Management challenges of deep infiltrating endometriosis.

Deep infiltrating endometriosis (DIE) is considered the most aggressive form among the three phenotypes that constitute endometriosis. It can affect the whole pelvis, subverting the anatomy and functionality of vital organs, with an important negative impact on the patient’s quality of life. The diagnosis of DIE is based on clinical and physical examination, instrumental examination, and, if surgery is needed, the identification and biopsy of lesions. The choice of the best therapeutic approach for women with DIE is often challenging. Therapeutic options include medical and surgical treatment, and the decision should be dictated by the patient’s medical history, disease stage, symptoms severity, and personal choice. Medical therapy can control the symptoms and stop the development of pathology, keeping in mind the side effects derived from a long-term treatment and the risk of recurrence once suspended. Surgical treatment should be proposed only when it is strictly necessary (failed hormone therapy, contraindications to hormone treatment, severity of symptoms, infertility), preferring, whenever possible, a conservative approach performed by a multidisciplinary team. All therapeutic possibilities have to be explained by the physicians in order to help the patients to make the right choice and minimize the impact of the disease on their lives

Genetic Characterization of Endometriosis Patients: Review of the Literature and a Prospective Cohort Study on a Mediterranean Population

The pathogenesis of endometriosis is unknown, but some evidence supports a genetic predisposition. The purpose of this study was to evaluate the recent literature on the genetic characterization of women affected by endometriosis and to evaluate the influence of polymorphisms of the wingless‐type mammalian mouse tumour virus integration site family member 4 (WNT4), vezatin (VEZT), and follicle stimulating hormone beta polypeptide (FSHB) genes, already known to be involved in molecular mechanisms associated with the proliferation and development of endometriotic lesions in the Sardinian population. Materials and Methods: In order to provide a comprehensive and systematic tool for those approaching the genetics of endometriosis, the most cited review, observational, cohort and case‐control studies that have evaluated the genetics of endometriosis in the last 20 years were collected. Moreover, 72 women were recruited for a molecular biology analysis of whole‐blood samples—41 patients affected by symptomatic endometriosis and 31 controls. The molecular typing of three single nucleotide polymorphisms (SNPs) was evaluated in patients and controls: rs7521902, rs10859871 and rs11031006, mapped respectively in the WNT4, VEZT and FSHB genes. In this work, the frequency of alleles, genotypes and haplotypes of these SNPs in Sardinian women is described. Results: From the initial search, a total of 73 articles were chosen. An analysis of the literature showed that in endometriosis pathogenesis, the contribution of genetics has been well supported by many studies. The frequency of genotypes observed in the groups of the study population of 72 women was globally coherent with the law of the Hardy–Weinberg equilibrium. For the SNP rs11031006 (FSHB), the endometriosis group did not show an increase in genotypic or allelic frequency due to this polymorphism compared to the control group (p = 0.9999, odds ratio (OR) = 0.000, 95% confidence interval (CI), 0.000–15.000 and p = 0.731, OR = 1639, 95% CI, 0.39–683, respectively, for the heterozygous genotype and the polymorphic minor allele). For the SNP rs10859871 (VEZT), we found a significant difference in the frequency of the homozygous genotype in the control group compared to the affected women (p = 0.0111, OR = 0.0602, 95% CI, 0.005–0.501). For the SNP rs7521902 (WNT4), no increase in genotypic or allelic frequency between the two groups was shown (p = 0.3088, OR = 0.4133, 95% CI, 0.10–1.8 and p = 0.3297, OR = 2257, 95% CI, 0.55–914, respectively, for the heterozygous genotype and the polymorphic minor allele). Conclusion: An analysis of recent publications on the genetics of endometriosis showed a discrepancy in the results obtained in different populations. In the Sardinian population, the results obtained do not show a significant association between the investigated variants of the genes and a greater risk of developing endometriosis, although several other studies in the literature have shown the opposite. Anyway, the data underline the importance of evaluating genetic variants in different populations. In fact, in different ethnic groups, it is possible that specific risk alleles could act differently in the pathogenesis of the disease

Mini-Laparoscopy or Single-Site Robotic Surgery in Gynecology? Let's Think out of the Box.

To date, the advancement of available technologies has led to the effective implementation of minimally invasive approaches in gynecology, with significant improvement of surgical as well as esthet..

Cesarean scar pregnancy treated by artery embolisation combined with diode laser: a novel approach for a rare disease

Cesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy which represents a consequence of a previous cesarean section. It is associated with major maternal morbidity and mortality and has potential implications on future fertility. Because of possible serious complications, CSP should be swiftly diagnosed and treated. There is no management protocol for this rare, life-threatening condition, and each patient should be evaluated individually. Several types of conservative treatment have been used to treat cesarean scar pregnancy: dilation and curettage (D&C), excision of trophoblastic tissues, local or systemic administration of methotrexate, bilateral hypogastric artery ligation, and selective uterine artery embolization with curettage and/or methotrexate administration. In our study we present a cesarean scar pregnancy of a 40-year-old woman who was treated with angiographic uterine artery embolization (UAE) followed by hysteroscopic diode laser resection. Our combined UAE-hysteroscopic laser surgery appears to offer an effective, safe, and minimally invasive surgical treatment

Effects of Pregnancy and Breastfeeding on Clinical Outcomes and MRI Measurements of Women with Multiple Sclerosis: An Exploratory Real-World Cohort Study

Pregnancy represents an important event for women with multiple sclerosis (MS) and is often accompanied by post-partum disease reactivation. To date, the influence of this reproductive phase on long-term MS outcomes is still largely unexplored. The objective of the study was characterise a large real-world cohort of women with MS to evaluate the effects of pregnancy and breastfeeding on short- and long-term clinical and magnetic resonance imaging (MRI) outcomes while exploring the relationships with MRI measurements of brain atrophy

Effects of different progesterone levels on reproductive outcomes in assisted reproductive technologies: from molecular basis to treatment strategies

Purpose: The aim of this narrative review is to offer an overview about the role of progesterone levels on pregnancy outcome in patients undergoing assisted reproductive technologies (ARTs). Methods: A detailed computerized search of the literature was performed in the main electronic databases (MEDLINE, EMBASE, Web of Science) to determine the importance of elevated progesterone levels at different stages of the cycle for pregnancy rates in the in vitro fertilization (IVF) cycle. Our review also provides information on the differences between elevated progesterone levels and their interpretation in normal and in poorly responding women. Results: After careful evaluation, our search strategy yielded a total of 15 included articles, showing the possible factors that may have had an impact on the increased progesterone level before human chorionic gonadotropin (HCG) injection and the different thresholds above which the pregnancy rate was lower. Furthermore, increased progesterone on cycle day 2 or 3 could serve as a marker for increased progesterone in the late follicular phase, which is associated with a lower pregnancy rate. Conclusion: Despite the literature data that support the negative effect of elevated progesterone on fresh cycles, due to lack of randomized controlled trials, the value of measuring progesterone in daily practice is questionable. Available evidence supports the detrimental effect of elevated progesterone in different subgroups of women, although there is still the need for defining different thresholds and durations of high progesterone exposure. The need for various thresholds for different cohorts of women, the inter-assay variability is making this decision harder

Impact of Menopause in Patients with Multiple Sclerosis: Current Perspectives

Given the aging population, with a peak age-specific prevalence that is shifting beyond the age of 50, several women currently living with MS are very close to menopause. Menopause is usually characterized by several specific symptoms with adverse impacts on different aspects of a woman’s quality of life, such as fatigue, and cognitive, mood and bladder disorders, which overlap with symptoms of MS. Generally, after this biological transition, women with MS appear to be subject to less inflammatory activity. However, several studies have reported an increase of disability accumulation after menopause, suggesting that it is a turning point to a more progressive phase of the disease. This may be attributable to the hormonal and immunological changes associated with menopause, with several effects on neuroinflammation and neurodegeneration increasing due to the immunosenescence of aging. This review summarizes the hormonal and immunological changes associated with menopause, detailing the effects on MS symptoms, outcomes, and the aging process. Furthermore, possible interventions to improve patients’ quality of life are evaluated. In fact, it is increasingly necessary to improve the global management of MS women, as well as their lives, at this multifaceted turning point

Chapter 13 Is There a Role for Laparoscopy in Ovarian Cancer?

During 1960s and 1970s, the first laparoscopic procedures concerned treatment of benign diseases. Today, indications have significantly increased even in ovarian borderline tumours and in ovarian cancer. Furthermore, the role of diagnostic laparoscopy remains apparent in the overall therapeutic setting of advanced ovarian cancer as well. The present chapter aims to summarize current evidence regarding potential role of laparoscopy in ovarian cancer treatment as well as indicate potential difficulties that should be raised during its usage

Post partum perineal dysfunctions: a prospectic analysis of risk factors

Background Many risk factors have been recognized to explain postpartum perineal dysfunctions such as multiparity, operative delivery, prolonged second stage of labor, epidural analgesia, perineal lacerations and fetal macrosomia. The perineal damage is correlated to pregnancy and vaginal delivery due to direct mechanic trauma on muscles the elevator ani and anal sphincter, neurologic damage of pelvic floor nerves and connective-fascial lesion of the urogenital hiatus. During pregnancy there is an excessive pressure on the anterior perineum due to the weight of the gravid uterus and the direct pressure on the urogenital hiatus. During vaginal birth, all the muscular and ligamentous structures of the pelvic floor are exposed to intense pressure and traction forces in lateral and longitudinal directions. During impingement of the presenting part, the bladder is compressed between pubic bones and the fetal head with a consequent trauma that is directly correlated with the length of the expulsion phase. Health workers must be able to recognize, prevent and treat perineal dysfunctions during and after pregnancy. The aim of our study was to evaluate different maternal, neonatal and delivery-associated risk factors and analyze the pelvic floor alterations in the puerperium compared with the perineal function before birth. Methods 106 primiparae women were enrolled, 4-5 months after delivery they underwent to an interview in order to evaluate urinary and anal incontinence, perineal pain, dyspareunia and a clinic examination of the functioning of the pelvic floor with pubococcygeus test (PC test). They also filled a questionnaire about the functioning of their pelvic floor during pregnancy. In order to obtain information about the risk factors there were considered: job, maternal age, gestational age, maternal weight before pregnancy, weight at term, maternal diseases, type of delivery (spontaneous, operative, caesarian section), episiotomy, grade of lacerations, Kristeller maneuver, type of induction (if any), length of labor, length of second stage of labor, head circumference, newborn’s weight, epidural analgesia. Results Vaginal birth correlate with lower scores at PC test, urinary incontinence that is also associated with maternal age and weight, dyspareunia and perineal pain, especially in women who had operative delivery, episiotomy and/or lacerations. Epidural analgesia seems to be protective for postpartum dyspareunia (31,8% vs 44,2%). A significant correlation has been demonstrated between newborn head circumference and weight and perineal dysfunction after delivery probably due to longer labor and increased stretching of pelvic tissues. Conclusions Our data are in line with literature and underline that urinary symptoms tends to ameliorate after delivery demonstrating that pregnancy itself is a risk factor. Moreover, we discovered that in women with perineal dysfunction in postpartum the symptoms were worse than during pregnancy. If pregnancy is a risk factor for perineal dysfunctions, delivery is a worsening factor for a pre-existing situation or the appearing of new symptoms