation of leuprolide acetate 28 days apart (group A, n = 35) or to direct surgery (group B, n = 32). In each group we studied the number, volume, and echogenicity of the larger fibroids; the resistance index of uterine arteries and of fibroid vessels; hematologic parameters; operative time; and blood loss.

RESULTS

The two groups did not differ significantly in basal ultrasonographic parameters and hematologic data. Postoperatively, the red blood cell count and the serum hemoglobin and iron levels were significantly (p < 0.05) lower in group B. Both blood loss (p < 0.01) and operative time (p < 0.05) were significantly lower in group A. However, the operative time was significantly longer when the main fibroid was markedly hypoechoic, probably because the increased softness of the tumor after leuprolide acetate pretreatment makes its enucleation much more cumbersome.

CONCLUSION

Our data confirm the therapeutic efficacy of preoperative administration of a gonadotropin-releasing hormone analog before laparoscopic myomectomy in reducing the blood loss and in decreasing the operative time. This preoperative course of leuprolide acetate in hypoechoic fibroids, because of the further reduction of the density of the myomas, causes a significant (p < 0.05) increase in operative time.

[Underestimation of ovarian pathology. Clinical aspects and medico-legal considerations]

In this review are reported the data regarding medical and gynecological responsibility in case of underestimation of ovarian pathology compared to epidemiological data. It is important to recognize the characteristics of the symptomatology, in general very mild, and the diagnostic tests suitable to detect ovarian masses. Four steps in the management of ovarian masses which may generate errors in the diagnostic and therapeutical process are stressed: the clinical diagnosis phase, the surgical phase, the management of borderline tumors, and the follow-up. It is also highlighted the importance of the concept of the "delay" in the medical action, both diagnostic and therapeutical, and an involvement of the Public Health Service, both in the prevention and the treatment of ovarian lesions, is ipothesized.

Increased concentrations of renin, aldosterone and Ca125 in a case of spontaneous, recurrent, familial, severe ovarian hyperstimulation syndrome

We report for the first time increased concentrations of aldosterone and renin in a case of spontaneous, recurrent, familial, severe ovarian hyperstimulation syndrome (OHSS). High concentrations of Ca125 were also found. Our patient was a 26 year old woman, gravida 2, para 1, affected by severe OHSS, who denied having ever consumed any ovulation drug. Both the patient and her only sister had suffered from a similar condition in their previous pregnancies. The patient was treated with i.v. fluid therapy. Paracentesis was performed on one occasion. The patient was dismissed after 25 days in good condition. Blood count and blood chemistry confirmed the severity of the clinical picture. We conclude that spontaneous OHSS, although very rare, may have been underestimated so far. It can be recurrent and may also be familial. The intra-ovarian prorenin-renin-angiotensin system may play a role in its aetiopathogenesis.

Controlled ovarian hyperstimulation: comparison between u-hFSH conventional protocol and a personalized approach

OBJECTIVE

To investigate the therapeutic effectiveness in infertile couples with anovulatory, mild endometriosis-related and unexplained infertility of a personalized approach to controlled ovarian hyperstimulation (COH) (group A) on the basis of body mass index (BMI) and waist/hip ratio (WHR) in comparison to a conventional protocol (group B).

RESULTS

In group A, we obtained a significantly higher pregnancy rate and number of multifollicular cycles in comparison to group B. In addition, the pregnancy rate/ovulatory cycle and the number of ovulatory cycles were higher (but not significantly) in group A. In group B, we observed a not significantly higher number of monofollicular cycles and required length of stimulation in comparison to group A.

CONCLUSION

A personalized therapeutic protocol, based on simple criteria such as BMI and WHR, leads to a higher number of single and twin pregnancies, without any significant increase of higher grade multiple pregnancies or severe ovarian hyperstimulation syndrome.

An overview on the effectiveness of natural family planning

Recent years have witnessed important developments in natural family planning (NFP), which is based on the observation of fertile and infertile periods of the menstrual cycle, so that the couple is able to know when sexual intercourse may lead to a pregnancy. A review of the main studies regarding the effectiveness of NFP showed a decrease in the Pearl Index and life table values from the early 1980s to date, indicating that progress both in the teaching and in the application of these contraception, methods has been achieved. The main cause of lack of success seems to be the misapplication of NFP rules, whereas the errors due to the method itself are few. Furthermore, it seems that the symptothermal method might give better results than the ovulation method, even though no comparative study has been carried out, and that the first studies on the lactational amenorrhea method show encouraging results. Finally, it seems that NFP is best suited for 'spacers' of pregnancies, rather than for 'limiters'. Indeed, the former are more likely to show good compliance, since the sexual abstinence periods are limited and an unwanted pregnancy is not regarded as a completely negative event.

[Postmenopausal osteoporosis: therapeutic approaches]

The preventive and therapeutical measures to be implemented the post-menopausal osteoporosis are varied, although there is no clear, single protocol of intervention. ESTROGENS AND PROGESTOGENS: It si verify that the administration of estrogens and/or progestogens prevents bone loss with an action on mineral components of bone and on collagenic metabolism. BIPHOSPONATES: Operate inhibiting mineralization and, particularly, bone reabsorption. At present its use, in low dosages, is reserved to "fast bone loser" patients. CALCITONIN: It increases bone mass and significantly reduces the frequency of fractures in comparison with only calcium, but its use is limited by high costs. IPRIFLAVONE: Anti-reabsorption effects has on bone and stimulates osteoblastic activity; besides, it seems to developed the effect of estrogens on the bone. FLUORIDES: Fluorides also operate on both components of bone turnover, with a most important action on bone formation. An interesting approach is the association of low doses of monofluorophosphate with calcium. However, further confirmation of the "quality" of neoformed bone is necessary. CALCIUM: Calcium supplementation is obligatory where the alimentary supply of calcium is lower then 1 g/die or where an osteomalacic component coexists; only dosages higher than 15 g/die can produce/pharmacological effects on bone turnover. CALCITRIOL: The use is still disputed. The calcitriol-calcium association seems convincing haveved. ORG: OD 14. The efficacy of this synthetic steroid to prevent bone loss is probably superimposable on the efficacy of classic estrogen therapy.