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Role of Hysteroscopy Prior to Assisted Reproductive Techniques in Patients with Previous IVF Failure
International Journal of Infertility & Fetal Medicine
Abstract
Background
There have been numerous advances in the area of assisted reproduction. Among the various reasons of implantation failure, intrauterine lesions play an important role.
Objective
The aim of the present study is to evaluate the role of hysteroscopy prior to any assisted reproductive technique in patients who had previous one or more failed IVF cycle(s).
Materials and methods
It is a retrospective study of 248 women who attended our infertility clinic over a period of 18 months, who had a variable number of failed IVF cycles previously.
Results
Out of the 248 women studied, in 62 (25%) patients, intrauterine pathology was detected, which when rectified by hysteroscopy gave a considerable increase in pregnancy rate.
Conclusion
According to this study it can be concluded that evaluating the uterine cavity is an important step before any assisted reproductive procedure.
... [3,4] Currently, it is recommended to examine intrauterine pathologies before starting IVF/intracytoplasmic sperm injection (ICSI). [5][6][7][8] The best methods for assessing uterine abnormalities typically include some combination of transvaginal sonography, hysterosalpingography, and hysteroscopy (HSC). [9] However, hysterosalpingography has low specificity, high false-negative and falsepositive rates. ...
... The preponderance of studies has suggested that HSC before IVF improves outcomes in patients undergoing their first IVF cycle and in patients with RIF. [6,7,15,36] Previous studies reported a higher rate of uterine abnormalities in patients with RIF than in the general IVF population. [6,13,15,16,37] Another study [22] indicated that HSC can identify uterine pathologies that previously determined to be normal by transvaginal ultrasound, and that this correction can improve the pregnancy rate and live birth rates. ...
... [6,13,15,16,37] Another study [22] indicated that HSC can identify uterine pathologies that previously determined to be normal by transvaginal ultrasound, and that this correction can improve the pregnancy rate and live birth rates. For example, Dalal et al [7] studied 248 women with a variable number of failed IVF cycles and showed that HSC identified 25% of female intrauterine pathologies. When the abnormality was identified, the pregnancy rate after IVF was significantly increased. ...
Objective:
To study if hysteroscopy (HSC) before starting an in-vitro fertilization (IVF) cycle improves IVF outcomes in women with recurrent implantation failure (RIF).
Methods:
The Medline, Cochrane, EMBASE, and Google Scholar databases were searched using the following keywords until March 31, 2017: in-vitro fertilization; infertility; hysteroscopy; recurrence; embryo implantation; and pregnancy. Randomized controlled trials (RCTs), two-arm prospective studies, and retrospective studies were included.
Results:
Three RCTs, 3 nonrandomized prospective studies, and 2 retrospective cohort studies were included. The eligible studies included 3932 women with RIF: 1841 in the HSC group and 2091 in the control group. The clinical pregnancy rate and implantation rate was significantly higher in the HSC group compared with the control group (for clinical pregnancy rate, pooled odds ratio [OR] = 1.64, 95% confidence intervals [CI]: 1.30-2.07, P < 0.001; for implantation rate, pooled OR = 1.22, 95% CI: 1.02-1.45, P = 0.025). The live birth rate (pooled OR = 1.30, 95% CI: 0.90-1.88, P = 0.168) and the miscarriage rate (pooled OR = 0.94, 95% CI: 0.66-1.35, P = 0.744) of the 2 groups were not statistically significantly.
Conclusions:
HSC improved the implantation rate and clinical pregnancy rates, but failed to improve live birth rate and did not affect the miscarriage rate in women with RIF undergoing IVF. Since HSC plays a significant role in pregnancy and birth outcomes of women with RIF, further studies are warranted.
... 5,6 Currently, it is recommended to carefully assess for intrauterine pathology before doing IVF-ET. [7][8][9][10] Transvaginal ultrasonography plays a vital role in fertility treatment and evaluation of the endometrium. Blood flow to the uterine and ovarian artery undergoes important changes corresponding to cyclical hormone changes and can be easily detected using color Doppler. ...
Background: Objective of current study was to correlate uterine artery Doppler parameters with endometrial findings on hysteroscopy and its importance for the prediction of intrauterine pathology inconclusive on 2-dimensional transvaginal imaging prior to frozen embryo transfer.Methods: This was a retrospective study conducted at Medicover fertility center, New Delhi, India. The study population comprised of women with infertility who have undergone hysteroscopy before frozen embryo transfer. Total 70 patients were recruited based on inclusion/exclusion criteria. Intrauterine pathology found in 57.2% (n= 40) patients and 42.8% (n=30) had normal endometrial cavity on hysteroscopy, they were categorized as group 1 and group 2 respectively based on their findings. Both the groups were compared for pre hysteroscopy uterine artery Doppler parameters, resistivity index and pulsatility index. Further clinical pregnancy rate and miscarriage rate were determined in both groups.Results: Both the groups were comparable for age, body mass index, duration, and type of infertility. Mean RI and PI was significantly higher in group 1 as compared to group 2 (0.90±0.025, 2.89±0.291 vs. 0.76±0.043, 1.82±0.27; p value <0.001). The best cut-off value of uterine artery RI was ≥0.87 with sensitivity of 90% (95% CI=0.7634-0.9721), specificity of 100% (95% CI=0.8843-1.0000) and PI was 2.46 with sensitivity of 100% (95% CI=0.9119-1.0000), specificity of 96.7% (95% CI=0.8278-0.9992).Conclusions: Uterine artery Doppler is a non-invasive, cost- effective useful add-on tool for routine endometrial evaluation and can be a good predictor for screening intrauterine pathology and valuable in decision making for pre-IVF hysteroscopy.
A total of 96 women undergoing in-vitro fertilization (IVF) treatment were examined by transvaginal ultrasonography with colour
and pulsed Doppler ultrasound on the 22nd day of the menstrual cycle preceding IVF. We assessed endometrial thickness, endometrial
morphology, myometrial echogenicity, subendometrial vascularization, the uterine artery pulsatility index, protodiastolic
notch and end diastolic blood flow in order to define a uterine score which could be correlated with the pregnancy rate. The
overall pregnancy rate was 30.2%, and there was no difference between the pregnant and non-pregnant groups with regard to
any of the ultrasonographic and Doppler parameters when examined separately. However, the uterine score was significantly
higher in the pregnant group (15.9 +/- 2.81 versus 12.7 +/- 5.3, P = 0.002; t-test). No pregnancy occurred if the score was
between 0 and 10. With a score of 11-15 there was a 34.7% chance of pregnancy, and scores >16 had a 42% chance of pregnancy.
In conclusion, individual ultrasonographic and Doppler parameters are not of sufficient accuracy to predict uterine receptivity.
The uterine score calculated prior to IVF cycles appears to be a useful predictor of implantation.
Our purpose was to investigate the effect of endometrial polyps on pregnancy outcome in an in vitro fertilization (IVF) program.
Endometrial polyps less than 2 cm in diameter were suspected by transvaginal ultrasound before oocyte recovery in 83 patients. Forty-nine women (Group I) had standard IVF-embryo transfer, while in 34 women (Group II) hysteroscopy and polypectomy were performed immediately following oocyte retrieval, the suitable embryos were all frozen, and the replacement cycle took place a few months later.
Of the 32 hysteroscopies, a polyp was diagnosed in 24 cases (75%) and polypoid endometrium in another 5 patients (15.6%). An endometrial polyp was confirmed by histopathological examination in 14 women (58.3%). The pregnancy rate in group I was similar to the general pregnancy rate of our unit over the same period (22.4 vs 23.4%) but the miscarriage rate was higher (27.3 vs 10.7%, P = 0.08). In Group II, the pregnancy and miscarriage rates were similar to those of the frozen embryo cycles at Bourn Hall (30.4 and 14.3 vs 22.3 and 12.1%, respectively).
Small endometrial polyps, less than 2 cm, do not decrease the pregnancy rate, but there is a trend toward increased pregnancy loss. A policy of oocyte retrieval, polypectomy, freezing the embryos, and replacing them in the future might increase the "take-home baby" rate.
Uterine malformations consist of a group of miscellaneous congenital anomalies of the female genital system. Their mean prevalence in the general population and in the population of fertile women is similar to4.3%, in infertile patients similar to3.5% and in patients with recurrent pregnancy losses similar to 13%. Septate uterus is the commonest uterine anomaly with a mean incidence of similar to 35% followed by bicornuate uterus (similar to 25%) and arcuate uterus (similar to 20%). It seems that malformed uterus and especially septate uterus is not an infertility factor in itself. However, it may have a part in the delayed natural conception of women with mainly secondary infertility. On the other hand, patients with uterine malformations seem to have an impaired pregnancy outcome even as early as their first pregnancy. Overall term delivery rates in patients with untreated uterine malformations are only similar to 50% and obstetric complications are more frequent. Unicornuate and didelphys uterus have term delivery rates of similar to 45%, and the pregnancy outcome of patients with untreated bicornuate and septate uterus is also poor with term delivery rates of only similar to 40%. Arcuate uterus is associated with a slightly better but still impaired pregnancy outcome with term delivery rates of similar to 65%. Women who have undergone hysteroscopic septum resection and have been reported in the different series comprise a highly selected group of symptomatic patients with term delivery and live birth rates of only similar to5%. Hysteroscopic treatment seems to restore an almost normal prognosis for the outcome of their pregnancies with term delivery rates of similar to 75% and live birth rates of similar to 85%. It seems, therefore, that hysteroscopic septum resection can be applied as a therapeutic procedure in cases of symptomatic patients but also as a prophylactic procedure in asymptomatic patients in order to improve their chances for a successful delivery.
To evaluate the efficacy of, and patients' satisfaction with, office hysteroscopic treatment of benign intrauterine pathologies using 5F hysteroscopic instruments.
Observational clinical study (Canadian Task Force classification II).
University center.
Four thousand eight hundred sixty-three (4863) women.
Office hysteroscopy without analgesia or anesthesia.
We used 5F mechanical instruments (scissors, grasping forceps) to treat cervical and endometrial polyps ranging between 0.2 and 3.7 cm, as well as intrauterine adhesions and anatomic impediments. From 71.9% to 93.5% of women underwent the procedure without discomfort for all pathologies treated except endometrial polyps larger than the internal cervical os, for which 63.6% experienced low or moderate pain. At 3-month follow-up, pathology persisted in 364 patients (5.6%).
Simple instruments enable us to perform many operative procedures in an office setting with excellent patient satisfaction, provided that the indications are correct.
Main symptoms related to submucous fibroids are menorrhagia, infertility, and postmenopausal bleeding. First experiences of hysteroscopic transcervical resection of fibroids have been published by Neuwirth in the late seventies. Reports with long-term follow-up in patients with abnormal uterine bleeding are available. After a follow-up period of five years and more, results are satisfactory in 70-85% of the patients. Intramural class 2 and larger fibroids (> 4cm) constitute the limits of the endoscopic technique. Prior to hysteroscopic myoma resection, pretreatment with GnRH agonists may be indicated in selected cases (large myomas, patients suffering from secondary anemia). Repeat resection is an option after failed primary hysteroscopic operation and may reduce the hysterectomy rate. In infertile women with submucosal or intracavitary fibroids, pregnancy and delivery rates are increased after hysteroscopic myomectomy. Operative hysteroscopy is also safe and effective in controlling persistent postmenopausal bleeding. To conclude, hysteroscopic resection is the gold standard for the treatment of symptomatic submucous fibroids.
Objective. – To evaluate the benefits of a diagnostic hysteroscopy prior to in vitro fertilization.Patients and methods. – We retrospectively studied 145 patients who underwent ICSI during a period of 6 months. Office hysteroscopy was systematically performed before the first stimulation cycle. If pathological findings were revealed, appropriate medical or surgical treatment was given.Results. – Pathological patterns were observed in 45% of hysteroscopies. Endometritis, polyps and myomas and mucosal diseases were the most frequently observed. The patients aged over 38 years didn’t show higher rate of pathology (29% vs 27% for the younger patients). The treatment of pathologies gave the same pregnancy rate than the normal cavities. Patients with endometritis were treated with antibiotics and 40% of them became pregnant in the following cycle.Discussion and conclusion. – Systematic hysteroscopy prior to IVF-ICSI showed to be an effective investigation that could improve the pregnancy rate.
Fifty patients who had undergone 2 or more failed in vitro fertilization (IVF) embryo transfer (ET) cycles or failed GIFT cycles where fertilization had been demonstrated, underwent hysteroscopy; 28% were found to have intrauterine abnormalities which may have been responsible for the failure of the IVF-ET or GIFT. Patients with an abnormality found at hysteroscopy had undergone a significantly higher mean number of transfer cycles. These results suggest that intrauterine abnormalities may be a cause for failure of IVF-ET or GIFT and therefore hysteroscopy should be part of the infertility work-up of all patients prior to undergoing IVF treatment.
Uterine leiomyomata, which occur in one of every four to five women in reproductive life, are the most common solid pelvic tumors in women. Nevertheless, etiology and symptomatology remain poorly understood, and management, inconsistent. In an effort to improve understanding of these aspects of uterine leiomyomata, we have reviewed the pertinent literature and have assessed reports of 4714 myomectomies and records of 59 personal cases. A plan for management of patients with uterine leiomyomata, based upon these findings, as well as an update of the technique for myomectomy, is presented.
To review the literature on the diagnosis, prevalence, and treatment of the septate uterus, with special reference to hysteroscopic metroplasty and its effect on reproductive outcome.
Pertinent studies were identified through a computer MEDLINE search. References of selected articles were hand-searched for additional citations.
Reliable diagnosis of the septate uterus depends on accurate assessment of the uterine fundal contour. At present, the combined use of laparoscopy and hysteroscopy is the gold standard for diagnosis, although recent reports of two-dimensional, transvaginal, contrast ultrasound and of three-dimensional ultrasound appear promising. The prevalence of the septate uterus is increased in women with repeated pregnancy loss. A metaanalysis of published retrospective data comparing pregnancy outcome before and after hysteroscopic septoplasty indicated a marked improvement after surgery.
The hysteroscopic approach to treatment, with its simplicity, minimal postoperative sequelae, and improved reproductive outcome, has enabled a more liberalized approach to treatment that is now being extended to include not only patients with recurrent pregnancy loss and premature labor but also patients with infertility, especially if IVF is being contemplated.
The general definition of infertility is a lesser capacity to conceive than the mean capacity of the general population and infertile couples can be characterized in two groups: those unable to conceive without therapy and those who are hypofertile, but conceive without therapy. The initial diagnostic tests for infertility should include a midluteal phase progesterone assay, a semen analysis and a test for tubal patency such as a hysterosalpingogram. Measuring progesterone is the best test for confirming ovulation. To predict ovulation, evaluating the luteinizing hormone (LH) surge is the best single assay while measurement of LH plus preovulatory oestrogen is the best prediction. Today primary investigation of the morphology of the uterus and tubes should be by hysterosalpingography. However, ultrasound, particularly with simple contrast media, is likely to gain in importance. Laparoscopy should be reserved as a further diagnostic procedure or in combination with endoscopic surgery. There are situations in which semen analysis is of utmost importance and of absolute predictive value, namely, in cases of azoospermia. In general semen analysis remains a substantial part of the fertility workup, but any consideration of its predictive value has to be cautious. Performing genetic tests before, during and after assisted reproductive techniques (ART) is an intrinsic part of good clinical practice. These tests allow one to reach a correct diagnosis, to give adequate genetic counselling to the couple and their families in cases such as (i) women with Turner syndrome; (ii) men with 47, XXY; (iii) men or women with structural chromosomal aberration; (iv) men with Yq11 deletion or (v) men with congenital bilateral absence of vas deferens. Patients should, of course, be made aware of the occurrence of de-novo mutations taking place in the testis and in the embryo. Treatment of some causes of infertility are of proven value. For example induction of ovulation. Others are more controversial. Among the many empirical treatments suggested for the treatment of the various form of subfertility, surgical treatment of varicocele in the male, treatment of pelvic endometriosis in the female and the efficacy of the ART strategies offered to the subfertile couple are considered. Many varicocele studies are of poor quality. A few are good, but small in size. They do not show an improvement in pregnancy rates. Therefore, at the moment, there is insufficient scientific evidence for recommending routinely surgical treatment in subfertile and/or oligozoospermic men with a varicocele. Randomized, double-blind controlled trials demonstrated the modest efficacy of endometriosis ablation in increasing the pregnancy rate in infertile women while drugs suppressing ovulation are of no benefit to infertile women with endometriosis. Although the largest body of evidence available suggests that IVF success declines in repeated ART cycles, an accurate estimate of the true success rate in the 'nth' cycle of IVF treatment is not possible. Similarly little is still known of the reasons for the overall low continuation rates with IVF treatment.
To investigate the role of sonographic parameters in assessing endometrial receptivity in an in vitro fertilization (IVF) program.
Prospective clinical study.
University setting.
One hundred thirty-five patients in our IVF program, selected prospectively on the day of oocyte retrieval.
Transvaginal ultrasound examination was performed before oocyte collection.
Association between implantation rate and spiral artery blood flow (primary outcome measure) and between implantation rate and endometrial measurements as well as uterine artery blood flow (secondary outcome measures).
Overall implantation rate was 23.7% per cycle. Subendometrial blood flow was detected in 113 (83.7%) cases, with pregnancy occurring in 21.2%. Mean spiral artery pulsatility index values were 1.12 +/- 0.28 and 1.21 +/- 0.27 for nonconception and conception cycles, respectively. Nondetectable spiral artery blood flow was not associated with a lower implantation rate. Neither endometrial thickness nor endometrial volume was correlated with the likelihood of successful implantation. Minimum endometrial thickness and volume associated with pregnancy were 6.9 mm and 1.59 mL, respectively.
Neither Doppler sonography of the spiral or uterine arteries nor measurement of the endometrial thickness or volume allowed a reliable prediction of subsequent IVF outcome.
Unlabelled:
A systematic literature review was performed to determine whether leiomyomata are associated with decreased fertility rates, and whether surgical removal increases fertility rates postoperatively. Meta-analysis was conducted when multiple studies addressed a single issue and were sufficiently homogeneous. Data were analyzed for effect of any fibroid upon fertility, as well as specific fibroid location. Results of studies comparing women with infertility and fibroids versus infertile controls showed widely disparate results. Subgroup analysis failed to indicate any effect on fertility of fibroids that did not have a submucous component. Conversely, women with submucous myomas demonstrated lower pregnancy rates (RR 0.30; 95% confidence interval [CI] 0.13--0.70) and implantation rates (RR 0.28; 95% CI 0.10--0.72) than infertile controls. Results of surgical intervention were similar. When all fibroid locations were considered together, myomectomy results were again widely disparate. However, when women with submucous myomas were considered separately, pregnancy was increased after myomectomy compared with infertile controls (RR 1.72; 95% CI 1.13--2.58) and delivery rates were now equivalent to infertile women without fibroids (RR 0.98; 95% CI 0.45--2.41). The current data suggest that only those fibroids with a submucosal or an intracavitary component are associated with decreased reproductive outcomes, and that hysteroscopic myomectomy may be of benefit.
Target audience:
Obstetricians & Gynecologists, Family Physicians
Learning objectives:
After completion of this article, the reader will be able to summarize the data on the role of fibroids and infertility, describe the effect of myomectomy on fertility, and list the methods used to evaluate intracavitary fibroids.
To evaluate the benefits of a diagnostic hysteroscopy prior to in vitro fertilization.
We retrospectively studied 145 patients who underwent ICSI during a period of 6 months. Office hysteroscopy was systematically performed before the first stimulation cycle. If pathological findings were revealed, appropriate medical or surgical treatment was given.
Pathological patterns were observed in 45% of hysteroscopies. Endometritis, polyps and myomas and mucosal diseases were the most frequently observed. The patients aged over 38 years didn't show higher rate of pathology (29% vs 27% for the younger patients). The treatment of pathologies gave the same pregnancy rate than the normal cavities. Patients with endometritis were treated with antibiotics and 40% of them became pregnant in the following cycle.
Systematic hysteroscopy prior to IVF-ICSI showed to be an effective investigation that could improve the pregnancy rate.
Main symptoms related to submucous fibroids are menorrhagia, infertility, and postmenopausal bleeding. First experiences of hysteroscopic transcervical resection of fibroids have been published by Neuwirth in the late seventies. Reports with long-term follow-up in patients with abnormal uterine bleeding are available. After a follow-up period of five years and more, results are satisfactory in 70-85% of the patients. Intramural class 2 and larger fibroids (> 4 cm) constitute the limits of the endoscopic technique. Prior to hysteroscopic myoma resection, pretreatment with GnRH agonists may be indicated in selected cases (large myomas, patients suffering from secondary anemia). Repeat resection is an option after failed primary hysteroscopic operation and may reduce the hysterectomy rate. In infertile women with submucosal or intracavitary fibroids, pregnancy and delivery rates are increased after hysteroscopic myomectomy. Operative hysteroscopy is also safe and effective in controlling persistent postmenopausal bleeding. To conclude, hysteroscopic resection is the gold standard for the treatment of symptomatic submucous fibroids.
To determine if the incidence of small endometrial polyps detected hysteroscopically in an infertile eumenorrheic population differed from that in an apparently fertile eumenorrheic population. Evidence was sought to determine whether removal of such lesions would enhance reproductive performance.
In a prospective study, 266 consecutive infertile women had undergone complete fertility evaluation. None of the women had experienced any change in their menstrual cycle. They were divided into two groups; 235 infertile patients (group 1) and 31 requesting a reversal of a previous tubal sterilization (group 2). All patients were examined by simultaneous combined laparoscopy and hysteroscopy as part of their routine infertility evaluation. When endometrial polyps were noted they were removed by hysteroscopy and histopathologically examined. Patients in whom the only apparent finding was endometrial polyps were followed up to determine their reproductive outcomes subsequent to removal of the polyps.
Of the 224 uterine cavities successfully visualized in the infertile group, 134 were judged to be normal (60%) and 90 were abnormal (40%). Endometrial polyps were noted in 35 patients of group 1 and in one patient of group 2 (P < 0.01). Most polyps were located in the region of the utero-tubal junction and proved to be functional. A 50% pregnancy rate was achieved by hysteroscopic polypectomy. Fertility-related factors in women whose only apparent finding was endometrial polyps before and after hysteroscopy were comparable.
Diagnostic hysteroscopy should be used routinely in the work-up of infertile woman, even in the presence of eumenorrhea. Persistent functional endometrial polyps, even if small, are likely to impair fertility in this select patient group. Removal of such lesions may improve subsequent reproductive performance.
The aim of this study was to compare traditional hysteroscopy with mini-hysteroscopy in terms of compliance, side effects and diagnostic efficacy.
We prospectively considered 950 female candidates for an IVF programme. All women underwent outpatient hysteroscopy; in 602 cases (Group A) a mini-hysteroscope was employed; in 348 women (Group B) a 5-mm hysteroscope was adopted.
Cavity findings were similar in both groups. Endometrial polyps and uterine septum seem to be more frequent in our infertile patients than in the general population. No significant differences in terms of side effects were found between the groups. Mean visual analogue pain scale score was significantly lower in the patients of Group A than in those of Group B (p<0.001).
Office mini-hysteroscopy is a very effective diagnostic tool in an infertility work-up and is more widely accepted than traditional hysteroscopy. Routine use of the technique should be considered.
A systematic review of studies evaluating the influence of outpatient (office) hysteroscopy on the outcome of the subsequent IVF cycle was conducted. MEDLINE, EMBASE, the Cochrane Library, National Research Register, ISI Conference Proceedings, ISRCTN Register and Meta-register were searched for randomized controlled trials (up to July 2007). All trials comparing the outcome of IVF treatment performed in patients who had outpatient hysteroscopy in the cycle preceding their IVF treatment with a control group in which hysteroscopy was not performed were included. Study selection, quality appraisal and data extraction were performed independently and in duplicate. Study authors were contacted for additional information. The main outcome measure was pregnancy rate. In total, 1691 participants were included in two randomized (n = 941) and three non-randomized controlled studies (n = 750). The quality of the studies was variable. Meta-analyses of the results of five studies showed evidence of benefit from outpatient hysteroscopy in improving the pregnancy rate in the subsequent IVF cycle (pooled relative risk = 1.75, 95% CI 1.51-2.03). The evidence from randomized trials was consistent with that from non-randomized controlled studies. Future robust randomized trials comparing outpatient hysteroscopy or mini-hysteroscopy with no intervention before IVF treatment would be a useful addition to further guide clinical practice.
Ongoing debate the real significance of the observed uterine pathology on fertility
- De Placido
- G Clarrizia
- R Cadente
- C Castaldo
- G Romano
- C Mollo
Service de Gynecologie-obstetrique B, hospital de la conception
- L Carvello
- A Agostini
- M Beerli
- V Roger
- F Bretelle
- B Blanc
Operative office hysteroscopy without anesthesia: A study of 4863 cases performed with mechanical instruments
- S Bettochi
- Cecio Nappi
- Di Venere
- R Pansini
- M V Pellegrino
- A Marello