Department of Obstetrics & Gynecology, “Magna Graecia” University, Gynecologic Oncology Unit, “Tommaso Campanella” Cancer Center of Germaneto, viale Europa, loc. Germaneto, 88100 Catanzaro “It is important to emphasize that in women undergoing surgery for endometriosis and not desiring pregnancy, a medical treatment is also extremely useful, if not mandatory, to prevent both pain relapse and disease recurrence rate.”
Preterm birth is the most important cause of perinatal morbidity and mortality worldwide, and ranks among the top 10 of global causes of burden of disease. Since treatment of threatened preterm delivery has limited effectiveness, the focus is on primary and secondary prevention. Identification of risk indicators in early pregnancy provides the opportunity for preventive measures. To determine the potential impact of individualized risk indicators on the prediction of preterm birth, we reviewed the literature on this topic. Risk indicators for spontaneous preterm birth can be categorized in five groups; characteristics of the individual (ethnicity/race), characteristics of the fetus (fetal gender fetal number and chorionicity), obstetric history (history of preterm birth), modifiable risk indicators (social status, life style, infection) and signs of early labour; potential predictors (sonographic markers, biomarkes). Risk for preterm birth can be seen as a continuous transition from one state to the other...
Ovarian endometrioma is a benign, estrogen-dependent cyst found in women of reproductive age. Infertility is associated with ovarian endometriomas; although the exact cause is unknown, oocyte quantity and quality are thought to be affected. The present research aims to analyze current treatment options for women with ovarian endometriomas, discuss the role of fertility preservation before surgical intervention in women with ovarian endometriomas and present guidelines for the selection of cases for surgery or expectant management. This review analyzed the factors of ovarian reserve, cyst laterality, size and location, patient age and prior surgical procedures. Based on these factors, the authors recommend three distinct treatment pathways: reproductive surgery to achieve spontaneous pregnancy following treatment, reproductive surgery to enhance IVF outcomes and expectant management with IVF.
Despite the lack of consensus among groups issuing recent guidelines, it is possible to identify options that are available for prenatal practitioners. Examples include the following: iodine supplements to protect against hypothyroidism; adjusting l-thyroxine dosage upward in women with previously diagnosed hypothyroidism to account for increased pregnancy needs; and screening for undetected thyroid deficiency via targeted questions and/or thyroid-stimulating hormone testing. Decision-making about thyroid status requires access to reliable, trimester-specific normative data for both thyroid-stimulating hormone and free thyroxine, as well as an understanding of the impact of human chorionic gonadotropin on thyroid function, especially during the first trimester. Continuity of care is enhanced by systematic follow-up postpartum, including attention to postpartum thyroid dysfunction that often occurs among women with raised antibody levels.
Selection of a spermatozoon presenting both motility and normal morphology is one of the main concerns in intracytoplasmic sperm injection. Spermatozoa appearing as morphologically normal at the 400× magnification could carry various structural abnormalities that could negatively influence embryo development and pregnancy establishment, but only be detected with the use of higher optical magnifications. This led to the development of motile sperm organelle morphology examination (MSOME), which can achieve magnification ranging from 6300× to 13000×. Several approaches were used to classify spermatozoa. However, the prevalence of morphologically normal spermatozoa in MSOME is low (usually less than 5%). The most striking abnormalities are vacuoles, thought to be of acrosomal and/or nuclear origin and related to failure of sperm chromatin condensation. Twelve years after the introduction of MSOME, many questions remain unsolved. A consensual definition of a ‘normal’ spermatozoon and a classification of abnormal spermatozoa accepted by all workers in this field is still awaited. We are far away from understanding the nature and the consequences of the vacuoles.
Recent publications have indicated that the risk of fetal loss following amniocentesis or chorionic villus sampling is lower than the figure widely quoted in pretest counseling. This review examines these publications and compares them with the original data on which the currently used risk figure is based. Of those studies using control figures and sample sizes >1000, none showed a statistical difference between miscarriage rates in test and control groups. The authors conclude that, since the publication of the original data, technology and expertise have improved to the extent that there is no longer a significant risk of procedure-related pregnancy loss (excluding early amniocentesis or early chorionic villus sampling) and that a change in pretest counseling is urgently needed.
The treatment of recurrent ovarian cancer continues to evolve with improved surgical, chemotherapeutic and targeted approaches resulting in improvements in survival. Effective salvage regimens mean that more patients who develop recurrent disease may go on to receive multiple lines of treatments over a longer period of time. New classes of targeted agents in the early and late stages of development bring hope for more gains to be made over the next few years. The paradigm of maintenance treatment is being slowly advanced with antiangiogenic therapies, although the longer term impact on overall survival at this juncture is still unclear. There are variations in practice across the world; for example, bevacizumab in platinum-sensitive ovarian cancer is approved in Europe but not in the USA. Subgroups of patients with chemotherapy-refractory or -resistant disease, clear cell and mucinous cancer still respond poorly to treatment and represent an area of urgent need. The molecular characterization of these tumors will help improve our understanding of these resistant subgroups and will open new avenues for more personalized and targeted treatments in the coming and near future.
Over the last few years, there has been an almost exponential rise in reports, both from the lay and scientific press, relating to the apparent importance of vitamin D to public health. Low levels ...
Endometriosis is the presence of endometrial glands or stroma outside of the uterine cavity. While it is difficult to estimate overall incidence, it is thought that up to 10% of reproductive-age women have endometriosis, which can often result in infertility and pelvic pain. The variation and spectrum of symptoms produced by endometriosis can make patient management challenging, as some patients will present with debilitating pelvic pain and some will have few, if any, symptoms. Definitive diagnosis is made surgically, often with histological correlation. Symptomatic women can be managed either medically or surgically. Further complicating the treatment is the infertile patient with known or suspected endometriosis. While surgical treatments may benefit many patients with endometriosis-associated infertility, there is a subset of patients who may benefit more from proceeding to assisted reproductive technology. This paper will discuss surgical management of endometriosis in women with the primary complaint of infertility and women with the primary complaint of pain. Additionally, we will cover the surgical management of endometriomas, as well as their impact on fertility. Finally, we will discuss recurrence following surgical treatment. In all women with endometriosis, recurrence is common and measures must be taken to reduce the recurrence risk after any treatment.
An estimated 17% of all new cancers in women worldwide are due to cancers of the cervix, the ovary and the uterus. Together, these cancers account for 14.6% of all female cancer deaths. This is a significant societal and economic burden, which can be limited through cancer screening. In the developed world, marked reductions of 50–90% in disease rates have been observed as a result of cervical cancer screening. By contrast, in developing countries, where more than 85% of all new cases and deaths from this cancer are reported, significant challenges need to be overcome. Although cytology remains a key component of cervical screening, the newer molecular tests offer a more targeted, risk-attuned approach. The situation for the other two gynecological cancers is different. The case for ovarian cancer screening has yet to be made with the results of key screening trials in high- and low-risk populations still pending. Screening for endometrial cancer is traditionally not advocated as women become symptomatic ...
Ovarian cancer is usually diagnosed after reaching an advanced stage, in part because of the nonspecific nature of the presenting symptoms. A method of early detection is urgently needed because of the stark difference in long-term survival between early- and late-stage disease. A useful screening test must be easy to perform, low cost, safe and have high positive-predictive value in order to reduce the number of unnecessary invasive procedures performed. A variety of modalities – from pelvic examination to transvaginal ultrasound to cancer antigen 125 to serum biomarker panels and proteomic and other novel approaches – have been explored as possible tests to detect early disease. To date, an effective screening approach has yet to be introduced to clinical practice. Here, the authors evaluate the approaches and highlight promising areas of new research aimed at improving early detection of ovarian cancer.
This overview focuses on the recent developments in the safety and efficacy of the levonorgestrel-releasing intrauterine system (LNG-IUS) on established indications, namely contraception, treatment of heavy menstrual bleeding as well as endometrial protection during estrogen therapy for menopausal symptoms. The LNG-IUS is one of the most efficacious reversible contraceptive methods available. It can be used by various patient groups, including nulliparous women, during breast-feeding, after elective pregnancy termination, in women suffering from various pre-existing medical conditions and menopausal women. This review provides an overview of the published literature on the LNG-IUS from the last 5 years, focusing on cost–effectiveness, safety-related outcomes, the use of LNG-IUS by young and/or nulliparous women as well as by various different patient groups. After decades of dominance by the ‘the Pill’, it is likely that in the future, long-acting reversible contraceptives, such as the LNG-IUS, will become the first-line contraceptive options, owing to their superior contraceptive effectiveness in real-life use, cost–effectiveness as well as their established safety profile.
Endometriosis is an inflammatory disease defined by the presence of ectopic endometrial tissue outside the uterine cavity and is associated with infertility. An aberrant molecular phenotype of the eutopic endometrium in women with endometriosis is thought to affect endometrial receptivity. For successful maternal-embryonic dialog, an appropriate expression of growth factors, cytokines and hormones and their regulation of cell adhesion molecules is necessary. Many articles have found that certain biomarkers such as leukemia inhibiting factor (LIF) from the IL-6 family, glycodelin A (GdA) and αvβ3 integrin are abnormally downregulated in women with endometriosis. The altered expression of progesterone receptor expression also decreased expression of HOX genes in the eutopic endometrium, leading to an abnormal activation or repression of the downstream genes regulated by the HOX genes that produce biomarkers of endometrial receptivity. Understanding the molecular and cellular mechanisms of endometriosis-rela...
At present, between 10 to 15% of couples are infertile, and half of all infertility cases are credited to a female factor. Determination of the source of the problem may hold the key to improving fertility for women. Emerging research demonstrates that reactive oxygen species and oxidative stress (OS) have strong connections with female reproductive function; increases in OS which is associated with certain lifestyle factors can negatively impact female fertility. Lifestyle factors including being obese or underweight, exercising, cigarette smoking, alcohol and caffeine consumption, drug use, psychological stress and environmental and occupational exposures can all have adverse effects on fertility due to their complex interactions and impact exerted via OS on female reproductive processes. Our review highlights these linkages to explain their impact on female fertility, as well as provide suggestions to reduce OS and improve reproductive potential in women.
Worldwide, the rate of delivery by cesarean section is increasing, such that the cesarean section rate is often greater than 30%. The reasons for this increase are many, but a major reason for this change is related to our relatively poor ability to manage labor. This review attempts to cover the issues that contribute to this. Issues regarding definition, assessment and management of labor progress as well as critical times in labor will be examined. Types of partograms are discussed as well as the maternal and fetal factors that influence progress of labor. To be able to care for women in labor, it is important to be aware of limitations of management and how best to overcome these.
The luteal phase is a critical component in supporting early pregnancy by forming the corpus luteum, and priming the endometrium for implantation following conception. Unfortunately, in assisted reproductive technology, ovarian stimulation protocols disrupt the hormonal milieu of the menstrual cycle, resulting in a largely defective luteal phase. For the last three decades, the optimum regimen for luteal phase support in assisted reproductive technology has been explored. Human chorionic gonadotropin was one of the first agents utilized to rescue the corpus luteum, given its high affinity for luteinizing hormone receptor. In this article, the author will summarize the role of human chorionic gonadotropin for luteal support in improving reproductive outcomes.
Within our society, despite peak fertility occurring during a woman’s 20s, many women are choosing to delay childbearing for a variety of reasons. Furthermore, the timeline of female fertility is not readily understood among the general population. Assisted reproductive technologies are being viewed by many as a strategy for coping with age-related infertility. Yet, assisted reproductive technology is limited in its ability to overcome age-related infertility. Fertility preservation strategies, such as egg and ovarian tissue cryopreservation, initially designed for woman receiving gonadotoxic therapies are being offered to a broader audience. Despite these strategies being investigational, according to the American Society of Reproductive Medicine, a majority of clinics in the USA are making egg freezing available to women of all ages for ‘social reasons’. While new technologies are sometimes quick to be embraced, their benefits may not always outweigh the costs. This article seeks to examine the true cost to society of delayed childbearing.
Giuseppe Benagiano speaks to Claire Attwood, Commissioning EditorProfessor Giuseppe Benagiano’s scientific interests have been in reproductive medicine, obstetrics and gynecology and public health. His early work focused on placental enzymes and the feto-placental unit. Then, for years, he focused his attention on contraception. More recently, his research activities have expanded to gynecological disorders of endocrine origin, such as endometriosis, adenomyosis and leiomyomata, and he has pioneered the use of GnRH analogues for these conditions. Over the last decade, he has dedicated himself to the issue of bioethics, published a number of essays on bioethics of reproduction and became coeditor of a special supplement of Reproductive BioMedicine Online called ‘Ethics, Bioscience and Life’. In recognition of his scientific achievements, he has been appointed Visiting Professor at the Ohio State University (OH, USA) and at the Peking Union Medical College University, Honorary Professor at the Health Science Center of Peking University (Beijing, China) and Professeur Associé at the University of Geneva (Switzerland). Benagiano is Honorary Fellow of the American and Indian Colleges of Gynecology and Obstetrics and Fellow ad eundem of the Royal College of Obstetricians and Gynecologists. He is past President of the International Society for the Advancement of Contraception and of the Italian Society for Clinical Sexology, past Secretary General of FIGO (the International Federation of Gynecology and Obstetrics) and past Vice-President of the Italian Society of Pathophysiology of Reproduction.
