[Show abstract][Hide abstract] ABSTRACT: This study aimed to assess the interest in robot-assisted laparoscopy for deep infiltrating endometriosis and to investigate the perioperative results.
From November 2008 to April 2012, 164 women with stage 4 endometriosis who underwent robot-assisted laparoscopy (da Vinci Intuitive Surgical System) were included by to eight international participating clinical centers. This study evaluated the procedures performed, the duration of the intervention, the complications, the recurrence, and the impact on fertility.
The average operative time was 180 min. The main complications were laparotomy (n = 1, 0.6 %), sutured bowel injury (n = 2, 1.2 %), transfusion for a 2,300-ml bleed (n = 1), prolonged urinary catheterization (n = 1, 0.6 %), ureter-bladder anastomotic leak (n = 1, 0.6 %), and ureteral fistula after ureterolysis (n = 2, 1.2 %). The reoperation rate was 1.8 % (n = 3). The mean follow-up period was 10.2 months. A full recovery was experienced by 86.7 % (98/113) of the patients. After surgery, 41.2 % (42/102) of the patients had a desire for pregnancy, and 28.2 % (11/39) of them became pregnant.
This study analyzed the largest series of robot-assisted laparoscopies for deep infiltrating endometriosis published in the literature. No increase in surgical time, blood loss, or intra- or postoperative complications was observed. The interest in robot-assisted laparoscopy for deep infiltrating endometriosis seems to be promising.
[Show abstract][Hide abstract] ABSTRACT: Objective: Thyroid function and gonadal axis are related throughout the woman's fertile period. Modifications of thyroid hormone levels have been reported as a consequence of controlled ovarian stimulation for infertility.Methods: A 28-yr old woman, with regular menses and a previous evidence of euthyroidism, underwent controlled ovarian hyperstimulation for assisted reproductive technology. FT4, FT3, TSH, thyroperoxidase and thyroglobulin autoantibodies were measured before COH. FT4, FT3 and TSH were re-evaluated 6 days, 2 wks (during oocyte retrieval) and one month after the beginning of the procedure.Results: Basal evaluation showed subclinical autoimmune hypothyroidism. The patient became hypothyroid at 6 day and 2 wks and returned spontaneously to euthyroidism one month after the COH.Conclusion: This is the first case of a woman with an unknown subclinical autoimmune hypothyroidism who developed overt and transient hypothyroidism as a consequence of COH. A careful thyroid evaluation is advised in women undergoing COH.
[Show abstract][Hide abstract] ABSTRACT: Androgens play a primary role in female physiopathology. The age-related reduction in the production of ovarian and adrenal androgens may significantly affect women's health. The decline of circulating androgens results from a combination of two events: reduced ovarian production and aged-related decline in adrenal androgen synthesis. The relative androgen deficiency in pre- and postmenopausal women may induce impairment of sexual function, libido, well-being, energy and may contribute to reduced cognitive functions. Whether androgen deficiency also affects cardiovascular or bone biology in women during reproductive aging is still controversial. Both in the central nervous system and peripheral tissues, there are multiple ways whereby androgens target their specific actions through a particular tropism of the brain areas that are involved in sexual function, behavior and cognition. Among circulating available androgens that are involved in several domains of sexual response, adrenal androgens seem to be related to some sexual symptoms as well as diminished cognitive function in postmenopausal women. The possibilities of treating low sexual desire/hypoactive sexual desire disorder are multifaceted and should include the combination of both pharmacological treatments able to maximize biological signals that drive the sexual response as well as individualized psychosocial therapies to overcome personal and relational difficulties. Transdermal testosterone has been proved to be effective but the use of additional treatment like oral or vaginal dehydroepiandrosterone is still controversial, despite many evidences support it. The decision to treat premenopausal or postmenopausal women with signs/symptoms of androgen insufficiency is mainly based on the clinical judgment, together with estrogens co-administration and following informed consent related to the unknown long-term risks.
Archives of Gynecology 08/2013; · 0.91 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Abstract Objective: To investigate whether laboratory strategies can improve in vitro fertilization (IVF) outcome in poor responder patients. We compared the effectiveness of conventional IVF and intra cytoplasmic sperm injection (ICSI) in assisted reproductive technologies cycles in which only one or two oocytes were retrieved at ovarian pick up, in the absence of male infertility. Design: Retrospective analysis of 425 cycles in 386 poor responder patients. Intervention(s): Standard stimulation protocol with gonadotropins and gonadotropin releasing hormone (GnRH) antagonist. Main outcome measure(s): Fertilization rate, cleavage rate, good-quality embryo rate, implantation rate, clinical pregnancy rate (PR) and miscarriage rate. Results: IVF was found to be more advantageous for implantation and PR, especially in patients under 35 years and in women aged between 35 and 38 years. No differences were noted in the other parameter evaluated. Patients aged over 38 years showed no difference using the two techniques. Conclusion: The employment of ICSI in the absence of a male factor can reduce reproductive outcome in poor responder. Probably because of aging-related defects overcoming the advantage of sperm selection, the choice of IVF technique is not relevant to reproductive success when oocyte quality is compromised by reproductive aging. Although further randomized trials are needed to confirm our results, we propose that, in absence of male infertility, conventional IVF might be the technique of choice in young patients, especially in those aged below 35 years.
[Show abstract][Hide abstract] ABSTRACT: Objective
To evaluate cumulus cell (CC) expression profile modulation after different stimulation protocols.
CCs transcriptome variations were evaluated by microarray in patients undergoing different treatments for ovarian stimulation, namely, r-hLH + r-hFSH and hp-hMG, compared with a control group treated with r-hFSH.
Healthy patients undergoing assisted reproduction protocols.
Sixteen healthy women with regular cycles and tubal disease or unexplained infertility.
Four patients received hp-hMG, four received r-hFSH + r-hLH, and eight received r-hFSH daily. Aspiration of the oocytes was performed 36 hours after hCG administration. Only samples derived from cumulus-oocyte complexes containing mature oocytes showing polar body were processed.
Main Outcome Measure(s)
Comparison of genes differentially expressed in both treatment groups with the use of a hierarchic clustering analysis.
Data clustering analysis allowed detection of four clusters containing genes differentially expressed in both treatment groups compared with control. Functional analysis of the affected transcripts revealed genes involved in oocyte development and maturation.
r-hLH and hCG, though acting on the same receptor, produce a differential activation of intracellular pathways. It can be hypothesized that this effect depends on their different structures and specific binding affinity for the receptor.
Fertility and sterility 06/2013; 99(7):2000–2008.e1. · 3.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE: The feasibility and safety of robotic surgery have been demonstrated by numerous comparative studies. The aim of our study was to compare several parameters related to robotic surgical procedures in uterine pathology, and to analyse clinico-biological parameters that may influence the post-operative evolution of the patients. STUDY DESIGN: Retrospective analysis of 100 patients with uterine pathology who had undergone robotic-assisted laparoscopic surgery at the Santa Chiara Hospital, Pisa, Italy, between 2008 and 2010. RESULTS: Duration of surgery, docking, hysterectomy, uterine suture, blood loss, and days of hospitalisation significantly improved in parallel with the increasing experience of the surgical team. Paradoxically, the length of myomectomy increased in the same time interval, probably due to operating on more complex clinical cases with this procedure as the surgical team's experience grew. None of the robotic surgeries was converted to laparotomy. No intra- or post-operative complications were noted. CONCLUSION: Since robotic-assisted laparoscopic surgery is becoming the preferred surgical technique for uterine pathology treatment, more clinical studies and development of protocols are essential to increase the quality of surgical treatment.
European journal of obstetrics, gynecology, and reproductive biology 04/2013; · 1.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Abstract Delta-5 androgen therapies seem to enhance the sexual response in experimental animal models and in clinical trial. This study analyzed the influence of dehydroepiandrosterone (DHEA) administration on receptive and proceptive components of female rat sexual behavior. Ovariectomized (OVX) adult rats were divided in six groups submitted to the following treatments for 4 weeks: DHEA 0.5 and 5 mg/kg, by oral gavage, alone or in combination with estradiol benzoate 3 µg/rat; EB 3 and 10 µg/rat as control groups. All animals received progesterone (500 µg/rat) 4 h before the behavioral tests. All animals were tested for the following: receptivity and proceptivity weekly for 4 weeks; partner preference and paced mating behavior at the end of the treatments. Oral administration of DHEA at 5 mg/kg in EB primed rats was able to significantly increase proceptive behaviors, already after 1 week of treatment. The increase was more marked after 3 and 4 weeks of treatment. Behavioral changes were associated to modifications of circulating and brain level of allopregnanolone and beta-endorphin, although circulating hormonal levels were within a physiological range. Hormonal treatment using physiological doses of delta-5 androgens (DHEA) positively affects sexual motivation in OVX rats.
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: The field of laparoscopy has undergone several changes to improve the morbidity and cosmesis of laparoscopic surgery. The robotic single-site surgery is the inevitable hybridization of robotic technology with laparoendoscopic single-site surgery. METHODS: Perioperative information of 12 robotic single-site hysterectomies (R-SSH) were collected to evaluate the surgical feasibility and the possible influence of the body mass index (BMI) and the uterine weight on operative times. RESULTS: The mean operative time was 85 ± 33 min (range, 355 to 149 min), the mean docking time was 9 ± 3 min, and the mean console time was 76 ± 33 min. The mean blood loss was 80 ± 18 mL, and the median weight of resected uteri was 220 ± 45 g. No serious postoperative complications occurred. The CUSUM learning curve was observed to consist of two different phases: phase 1 (the initial 6 cases) and phase 2 (the last 6 cases) with significant reduction in operative and console time observed between the two phases. For BMI, no correlation was found with operative times, console times, and docking times, and no correlation was found between uterine weight and operative time. CONCLUSIONS: This series, identifying two different phases of the learning curve and suggesting that the initial learning phase for the procedure can be achieved after six cases, confirms the feasibility and safety of a robotic approach for single-site hysterectomy. However, the limits of this study mainly rely on the limited casuistic and short follow-up, although the preliminary results appear promising. Larger series and prospective studies comparing R-SSH hysterectomy with standard robotic multiport hysterectomy are necessary to define properly the role of this innovative surgical technique.
[Show abstract][Hide abstract] ABSTRACT: Brain-Derived Neurotrophic Factor (BDNF) is a neurotrophin abundantly expressed in several areas of CNS and known to induce a lasting potentiation of synaptic efficacy, to enhance specific learning and memory processes. BDNF is one of the key molecules modulating brain plasticity and it affects cognitive deficit associated with aging and neurodegenerative disease. Several studies have shown an altered BDNF production and secretion in a variety of neurodegenerative diseases like Alzheimer's and Parkinson's diseases but also in mood disorders like depression, eating disorders and schizophrenia. Plasma BDNF is also a biomarker of impaired memory and general cognitive function in ageing women. Gonadal steroids are involved in the regulation of several CNS processes, specifically mood, affective and cognitive functions during fertile life and reproductive aging. These observations lead many scientists to investigate a putative co-regulation between BDNF and gonadal and/or adrenal steroids and their relationship with gender difference in the incidence of mental diseases. This overview aims to summarize the current knowledge on the correlation between BDNF expression/function and both gonadal (progesterone, estrogens, testosterone) and adrenal hormones (mainly cortisol and DHEA) with relevance for clinical application.
[Show abstract][Hide abstract] ABSTRACT: Abstract Operative laparoscopy is the gold standard in the treatment of endometriotic ovarian cysts. Excisional surgery is the best technique to prevent recurrences and improve symptoms but it may result in ovarian reserve damage due to the removal of healthy ovarian cortex. The aim of this study was to investigate the extent of the ovarian reserve damage after stripping technique of unilateral endometriomas, by dosing the Anti-Müllerian Hormone (AMH). This prospective study was conducted at the Center of Minimally Invasive Pelvic Surgery of the Department of Health of Woman and Child, University of Padua, from October 2010 to June 2012. Twenty-five women underwent excision of monolateral endometriosis ovarian cyst by stripping without accessing a bipolar coagulation and performing an intracortical suture. The AMH serum levels were estimated in the early proliferative phase of the cycle, before surgery (time 0), 24 h after surgery (time 1), the first menstrual cycle after surgery (time 2) and the third menstrual cycle after surgery (time 3). We found a nonstatistically significant decreases in serum AMH levels after surgical excision of the cysts. Our results suggest that an appropriate surgical technique, without the use of the bipolar coagulation of ovarian border, does not determine a significant reduction of ovarian reserve.
[Show abstract][Hide abstract] ABSTRACT: Abstract Objective: To evaluate the effects the administration of myo-inositol (MYO) on hormonal parameters in a group of polycystic ovary syndrome (PCOS) patients. Design: Controlled clinical study. Setting: PCOS patients in a clinical research environment. Patients: 50 overweight PCOS patients were enrolled after informed consent. Interventions: All patients underwent hormonal evaluations and an oral glucose tolerance test (OGTT) before and after 12 weeks of therapy (Group A (n¼10): MYO 2 g plus folic acid 200 mg every day; Group B (n¼10): folic acid 200 mg every day). Ultrasound examinations and Ferriman-Gallwey score were also performed. Main outcome measures: Plasma LH, FSH, PRL, E2, 17OHP, A, T, glucose, insulin, C peptide concentrations, BMI, HOMA index and glucose-to-insulin ratio. Results: After 12 weeks of MYO administration plasma LH, PRL, T, insulin levels and LH/FSH resulted significantly reduced. Insulin sensitivity, expressed as glucose-to-insulin ratio and HOMA index resulted significantly improved after 12 weeks of treatment. Menstrual cyclicity was restored in all amenorrheic and oligomenorrheic subjects. No changes occurred in the patients treated with folic acid. Conclusions: MYO administration improves reproductive axis functioning in PCOS patients reducing the hyperinsulinemic state that affects LH secretion.
[Show abstract][Hide abstract] ABSTRACT: Objective
To compare the safety, efficacy, and tolerability of subcutaneous progesterone (Prolutex, 25 mg; IBSA Institut Biochimique SA) with vaginal progesterone gel (Crinone, 8%; Merck Serono) for luteal phase support (LPS) in assisted reproduction technologies (ART) patients.
Prospective, open-label, randomized, controlled, parallel-group, multicenter, two-arm, noninferiority study.
Thirteen European fertility clinics.
A total of 683 ART patients randomized to two groups: Prolutex, 25 mg subcutaneously daily (n = 339); and Crinone, 90 mg 8% gel daily (n = 344).
In vitro fertilization and embryo transfer were performed according to site-specific protocols. On the day of oocyte retrieval, Prolutex or Crinone gel was begun for LPS and continued for up to 10 weeks.
Main Outcome Measure(s)
Ongoing pregnancy rate.
The primary end point, ongoing pregnancy rates at 10 weeks of treatment were 27.4% and 30.5% in the Prolutex and Crinone groups, respectively (intention to treat [ITT]). The nonsignificant difference between the groups was −3.09% (95% confidence interval [CI] −9.91–3.73), indicating noninferiority of Prolutex to Crinone. Delivery and live birth rates resulted to be equivalent between the two treatments (26.8% vs. 29.9% in the Prolutex and Crinone groups, respectively [ITT]; difference −3.10 [95% CI −9.87–3.68]). No statistically significant differences were reported for any of the other secondary efficacy endpoints, including comfort of usage and overall satisfaction.
Implantation rate, pregnancy rate, live birth rate, and early miscarriage rate for Prolutex were similar to those for Crinone. The adverse event profiles were similar and Prolutex was safe and well tolerated.
Clinical Trial Registration Number
[Show abstract][Hide abstract] ABSTRACT: Thyroid autoimmunity is the most prevalent autoimmune state that affects up to 5-20% of women during the age of fertility. Prevalence of thyroid autoimmunity is significantly higher among infertile women, especially when the cause of infertility is endometriosis or polycystic ovary syndrome. Presence of thyroid autoimmunity does not interfere with normal embryo implantation and have been observed comparable pregnancy rates after assisted reproduction techniques in patients with or without thyroid autoimmunity. Instead, the risk of early miscarriage is substantially raised with the presence of thyroid autoimmunity, even if there was a condition of euthyroidism before pregnancy. Furthermore the controlled ovarian hyperstimulation, used as preparation for assisted reproduction techniques, can severely impair thyroid function increasing circulating estrogen levels. Systematic screening for thyroid disorders in women with a female cause of infertility is controversial but might be important to detect thyroid autoimmunity before to use assisted reproduction techniques and to follow-up these parameters in these patients after controlled ovarian hyperstimulation and during pregnancy.
[Show abstract][Hide abstract] ABSTRACT: To analyze the effect of dehydroepiandrosterone (DHEA) supplementation on follicular microenvironment and on in vitro fertilization (IVF) outcomes among poor responder patients.
We enrolled 24 patients diagnosed as poor responders based on ESHRE consensus criteria. One group received 25 mg/die three times daily of DHEA supplementation for 3 months previous to IVF cycle, while the other did not receive any treatment. COH was performed with rFSH and hMG, and a GnRH antagonist was administered according to a flexible protocol. We evaluated perifollicular vascularization of recruited follicles through power Doppler blood flow analysis and follicles were graded as described by Chui et al. Follicular fluids (FF) from F3-F4 follicles were collected, and FF levels of vascular endothelial growth factor (VEGF) and hypoxic inducible factor1 (HIF1) were measured.
FF levels of HIF1 were statistically significant lower in women treated with DHEA (14.76 ± 51.13 vs. 270.03 ± 262.18 pg/ml; p = 0.002). On the contrary, VEGF levels did not differ between the two groups. Concerning COH, in the DHEA-group the mean duration of treatment was significantly shorter (9.83 ± 1.85 vs. 12.09 ± 2.81; p = 0.023). Total numbers of oocytes retrieved, fertilized oocytes, good quality embryos, number of transferred embryos and clinical pregnancies tended to be higher in study group, but the results were not significant. On the other hand, considering the oocytes retrieved in selected F3-F4 follicles, there was a relation between HIF1 levels and oocytes quality. In fact, mature oocytes retrieved in selected follicles were significantly more numerous in DHEA-group (0.50 ± 0.52 vs. 0.08 ± 0.29; p = 0.018).
The improvement of reproductive parameters after DHEA supplementation in poor responders may be explained through the effect that this pro-hormone exerts on follicular microenvironment.
[Show abstract][Hide abstract] ABSTRACT: Introduction: Laparoscopic myomectomy has recently gained wide acceptance but this procedure remains technically highly demanding and concerns have been raised about the increased blood loss and an higher risk of postoperative uterine rupture of the pregnant uterus. Objective: The aim of the present study is to evaluate the fertility and endocrine outcome in women underwent robot-assisted laparoscopic myomectomy (RALM). Methods: Data from 48 RALM performed in our department between the years 2007 and 2011 have been collected. Conception rate, abortion rate, incidence of feto-maternal morbidity or severe pregnancy and labor-related complications were reported; FSH and AMH levels and ultrasound valuation of AFC has been made before and 6 months after operation. Number of cesarean sections and vaginal deliveries were described. Results: The average age of the patients was 35 years and median Body Mass Index was 23 kg/m(2) (range 18-35 kg/m(2)). Seven women (13%) became pregnant after RALM with eight pregnancies. One pregnancy is actually on going; there were six deliveries with caesarian section and one spontaneous delivery. No spontaneous abortions. No uterine ruptures occurred. No significant modification of ovarian function was found after myomectomy. Conclusion: RALM seems to have a favorable impact on the reproductive outcome of young patients with no impact on the ovarian function.
[Show abstract][Hide abstract] ABSTRACT: PURPOSE: The goal of this study was to determine the accuracy of three-dimensional (3D) MRI reconstructions obtained with segmentation technique in the preoperative assessment of deep infiltrating endometriosis (DIE) and in particular to evaluate rectosigmoid and bladder wall involvement. MATERIALS AND METHODS: Institutional review board approval for this study was obtained, and each patient gave written informed consent. Fifty-seven consecutive patients with diagnosis of DIE who had undergone pelvic MRI at 1.5 T before surgery between 2007 and 2011, were retrospectively evaluated and 3D post-processed in order to obtain a detailed mapping of DIE. A blinded reader interpreted images. MRI results were compared with surgical findings and were scored by using a four-point scale (0_3 score). RESULTS: 36/57 patients with symptomatic DIE underwent surgery: 18/36 had endometriotic nodules infiltrating the rectouterine pouch, 12/36 the vesicouterine pouch, and 6/36 the rectovaginal pouch. The sensitivity of MRI and 3D MRI vs. surgery was, respectively, 64% vs. 83%; diagnostic accuracy of 3D MRI respect to MRI alone was 86% vs. 67% for localization; 86% vs. 67% for dimension; 79% vs. 58% for rectosigmoid infiltration; 92% vs. 75% for bladder infiltration. CONCLUSIONS: In this preliminary study, 3D MRI reconstructions obtained with semi-automatic method of segmentation provided encouraging results for staging DIE preoperatively. In fact, the addition of 3D MRI reconstructions improved diagnostic accuracy and staging of DIE providing the exact volume of the lesions and enabling a precise mapping of these before surgery.
[Show abstract][Hide abstract] ABSTRACT: Polycystic ovary syndrome is one of the most common endocrine disorders in women of reproductive age. Features of PCOS are hyperandrogenism, chronic anovulation and polycystic ovaries on ultrasonography. Follicle development is a complex and carefully orchestrated phenomenon, involving gonadotropins and a rapidly expanding list of other intraovarian regulators, such as brain-derived neurotrophic factor (BDNF). The aim of this study is to evaluate BDNF in plasma and in follicular fluid in women affected by PCOS and in normal menstruating women. In PCOS patients the BDNF levels in plasma and in follicular fluid are higher than values obtained in healthy controls. Therefore we can hypothsize that high levels of luteinizing hormone, probably increase the secretion of BDNF in PCOS patients.
[Show abstract][Hide abstract] ABSTRACT: In the last years, the practice of surgery is evolved thanks to the introduction of videolaparoscopic and robotic
techniques. Laparoscopic surgery has revolutionized the concept of minimally invasive surgery in the last decades but it presents limitations due to the normal mechanism of the human hand. The robotic-assisted surgery is designed to overcome these limitations. In comparison with laparoscopic surgery, the robotic technique presents many advantages such as 3-dimensional vision, a decrease of surgeon’s fatigue and tremors, and an increase of wrist motion improved dexterity and greater surgical precision. Many procedures have already been performed with this technique in urology, cardiac surgery and general surgery. Nowadays the use of the robotic technique is becoming more frequent also in gynaecological surgery and it is preferred to conventional laparoscopy for the treatment of gynaecological malignancies and most of the benign disease of certain complexity, such as hysterectomy or myomectomy.
Archives of Perinatal Medicine. 01/2012; 18((2)):70-75.