Minerva obstetrics and gynecology最新文献

Background: Controlled ovarian stimulation during in-vitro fertilization (IVF) is personalized based on anticipated hyper, normal, poor response. With respect to poor responders, who are often treated using higher gonadotropin dosing and combination of urinary and recombinant gonadotropins (rFSH) with marginal benefit, we report our experience with a newer, more potent rFSH (Follitropin-δ) undergoing IVF.

Methods: Retrospective analysis of all IVF cycles in which follitropin-δ was used alone or combined with urinary gonadotropins over a 3-year period. Patients were grouped according to the POSEIDON Classification as expected low responders (POSEIDON 3-4; AMH<1.2; N.=45), unexpected low responders (POSEIDON 1-2; retrieval of ≤9 oocytes; N.=67) and those with a normal response (N.=93). Demographic, stimulation (including target number of retrieved oocytes [8 to14]), embryology and clinical outcome parameters (clinical pregnancy rate [CPR], live birth rate [LBR], cumulative live birth rate [cLBR]) were compared.

Results: Those categorized as POSEIDON patients were older, had lower ovarian reserve, were more likely to use a mixed protocol, less likely to reach the target oocytes retrieved (35.7% vs. 51.6%, P<0.001), and had a lower cLBR per patient (29.5% vs. 38.7%, P=0.006) when compared to non-POSEIDON patients. Expected low responders (POSEIDON 3-4) were older and had lower AMH when compared to unexpected low responders (POSEIDON 1-2), but no differences in the target of oocytes retrieved (33.3% vs. 37.3%, P=0.66) and cLBR (28.9% vs. 37.3%, P=0.06) were noted.

Conclusions: In expected low responders, follitropin-δ can be used to optimize oocyte collection and clinical outcome though one may need to deviate from the algorithm-suggested dose. Future studies should explore stimulation modifications in unexpected low responders.

Background: Histological evaluation of ovarian tissue harvested as part of the attempt to preserve fertility might clarify the mechanism by which ovarian failure is caused. The purpose of this study was to compare the histologic appearance of ovarian tissue harvested for ovarian tissue cryopreservation (OTC) in chemotherapy naïve and chemotherapy exposed patients regarding the presence of follicles in different stages of development and to explore ovarian tissue histology in patients exposed to low- and high-cytotoxicity risk chemotherapy.

Methods: A cohort of post-pubertal cancer survivors who underwent OTC between 1997 and 2018 was evaluated. An expert pathologist reviewed the pathology slides taken during OTC. The assessment included counting number of primordial, primary, secondary, and antral follicles. A comparison was made between chemotherapy naïve and chemotherapy exposed women and further between women who previously received low- versus high-risk gonadotoxic regimens.

Results: Seventy post-pubertal patients were included in the study. Seventeen (24.3%) received chemotherapy prior to OTC, and 53 (75.7%) were chemotherapy naïve at the time of OTC. A significant difference was found only in the number of secondary follicles, which was increased in chemotherapy naïve patients (2.81±4.26 vs. 0.88±1.18, respectively; P=0.005). Similar results were observed in a subgroup analysis of hematologic malignancies separately. Comparison of patients with previous exposure to chemotherapy revealed similar follicular appearance, except for the number of secondary follicles, which was higher in patients receiving low-risk compared to high-risk chemotherapy (1.40±1.28 vs. 0.14±0.35, respectively; P=0.006).

Conclusions: The ovarian follicular pool at OTC appears comparable between chemotherapy naïve individuals and those post-exposure, as well as among patients receiving low versus high-risk gonadotoxic regimens, with the exception of secondary follicles, which are presented in increased numbers in chemotherapy naïve and those exposed to low-risk gonadotoxic chemotherapy.

Uterus transplantation (UTx) emerged as a groundbreaking solution for women facing absolute uterine factor infertility (AUFI), offering hope for childbearing since the first proof-of-concept of UTx in 2014 by the first live birth from a woman with uterine graft. This review provides a comprehensive overview of the evolution of UTx from foundational animal research to current clinical trials and cases. Recent advancements in surgical techniques, including a shift towards robotic approaches, have improved graft removal and transplantation, though challenges persist in optimizing immunosuppressive strategies and rejection monitoring. Given the absence of Fallopian tube transplantation in UTx, in vitro fertilization (IVF) is an integral part of the process. This review delves into the intricacies of combining UTx with IVF, addressing crucial questions about the timing of oocyte retrieval, cryopreservation of oocytes or embryos, and the optimal timing for the first embryo transfer post-UTx. The significance of the International Society Uterus Transplantation (ISUTx) registry is highlighted for evaluating overall success rates, complications, and live births. Examining the long-term health outcomes for donors, recipients, partners, and children born from transplanted grafts, the review acknowledges the life-giving nature of UTx. Cost considerations are explored, anticipating a potential decrease in costs with enhanced efficiency. The discussion emphasizes the evolving landscape of UTx, proposing a scheme for program setup and outlining future directions. This comprehensive analysis marks a significant milestone in the field, transitioning UTx from experimental to mainstream clinical practice. As criteria widen and outcomes improve, UTx is poised to become a realistic and accessible alternative for treating AUFI, representing a significant advancement in reproductive medicine worldwide.

Background: The primary purpose of this study was to verify if trabecular bone score (TBS) might fit with the changes of bone mineral density (BMD) confirming as a reliable marker of bone fragility.

Methods: A retrospective observational study on 898 Italian women (aged 40-90 years) was conducted between January 2021 and February 2023. All recruited women were divided into two main groups according to TBS (Group A: TBS ≥1.31; Group B: TBS<1.31) and, further, in five subgroups according to age.

Results: According to univariate ANOVA, there was not significant difference of BMI between group A and group B but Bonferroni Test found that BMI significantly differed for age subgroups and TBS value (P<0.05). ANOVA analysis reported that mean L1-L4 BMD and/or T-score were significantly different for age and TBS (P=0.000); Bonferroni Test found that L1-L4 BMD significantly differed in the comparison of age subgroups for Group A and Group B (P<0.05). Besides, Bonferroni analysis found significant differences regarding total and neck femoral BMD and/or T-score in the comparison between age subgroups for group A and group B (P<0.05). As for neck femoral BMD and T-score, all significances were observed for group B in the comparison between subgroups aged over 60 years and others (P<0.05). Multivariate logistic regression analysis showed that age and femoral neck BMD significantly contribute to TBS (P<0.05).

Conclusions: Our results seem to suggest that low level of TBS may detect patients that could be more prone to bone frailty consistently with age and BMD at both vertebral and cortical level. However, its role in clinical practice should be refined.

Introduction: The purpose of this review was to provide current evidence of the relationship between fibroid surgery (hysteroscopic, laparoscopic/robotic, open) and the formation of intrauterine adhesions (IUA).

Evidence acquisition: A systematic electronic literature search was conducted to provide a survey of the various surgical modalities and their relevant incidence of intrauterine adhesions. Utilizing PRISMA methodology the search identified 23 full text original studies that were included in the analysis.

Evidence synthesis: Our analysis identified 2437 cases reported in the international literature whereby the de novo formation of IUAs were systematically assessed with second look hysteroscopy at least 4 weeks and usually up to 3 months after the surgery. In our analysis, out of 1678 hysteroscopic cases the mean incidence was 9.4% for all different techniques, including monopolar or bipolar diathermy, cold loop and radio frequency ablation. The reported numbers for laparoscopic/robotic and open surgery were 399 and 360 cases respectively. The incidence of IUA following endoscopic abdominal surgery was 12.8% and for the traditional open approach (laparotomy) was 18.3%. There is substantial heterogeneity on the reported data regarding risks factors contributing to IUAs; such as fibroid size, location, number as well as uterine cavity breach during abdominal surgery (either open, laparoscopic or robotic).

Conclusions: Iatrogenic IUAs following myomectomies are not uncommon and may be implicated in patient morbidity and sub fertility. Further studies are necessary to evaluate the prevention of such sequelae and improve therapeutic outcomes following fibroid surgery.

Background: Hypercoagulability exceeding normal physiological changes in pregnancy may lead to adverse outcomes in select populations, but most prior studies have tested women outside of pregnancy. Rotational thromboelastometry (ROTEM), which performs a comprehensive clotting evaluation, may demonstrate abnormalities during early pregnancy that contribute to adverse outcomes. This study evaluated the relationship between ROTEM coagulation profiles during pregnancy with the outcome of miscarriage.

Methods: This was a prospective cohort study from a single center. Patients in early pregnancy (less than 20 weeks) were recruited from the obstetric clinic and the Emergency Department for ROTEM testing using extrinsic thromboelastometry (EXTEM), intrinsic thromboelastometry (INTEM), and natural thromboelastometry (NATEM) tracings. The cohort was followed to determine pregnancy outcomes for association with ROTEM clot formation kinetics. Results were analyzed using univariate analysis and multiple linear regression, controlling for patient age and estimated gestational age (EGA) in weeks.

Results: Over the study, 98 patients were recruited with 14 lost to follow-up and 7 having elective abortion. Miscarriage occurred in 26 patients, with live delivery without complications occurring in 51 patients. Both groups had similar mean patient age and racial and ethnic breakdown. ROTEM results were similar between groups on univariate analysis. After controlling the patient age and estimated gestational age, only EXTEM clotting time (CT) results differed between groups.

Conclusions: In patients tested during early pregnancy, ROTEM profiles were not associated with adverse pregnancy outcomes in this cohort except for EXTEM CT. This suggests that ROTEM clotting profiles may not be useful in identifying patients at higher risk for adverse pregnancy outcomes.

Background: Surgical audits are quality improvement initiatives developed to enhance the quality of surgical care and to highlight sub-optimal local practices. The aim of this audit was to collate necessary data to track and analyze gynecological surgery complications for quality assurance in operative care.

Methods: A retrospective study of all patients who underwent both elective and emergency gynecological surgery across two health care institutions was undertaken over a 10-year period.

Results: The incidence of complications and mortality was low in a review of over 9000 gynecological surgeries. Patients who underwent major surgeries such as operative laparoscopies and hysterectomies, which made up of 30% of all surgeries, had a longer postoperative mean length of stay - one variable noted was majority of these patients live in remote areas. Other morbidities such as postoperative pneumonia, bradycardia and hypotension related intensive care admissions were associated with obesity and medical co-morbidities. There was no statistical difference in operative complication between elective and emergency surgeries.

Conclusions: The morbidity and mortality associated with modern gynecological surgery occurred infrequently, especially postoperative venous thromboembolism and wound site infection. Implementation of an enhanced recovery after surgery program and an increasing trend in minimally invasive surgery were key practices contributing to this low rate. Future assessments should include comparison of outcomes against local and international outcome databases such as the American College of Surgeons National Surgical Quality Improvement Program for further evaluation.

Background: It is known that 17-beta estradiol, administered in the postmenopausal period, is able to positively influence blood glucose concentration, as well as the incidence of DM over time. Postmenopausal hypertensive women are a group of patients at high risk of developing diabetes mellitus. The aim of this prospective matched cohort study was to evaluate whether estrogen influences the glycometabolic profile also in postmenopausal hypertensive women.

Methods: The present study selected hypertensive postmenopausal women, treated with 17-beta estradiol administered transdermally at a dose of 50 µg per 24 hours. Hypertensive patients who were never treated with hormones served as control group.

Results: We compared HbA1c among 1418 postmenopausal hypertensive women: 709 treated with 17-beta estradiol, and 709 age-matched never treated with hormones. Length of the follow-up resulted in a median time of 4.5 years (25^th-75^th percentiles=3.0-5.5 years). At baseline, the concentration of HbA1c was 5.6% in both groups. HbA1c (mean±SEM) was significantly lower at 6-months in patients treated with 17-beta estradiol (5.0±0.05%) compared with no-hormones group (5.5±0.04%); absolute decline from baseline was -0.6±0.06% with 17-beta-estradiol, compared with -0.1±0.04% (P<0.0001). New-onset DM was significantly reduced in the group of 17-beta estradiol (adjusted relative risk=2.04; 95%CI: 1.03-3.05; P=0.01).

Conclusions: 17-beta estradiol significantly improved HbA1c and reduced the long-term incidence of new-onset diabetes mellitus in the postmenopausal hypertensive population.