Speciality
Spotlight

 




 


Obstetric & Gynaecology


 

 





Gynaecology

   

  • Yolanda R Smith, and Jon-Kar Zubieta

    Neuroimaging of aging and estrogen effects on central nervous system physiology

    Fert. & Ster.76(4), Oct.2001,pg.651-659




    Objective:
    To review the literature on neuroimaging studies focusing on gender differences in the aging process and on the effects of postmenopausal estrogen use on the brain.



    Pertinent studies were identified through a computer MEDLINE search. References of selected articles were hand-searched for additional citations.




    Conclusion(s):
    The current literature suggests that estrogen replacement may decrease brain white matter lesions, increase cerebral blood flow, alter regional brain activation patterns during cognitive processing, and have modulatory effects on various neurotransmitter systems. Overall, this points to a functional plasticity in higher order brain processing that can be altered by gonadal steroids.      

                     

  • Andrew J Levi, Mary F Raynault, et al 

    Reproductive outcome in patients with diminished ovarian reserve

    Fert & Ster.76(4), October 2001,pg.666-9

                        

    Objective: To compare reproductive outcome between women with normal ovarian reserve and women with abnormal ovarian reserve.

                        

    Patients: Nine thousand eight hundred and two patients who had basal follicle-stimulating hormone (FSH) concentrations measured as part of an infertility evaluation.

                     

    Conclusion(s) :Women with DOR have exceedingly high rates of pregnancy loss, regardless of age. Women with diminished ovarian reserve should be counseled that, in addition to a low probability of conception, live birth rates are poor. 

                                                 

    Discussion: Women with diminished ovarian reserve (DOR) respond poorly to ovarian stimulation and have extremely low pregnancy rates in in-vitro fertilization (IVF) cycles. Subfertile women are routinely screened for DOR prior to starting therapy because of the relationship between DOR and poor IVF outcome. A number of tests have been described that attempt to best assess ovarian reserve. Serum basal follicle-stimulating hormone (FSH) levels and the clomiphene citrate challenge test (CCCT), however, continue to correlate best with the probability of conception in assisted reproductive technology (ART) cycles. While the CCCT can be especially useful as a provocative screening test of ovarian reserve, the measurement of a single basal FSH level remains most practical for patients and clinicians alike. Patients with abnormal basal FSH concentrations who do respond to stimulation occasionally become pregnant; unfortunately, overall pregnancy rates in the population are poor.  

                         

  • Andrew J Levi, Michael R Drewis et al 

    Controlled ovarian hyperstimulation does not adversely affect endometrial receptivity in in vitro fertilization cycles.

    Ster.& Fert., vol.76(4), October 2001, pg. 670-4

                   

    Objective: To determine whether exposure of developing endometrium to supraphysiologic E2 levels during controlled ovarian hyperstimulation (COH) in IVF cycles inhibits endometrial receptivity.

                        

    Patients: Four hundred ten patients <33 years of age undergoing IVF-ET AND 181 anonymous ovum donors (<33 years of age) and their associated ovum recipients.

                          

    Conclusion(s): Exposure of the developing endometrium to controlled ovarian hyperstimulaiton during IVF cycles does not inhibit embryo implantation or affect pregnancy and delivery rates.

                                       

    Since the advent of assisted reproduction, investigators have sought to elucidate factors that may limit successful embryo implantation in IVF-ET cycles. Embryo quality and endometrial receptivity were identified as important determinants of reproductive outcome in assisted reproduction, and investigators subsequently developed models to help predict successful embryo implantation. The high rates of embryo implantation in donor oocyte cycles supported the theory that altered endometrial receptivity hindered embryo implantation in IVF-ET cycles. The high implantation rates observed in donor oocyte cycles were attributed to the high fertility potential of oocytes obtained from young donors. Paulson et la further postulated that these increased implantation rates resulted from a more physiologic hormonal milieu observed during cycles involving donor oocyte recipients. The superphysiologic E2 levels associated with COH, in contrast, were thought to diminish endometrial receptivity and thus inhibit embryo implantation.

       

  • Luigi
    Fedele, Stefano Bianchi, et al

    Use of a levonorgestrel-releasing intrauterine device in the treatment of rectovaginal endometriosis.

    Fert.& Ster. vo.75(3), March 2001, pg.485

      

    Objective: To evaluate the effectiveness of a levonorgestrel-releasing IUD as therapy for endometriosis of the rectovaginal septum.

      

    Design: Prospective therapeutic non-randomized, self-controlled clinical trial analysing changes in pain symptoms and size of lesions induced by the levonorgestrel-releasing IUD over 12 months.

      

    Interventions: A levonoargestrel-releasing IUD was inserted and maintained for 12 months.

      

    Main Outcome Measure: Severity of dysmenorrhoea, pelvic pain, and deep dyspareunia were assessed before insertion of the IUD and throughout treatment. The size of rectovaginal endometriotic lesions were evaluated by using transrectal and transvaginal
    ultrasonography.

      

    Results: Dysmenorrhoea, pelvic pain and deep dyspareunia greatly improved and the size of the endometriotic lesions was significantly reduced by treatment.

      

    Conclusion: Insertion of a levonorgestrel-releasing IUD alleviates pain and reduces the size of lesions in patients with endometriosis of the rectovaginal septum.

      

    The small sample and absence of a control group are intrinsic limitations of the study. However, endometriosis of the rectovaginal septum is uncommon, and there is no known and accepted medical treatment.

      

    The levonorgestrel-releasing IUD has proved efficacy in treatment of uterine adenomyosis. Some investigators believe that endometriosis of the rectovaginal septum histologically resembles adenomyosis, in that both lesions are predominantly composed of smooth muscle cells and fibrous tissue.

      

    The mechanism of action of the levonorgestrel-releasing IUD is probably a receptor-mediated effect of levonorgestrel at the level of the endometriosis.

       

    Another mechanism of action that may explain the therapeutic effects of the levonorgestrel-releasing IUD is secondary oligoamenorrhoea and the consequent reduction in cyclic bleeding at ectopic endometrial sites.

      

    The most frequent side effects of the levonorgestrel releasing IUD were menstrual cycle disruption, breast tenderness, mood changes, and acne. Such effects were reported mainly at the start of treatment, and their prevalence is low. Of note, levonorgestrel releasing IUD has been evaluated in much larger series that focused on its contraceptive properties; data from those studies show absence of side effects in 85% of the patients after 5 years of use.

        

  • Francesco
    Massart, Lucia Becherini, et al

    Genotype distribution of estrogen receptor -a-
    gene polymorphisms in Italian women with surgical
    uterine leiomyomas.


    Fert.& Ster.vol.75(3), March 2001, pg.567-70

      

    Objective: To explore a possible association between estrogen receptor-a (ER-a) gene polymorphisms and development of uterine leiomyomas.

      

    Design: Case control study

     

    Setting: University teaching hospital

      

    Patients: 119 women with clinically and surgically diagnosed uterine leiomyomas

      

    Interventions: Therapeutic hysterectomy

     

    Main Outcome Measures: Frequency an distribution of ER-a gene polymorphisms.

     

    Conclusions: The Pvu II and Xba I polymorphisms in the ER-a gene do not produce different risks of developing uterine leiomyomas.

       

  • Maria Elisabetta Coccia, Carolina Becattini, et al

    Pressure lavage under ultrasound guidance: a new approach for outpatient treatment of intrauterine adhesions.

    Fert.& Ster. Vol.75(3), March 2001, pg.7601-6

      

    Objective: To present pressure lavage under ultrasound guidance (PLUG) as a new therapeutic procedure for selected cases of intrauterine adhesions (IUA).

     

    Design: An open clinical investigation with no control group.

     

    Patient(s): Seven consecutive patients referred for secondary amenorrhea due to IUA.

     

    Intervention(s): A newly developed technique based on sonohysterogrpahy was used to monitor the effects of intrauterine injections of saline solution on the continuous accumulation of saline in the uterine cavity for the mechanical disruption of IUA.

      

    Main Outcome Measures: Lysis of intrauterine adhesions, restoration of menses, and increased pregnancy rate in infertile patients.

      

    Results: Five patients with mild IUA obtained satisfactory lysis of adhesions by the use of the PLUG technique. A second-look hysteroscopy after 1 month showed that filmy adhesions persisted in two patients with moderate IUA. These adhesions were removed successfully during hysteroscopy. Restoration of menses was obtained and has continued in all patients. Two of the three infertile patients became pregnant.

      

    Conclusions: This technique is safe and ideal as an in-office procedure. PLUG allows complete lysis in mild IUA cases, and the need for therapeutic, and possibly follow-up hysteroscopy, can be avoided. In moderate IUA cases, the procedure may represent a useful initial step in reducing the need for operative hysteroscopy.

         

  • D.I.
    Lebovic, M..D Mueller, and R.N. Taylor

    Immunology of endometriosis

    Fert.& Ster. Vol.75(1), Jan.2001, pg. 1-10

     

    Results: Defective immunosurveillance in women who are destined to develop endometriosis may allow for the survival of ectopic endometrial tissue. The evidence includes endometrial cell resistance to apoptosis, perhaps through the secretion of proteins that interfere with implant recognition and/or FasL expression by stromal cells, inducing apoptosis of Fas-bearing immune cells. Although the immune response may be defective, aspects of it clearly are enhanced in endometriosis, as is seen by the generalized polyclonal B-cell autoimmune activation and secretion of immune proteins. Several cytokines, chemokines, and growth factors (including vascular growth factors) are increased in women with endometriosis.

     

    Conclusions: A complex network of locally produced cytokines modulate the growth and inflammatory behaviour of ectopic endometrial implants. Proinflammatory proteins from endometriotic lesions and associated immune cells contribute to the enhanced inflammatory reaction associated with endometriosis that subserves the survival of these lesions instead of leading to their demise.

       

  • Stampfer MJ, Hu FB, et al (Harvard Med School, Boston; Harvard School of Public Health, Boston)

    Primary Prevention of Coronary Heart Disease in Women Through Diet and Lifestyle

    N Engl J Med 343: 16-22, 2000

      

    Methods: In 1980 and beyond, inquiries about physical activity and diet were added to follow-up questionnaires. The low-risk group was defined as current nonsmokers with a body mass index less than 25, an average daily alcohol consumption of at least half a drink per day, and moderate-to-vigorous physical activity for at least 30 minutes a day. In addition, they scored in the highest 40th percentile of the cohort for consumption of fiber, marine n-3 fatty acid, and folate, with a high ratio of polyunsaturated to saturated fat, and consumed a diet low in transfer and sugar.

      

    Women were stratified by coronary heart disease risk group according to diet and lifestyle. Outcome measures were major coronary events occurring between 1980 and June 1, 1994.

      

    Editor’s Comments: These data from a very large cohort of women followed up for a long duration provide a good level of evidence that moderate exercise, a low fat diet, and moderate alcohol intake together with lack of obesity and cigarette smoking substantially reduces the risk of major coronary artery events.

      

    When providing primary health care for women, clinicians should counsel their patients about adopting a lifestyle that will reduce the risk of the major cause of death in women.

       

  • Hu FB, Stampfer MJ, et al ( Harvard School of Public Health, Boston; Harvard Med School, Boston)

    Trends in the Incidence of Coronary Heart Disease and Changes in Diet and Lifestyle in Women

    N Engl J Med 343: 530-537, 2000

       

    Objective: Reductions in blood pressure and cholesterol levels have contributed to declines in the incidence and mortality rate of coronary heart disease (CHD). Data from the Nurses’ Health Study were analyzed to assess the impact of diet and lifestyle factors on the incidence of
    CHD.

      

    Results: With adjustment for age, the incidence of CHD declined by 31% between 1980 and 1982 and 1992 and 1994. The number of subjects who currently smoked decreased by 41%. Other trends included a 175% increase in the proportion of postmenopausal women receiving hormone replacement therapy (HRT) and a 38% increase in the prevalence of being overweight (body mass index, 25 kg/m).

      

    Conclusion: Recent declines in the incidence of CHD in women appear to result from lifestyle changes such as reduced smoking, better diet, and increased postmenopausal hormone replacement. Further declines have been prevented by the increasing prevalence of being overweight. Dietary and lifestyle practices have a major role to play in the primary prevention of
    CHD.

        

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Speciality Spotlight

 

 

Gynaecology
   

  • Yolanda R Smith, and Jon-Kar Zubieta
    Neuroimaging of aging and estrogen effects on central nervous system physiology
    Fert. & Ster.76(4), Oct.2001,pg.651-659

    Objective: To review the literature on neuroimaging studies focusing on gender differences in the aging process and on the effects of postmenopausal estrogen use on the brain.

    Pertinent studies were identified through a computer MEDLINE search. References of selected articles were hand-searched for additional citations.

    Conclusion(s): The current literature suggests that estrogen replacement may decrease brain white matter lesions, increase cerebral blood flow, alter regional brain activation patterns during cognitive processing, and have modulatory effects on various neurotransmitter systems. Overall, this points to a functional plasticity in higher order brain processing that can be altered by gonadal steroids.      
                     

  • Andrew J Levi, Mary F Raynault, et al 
    Reproductive outcome in patients with diminished ovarian reserve
    Fert & Ster.76(4), October 2001,pg.666-9
                        
    Objective: To compare reproductive outcome between women with normal ovarian reserve and women with abnormal ovarian reserve.
                        
    Patients: Nine thousand eight hundred and two patients who had basal follicle-stimulating hormone (FSH) concentrations measured as part of an infertility evaluation.
                     
    Conclusion(s) :Women with DOR have exceedingly high rates of pregnancy loss, regardless of age. Women with diminished ovarian reserve should be counseled that, in addition to a low probability of conception, live birth rates are poor. 
                                                 
    Discussion: Women with diminished ovarian reserve (DOR) respond poorly to ovarian stimulation and have extremely low pregnancy rates in in-vitro fertilization (IVF) cycles. Subfertile women are routinely screened for DOR prior to starting therapy because of the relationship between DOR and poor IVF outcome. A number of tests have been described that attempt to best assess ovarian reserve. Serum basal follicle-stimulating hormone (FSH) levels and the clomiphene citrate challenge test (CCCT), however, continue to correlate best with the probability of conception in assisted reproductive technology (ART) cycles. While the CCCT can be especially useful as a provocative screening test of ovarian reserve, the measurement of a single basal FSH level remains most practical for patients and clinicians alike. Patients with abnormal basal FSH concentrations who do respond to stimulation occasionally become pregnant; unfortunately, overall pregnancy rates in the population are poor.  
                         

  • Andrew J Levi, Michael R Drewis et al 
    Controlled ovarian hyperstimulation does not adversely affect endometrial receptivity in in vitro fertilization cycles.
    Ster.& Fert., vol.76(4), October 2001, pg. 670-4
                   
    Objective: To determine whether exposure of developing endometrium to supraphysiologic E2 levels during controlled ovarian hyperstimulation (COH) in IVF cycles inhibits endometrial receptivity.
                        
    Patients: Four hundred ten patients <33 years of age undergoing IVF-ET AND 181 anonymous ovum donors (<33 years of age) and their associated ovum recipients.
                          
    Conclusion(s): Exposure of the developing endometrium to controlled ovarian hyperstimulaiton during IVF cycles does not inhibit embryo implantation or affect pregnancy and delivery rates.
                                       
    Since the advent of assisted reproduction, investigators have sought to elucidate factors that may limit successful embryo implantation in IVF-ET cycles. Embryo quality and endometrial receptivity were identified as important determinants of reproductive outcome in assisted reproduction, and investigators subsequently developed models to help predict successful embryo implantation. The high rates of embryo implantation in donor oocyte cycles supported the theory that altered endometrial receptivity hindered embryo implantation in IVF-ET cycles. The high implantation rates observed in donor oocyte cycles were attributed to the high fertility potential of oocytes obtained from young donors. Paulson et la further postulated that these increased implantation rates resulted from a more physiologic hormonal milieu observed during cycles involving donor oocyte recipients. The superphysiologic E2 levels associated with COH, in contrast, were thought to diminish endometrial receptivity and thus inhibit embryo implantation.
       

  • Luigi Fedele, Stefano Bianchi, et al
    Use of a levonorgestrel-releasing intrauterine device in the treatment of rectovaginal endometriosis.
    Fert.& Ster. vo.75(3), March 2001, pg.485
      
    Objective: To evaluate the effectiveness of a levonorgestrel-releasing IUD as therapy for endometriosis of the rectovaginal septum.
      
    Design: Prospective therapeutic non-randomized, self-controlled clinical trial analysing changes in pain symptoms and size of lesions induced by the levonorgestrel-releasing IUD over 12 months.
      
    Interventions: A levonoargestrel-releasing IUD was inserted and maintained for 12 months.
      
    Main Outcome Measure: Severity of dysmenorrhoea, pelvic pain, and deep dyspareunia were assessed before insertion of the IUD and throughout treatment. The size of rectovaginal endometriotic lesions were evaluated by using transrectal and transvaginal ultrasonography.
      
    Results: Dysmenorrhoea, pelvic pain and deep dyspareunia greatly improved and the size of the endometriotic lesions was significantly reduced by treatment.
      
    Conclusion: Insertion of a levonorgestrel-releasing IUD alleviates pain and reduces the size of lesions in patients with endometriosis of the rectovaginal septum.
      
    The small sample and absence of a control group are intrinsic limitations of the study. However, endometriosis of the rectovaginal septum is uncommon, and there is no known and accepted medical treatment.
      
    The levonorgestrel-releasing IUD has proved efficacy in treatment of uterine adenomyosis. Some investigators believe that endometriosis of the rectovaginal septum histologically resembles adenomyosis, in that both lesions are predominantly composed of smooth muscle cells and fibrous tissue.
      
    The mechanism of action of the levonorgestrel-releasing IUD is probably a receptor-mediated effect of levonorgestrel at the level of the endometriosis.
       
    Another mechanism of action that may explain the therapeutic effects of the levonorgestrel-releasing IUD is secondary oligoamenorrhoea and the consequent reduction in cyclic bleeding at ectopic endometrial sites.
      
    The most frequent side effects of the levonorgestrel releasing IUD were menstrual cycle disruption, breast tenderness, mood changes, and acne. Such effects were reported mainly at the start of treatment, and their prevalence is low. Of note, levonorgestrel releasing IUD has been evaluated in much larger series that focused on its contraceptive properties; data from those studies show absence of side effects in 85% of the patients after 5 years of use.
        

  • Francesco Massart, Lucia Becherini, et al
    Genotype distribution of estrogen receptor -a- gene polymorphisms in Italian women with surgical uterine leiomyomas.
    Fert.& Ster.vol.75(3), March 2001, pg.567-70
      
    Objective: To explore a possible association between estrogen receptor-a (ER-a) gene polymorphisms and development of uterine leiomyomas.
      
    Design: Case control study
     
    Setting: University teaching hospital
      
    Patients: 119 women with clinically and surgically diagnosed uterine leiomyomas
      
    Interventions: Therapeutic hysterectomy
     
    Main Outcome Measures: Frequency an distribution of ER-a gene polymorphisms.
     
    Conclusions: The Pvu II and Xba I polymorphisms in the ER-a gene do not produce different risks of developing uterine leiomyomas.
       

  • Maria Elisabetta Coccia, Carolina Becattini, et al
    Pressure lavage under ultrasound guidance: a new approach for outpatient treatment of intrauterine adhesions.
    Fert.& Ster. Vol.75(3), March 2001, pg.7601-6
      
    Objective: To present pressure lavage under ultrasound guidance (PLUG) as a new therapeutic procedure for selected cases of intrauterine adhesions (IUA).
     
    Design: An open clinical investigation with no control group.
     
    Patient(s): Seven consecutive patients referred for secondary amenorrhea due to IUA.
     
    Intervention(s): A newly developed technique based on sonohysterogrpahy was used to monitor the effects of intrauterine injections of saline solution on the continuous accumulation of saline in the uterine cavity for the mechanical disruption of IUA.
      
    Main Outcome Measures: Lysis of intrauterine adhesions, restoration of menses, and increased pregnancy rate in infertile patients.
      
    Results: Five patients with mild IUA obtained satisfactory lysis of adhesions by the use of the PLUG technique. A second-look hysteroscopy after 1 month showed that filmy adhesions persisted in two patients with moderate IUA. These adhesions were removed successfully during hysteroscopy. Restoration of menses was obtained and has continued in all patients. Two of the three infertile patients became pregnant.
      
    Conclusions: This technique is safe and ideal as an in-office procedure. PLUG allows complete lysis in mild IUA cases, and the need for therapeutic, and possibly follow-up hysteroscopy, can be avoided. In moderate IUA cases, the procedure may represent a useful initial step in reducing the need for operative hysteroscopy.
         

  • D.I. Lebovic, M..D Mueller, and R.N. Taylor
    Immunology of endometriosis
    Fert.& Ster. Vol.75(1), Jan.2001, pg. 1-10
     
    Results: Defective immunosurveillance in women who are destined to develop endometriosis may allow for the survival of ectopic endometrial tissue. The evidence includes endometrial cell resistance to apoptosis, perhaps through the secretion of proteins that interfere with implant recognition and/or FasL expression by stromal cells, inducing apoptosis of Fas-bearing immune cells. Although the immune response may be defective, aspects of it clearly are enhanced in endometriosis, as is seen by the generalized polyclonal B-cell autoimmune activation and secretion of immune proteins. Several cytokines, chemokines, and growth factors (including vascular growth factors) are increased in women with endometriosis.
     
    Conclusions: A complex network of locally produced cytokines modulate the growth and inflammatory behaviour of ectopic endometrial implants. Proinflammatory proteins from endometriotic lesions and associated immune cells contribute to the enhanced inflammatory reaction associated with endometriosis that subserves the survival of these lesions instead of leading to their demise.
       

  • Stampfer MJ, Hu FB, et al (Harvard Med School, Boston; Harvard School of Public Health, Boston)
    Primary Prevention of Coronary Heart Disease in Women Through Diet and Lifestyle
    N Engl J Med 343: 16-22, 2000
      
    Methods: In 1980 and beyond, inquiries about physical activity and diet were added to follow-up questionnaires. The low-risk group was defined as current nonsmokers with a body mass index less than 25, an average daily alcohol consumption of at least half a drink per day, and moderate-to-vigorous physical activity for at least 30 minutes a day. In addition, they scored in the highest 40th percentile of the cohort for consumption of fiber, marine n-3 fatty acid, and folate, with a high ratio of polyunsaturated to saturated fat, and consumed a diet low in transfer and sugar.
      
    Women were stratified by coronary heart disease risk group according to diet and lifestyle. Outcome measures were major coronary events occurring between 1980 and June 1, 1994.
      
    Editor’s Comments: These data from a very large cohort of women followed up for a long duration provide a good level of evidence that moderate exercise, a low fat diet, and moderate alcohol intake together with lack of obesity and cigarette smoking substantially reduces the risk of major coronary artery events.
      
    When providing primary health care for women, clinicians should counsel their patients about adopting a lifestyle that will reduce the risk of the major cause of death in women.
       

  • Hu FB, Stampfer MJ, et al ( Harvard School of Public Health, Boston; Harvard Med School, Boston)
    Trends in the Incidence of Coronary Heart Disease and Changes in Diet and Lifestyle in Women
    N Engl J Med 343: 530-537, 2000
       
    Objective: Reductions in blood pressure and cholesterol levels have contributed to declines in the incidence and mortality rate of coronary heart disease (CHD). Data from the Nurses’ Health Study were analyzed to assess the impact of diet and lifestyle factors on the incidence of CHD.
      
    Results: With adjustment for age, the incidence of CHD declined by 31% between 1980 and 1982 and 1992 and 1994. The number of subjects who currently smoked decreased by 41%. Other trends included a 175% increase in the proportion of postmenopausal women receiving hormone replacement therapy (HRT) and a 38% increase in the prevalence of being overweight (body mass index, 25 kg/m).
      
    Conclusion: Recent declines in the incidence of CHD in women appear to result from lifestyle changes such as reduced smoking, better diet, and increased postmenopausal hormone replacement. Further declines have been prevented by the increasing prevalence of being overweight. Dietary and lifestyle practices have a major role to play in the primary prevention of CHD.
        

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