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To assess maternal and neonatal outcomes in women with or without preexisting diabetes mellitus (DM) undergoing assisted reproduction technology (ART) treatment. Prospective or retrospective controlled trials reporting on women with or without preexisting DM undergoing ART treatment were considered eligible. Twelve electronic databases were systematically searched up to December 2020. The risk of bias was assessed by the Cochrane Risk OF Bias In Non-randomized Studies of Interventions (ROBINS-I) tool. Each primary outcome was extracted and pooled as maternal- or neonatal-related. Two studies were included in the systematic review, reporting on both maternal- and neonatal-related parameters after ART treatment. Due to the limited data, no meta-analysis was conducted. Preterm birth, placenta previa, and excessive bleeding during pregnancy were observed more often in pregnancies complicated by preexisting DM conceived by ART compared with pregnancies without DM. There was no difference in the risk for placental abruption between the groups. Regarding the neonatal outcomes, large-for-gestational-age (LGA) embryos and neonatal intensive care unit (NICU) admission were more commonly reported for women with preexisting DM. In one study, preexisting DM was marginally associated with infant mortality. Despite the scarce data, preexisting DM in pregnancies conceived by ART is associated with increased risk for maternal and neonatal complications. Registered in PROSPERO (registration number: 143187).

In the surgical correction of tuberous breast deformity, implants and regional flaps play a prominent role. Lately, fat grafting has been used as an alternative, but there is evidence that patient satisfaction is higher after correction with implants compared with lipofilling. We report a tuberous breasts correction series of ten cases, enrolled between 2015 and 2018. Percutaneous fasciotomies and fat grafting were performed by the Body-Jet technique. Analysis of outcomes was undertaken with BREAST-Q surveys. The breast satisfaction scores increased from 0 to 75 (p < 0.01), the psychological well-being scores from 20 to 70 (p < 0.01) and the sexual well-being scores from 18.5 to 58 (p = 0.02), while the physical well-being scores remained stable (from 68 to 63, p = 0.2). The median outcome satisfaction score was 86. Scores of patient-reported outcomes after lipofilling can reach and even exceed those of patients corrected with implants, at the cost of more interventions. Fat grafting is beginning to establish itself as a true alternative in the treatment of tuberous breast deformity in patients with the appropriate fat deposits. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266 .

Background Auto-augmentation mastopexy after implant removal has been described as a possible alternative for women who do not opt for implant replacement and decline major reconstructive surgery. Objectives This study aimed to evaluate patient satisfaction after auto-augmentation mastopexy relative to the final breast volume and to assess the role of fat grafting on patients’ satisfaction and quality of life according to the BREAST-Q questionnaire. Methods Forty-seven breasts from 28 patients who underwent implant removal and auto-augmentation mastopexy were reviewed; 9 patients (group 1) were primarily treated with several fat grafting sessions with subsequent auto-augmentation, 5 (group 2) were treated primarily with auto-augmentation, but subsequently expressed a wish for breast augmentation by lipofilling, and 14 patients (group 3, control) had only auto-augmentation. Results Group 1 patients maintained their breast volume, and showed significant improvements in breast satisfaction, psychosocial well-being, and contentment with breast surgery outcomes (P = 0.01, ˂0.01, and ˂0.01, respectively). However, the physical well-being of this group, as well as response to final cup size or interaction parameters, did not improve (P = 0.06). In group 2, all except 1 patient had breast volume reduction to A cup, as was the case with one-third of the patients in control group 3 (group 3A, n = 5) who scored lower, and thus were less satisfied with the breast auto-augmentation than group 3B, who achieved final bigger cup sizes (P ˂ 0.01). Conclusions Auto-augmentation mastopexy resulted in substantial improvements in the parameters measured by BREAST-Q. Thus, combined auto-augmentation mastopexy and lipofilling provided a better alternative treatment after breast implant removal. Level of Evidence: 4

Women ≤ 35 years old with breast cancer constitute a special group. Considering the impact of the disease and its prognosis, these patients face some specific problems that are not present in older women. What are the prognostic features of the survival rate in very young women with breast cancer?Retrospective analysis of very young women with breast cancer from the Surgical-Oncologic Breast Cancer Department at "Theagenio" Anticancer Hospital, 2003-2016. Patient and tumor characteristics, treatment options and follow-up information were collected. Univariate-multivariate analyses were conducted and survival rates were calculated.The median age was 34 years old. 53 patients (41%) had T1, 36 (28%) had T2, 7 (5.4%) had T3 and 33 (25.6%) had T4 stage tumors. Most women, 114 (88.4%), had ductal carcinoma in their histology. Furthermore, positive axillary lymph nodes were present in 62 women (48%). In the immunochemistry report, 91 patients (70.5%) were hormone receptor positive, HER2 was overexpressed in 32 patients (24.8%) and 27 patients presented with triple-negative subtype. Out of 65 patients tested for Ki-67, 51 (78.5%), had a high expression (cut-off value of 20%). After adjusting for all possible factors, the risk of recurrence and death was six times higher in the positive lymph node group, (p 0.001). The median disease-free and overall survival was 133 and 173 months, respectively.Breast cancer in very young women appears with large size and high-grade tumors, high incidence of infiltrated axillary lymph nodes, high Ki-67 expression and intrinsic subtypes with poor prognosis. As a result, these women need to be treated by a multidisciplinary team.

PURPOSE: The objective of this systematic review and metaanalysis was to examine if the probability of pregnancy after ovarian stimulation for in vitro fertilization (IVF), using GnRH analogues and gonadotrophins is associated with serum estradiol level (Ε(2)) on the day of triggering final oocyte maturation with human chorionic gonadotrophin (hCG). METHODS: Twenty-one studies were eligible for this systematic review, including 19,598 IVF cycles, whereas three studies were eligible for metaanalysis, including 641 IVF cycles. The main outcome measure was achievement of ongoing pregnancy/live birth and, if not available, clinical pregnancy or biochemical pregnancy. RESULTS: Pooling of data showed no differences in the probability of clinical pregnancy between patients with high and low Ε(2) levels on the day of triggering final oocyte maturation. The pooled effect sizes for the Ε(2) thresholds groups constructed, regarding clinical pregnancy were 2000–3000 pg/mL—OR 0.91, 95% CI 0.55 to 1.50, (fair quality/moderate risk of bias, n = 1 study), 3000–4000 pg/mL—OR 0.89, 95% CI 0.46 to 1.70, (fair quality/moderate risk of bias, n = 1 study, good quality/no information on which to base a judgement about risk of bias n = 2 studies), 4000–5000 pg/mL—OR 0.74, 95% CI 0.37 to 1.49 fair quality/moderate risk of bias, n = 1 study), 5000–6000 pg/mL—OR 0.62, 95% CI 0.19 to 1.98, (fair quality/moderate risk of bias, n = 1 study). In addition, no difference was observed in the probability of ongoing pregnancy for the Ε(2) threshold group of 3000–4000 pg/mL OR 0.85, 95% CI 0.40 to 1.81(good quality/no information on which to base a judgement about risk of bias, n = 1 study). CONCLUSION: Currently, there is insufficient evidence to support or deny the presence of an association between the probability of pregnancy and serum Ε(2) levels on the day of triggering final oocyte maturation with hCG in women undergoing ovarian stimulation for IVF. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s10815-020-01829-z) contains supplementary material, which is available to authorized users.

Introduction/Background* Complete cytoreduction is the cornerstone of the treatment for advanced ovarian cancer (AOC). To achieve this goal multiple organ resection is required, with an important impact on the patient’s overall health. These patients may benefit from the implementation of enhanced recovery after surgery (ERAS). The aim of this study is to evaluate the possible benefit in the patient’s postoperative morbidity. Methodology Retrospective analysis of women with AOC from the 1st Department of Obstetrics & Gynecology AUTh at “Papageorgiou” Hospital (ESGO Certified Center for AOC), 2014 – 2019. From 2014 to 2016 conventional management (CM) was applied, while from 2017 to 2019 patients where managed with ERAS protocol. Patient & tumor characteristics, treatment options and follow-up information were collected. Primary outcomes where ICU admittance, post-operative complications (Clavien – Dindo classification) and hospitalization. Result(s)* 142 patients met the inclusion criteria. Patients underwent either primary debulking surgery (PDS) or interval debulking surgery (IDS). 84 patients were treated with conventional management and 58 with ERAS protocol. The mean age for the ERAS group was 60 ± 13 vs. 61 ± 13 years old for the CM group (p=0.8315). Furthermore, there was no difference between the type of surgery operation duration between the 2 groups. (CM group: 210min vs. ERAS group: 240min, p=0.1497/CM group: 50% PDS – 50% IDS vs. ERAS group: 38% PDS – 62% IDS, p=0.1554). However, the occurrence of ICU admittance (32% vs. 14%, p=0.01263), overall postoperative complications (32 vs. 22.6, p=0.004) and hospitalization (9 vs. 7 days, p Conclusion* The implementation of the ERAS program in the management of AOC improves patient’s postoperative morbidity, reducing the interval time between surgery and systematic therapy. Less need for the ICU and fewer days in the hospital can decrease healthcare costs in high-volume gynecological – oncological centers.

Introduction/Background* Complete cytoreduction is the cornerstone of the treatment for ovarian cancer (OC). Patients are triaged either for primary debulking surgery (PDS) or neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS), based on the preoperative assessment. The aim of this study is to evaluate the impact of the enhanced recovery after surgery (ERAS) protocol in postoperative morbidity for both groups (PDS vs. IDS). Methodology Retrospective analysis of women with OC from the 1st Department of Obstetrics &amp Gynecology AUTh at ‘Papageorgiou’ Hospital (ESGO Certified Center for AOC), 2017 – 2019. Patients were triaged for PDS or IDS based on preoperative imaging and ‘laparoscopic Fagotti’s score’. Patient & tumor characteristics, treatment options and follow-up information were collected. Primary outcomes were ICU admittance, post-operative complications (Clavien – Dindo classification) and duration of hospitalization. Result(s)* 78 patients met the inclusion criteria: 40 underwent PDS and 38 IDS. The two groups had no significant difference in patients characteristics (age, Charlson comorbidity index (CCI)). Furthermore, concerning surgical outcomes PDS vs IDS group had higher surgical complexity score (SCS), blood loss and complete debulking rate, but with no statistical significance (5 vs. 4, p=0.1466/350 vs. 300, p=0.1197/77.5% vs. 68.4%, p=0.5958 respectively). Only the duration of the surgery was statistically significant in the PDS group (300 vs. 195 min, p = 0.007). The implementation of the ERAS protocol led to comparable results with no statistical significance for postoperative morbidity, between the two groups: The PDS group had higher ICU admittance (17.5% vs. 2.6%, p=0.9741), lower overall complications (15 vs. 19, p=0.9741) and the same hospitalization (8 ± 3 vs. 8 ± 2.8 days, p=0.3805). Conclusion* Careful preoperative selection of patients and the implementation of the ERAS program in the management of OC results in comparable postoperative morbidity between PDS and IDS, regardless of the higher SCS in the upfront surgery or the toxicity of the NACT. Further prospective studies are needed to validate these results.

Introduction/Background* Cytoreductive surgery is the cornerstone treatment in the armamentarium for women with advanced ovarian cancer. The goal of successful cytoreduction is achiving no visible tumor or residual disease less than 1 cm. This prerequisite is a demanding process with high morbidity, requiring high clinical expertise and enhanced surgical skills. The objective of the presented analysis is to identify whether the usage of the Ligasure® Maryland jaw open sealer/divider (LMjsd) with nanocoating facilitates cytoreductive surgery by reducing intraoperative bleeding and hence other parameters regarding hospitalization. Methodology Women with advanced stage ovarian cancer (stage III or IV) who were referred to the Department of Gynecologic Oncology, 1st Department of Obstetrics and Gynecology, Papageorgiou General Hospital, Thessaloniki, Greece, and were subjected to either primary or interval cytoreductive surgery were included in the analysis. Women, who were operated on by the same group of Gynecologic Oncologists, were retrospectively allocated into two distinct groups comprised of women subjected to surgery with or without using the LMjsd. The analysis focused on differences between the two groups regarding intraoperative blood loss and blood transfusion, duration of surgery, blood transfusion within the post-operative course, Intensive Care Unit (ICU) and overall hospital length of stay. Result(s)* Between 2012 and 2020, 284 women with ovarian cancer were subjected to surgery; of these, 208 had ovarian cancer stage III or IV. In the group of women (N=34), who were operated on using the LMjsd, duration of surgery, and blood loss during surgery were significantly decreased (p Conclusion* The LMjsd with nanocoating reduces intra-operative bleeding and transfusion rates, and improves duration of surgery, and ICU and overall hospital length of stay in women subjected to cytoreductive surgery for advanced ovarian cancer.

Introduction/Background* Women ≤35 years old with breast cancer constitute a special group. Considering the impact of the disease and its prognosis, these patients face some specific problems, that are not present in older women. What are the prognostic features of the survival rate in very young women with breast cancer? Methodology Retrospective analysis of very young women with breast cancer from the Surgical-Oncologic Breast Cancer Department at ‘Theagenio’ Anticancer Hospital, 2003 – 2016. Patient & tumor characteristics, treatment options and follow-up information were collected. Univariate – multivariate analyses were conducted and survival rates were calculated. Result(s)* 129 patients met the inclusion criteria. The median age was 34 years old. 53 patients (41%) had T1, 36 (28%) had T2, 7 (5.4%) had T3 and 33 (25.6%) had T4 stage tumors. Most women, 114 (88.4%), had ductal carcinoma in their histology. Furthermore, positive axillary lymph nodes were present in 62 women (48%). In the immunochemistry report, 91 patients (70.5%) were hormone receptor positive, HER2 was overexpressed in 32 patients (24.8%) and 27 patients presented with Triple negative subtype. Out of 65 patients tested for Ki-67, 51 (78.5%), had a high expression (cut off value of 20%). After adjusting for all possible factors, the risk of recurrence and death was six times higher in the positive lymph nodes group, (p 173 months, respectively. Conclusion* Breast cancer in very young women appears with large size and high-grade tumors, high incidence of infiltrated axillary lymph nodes, high Ki-67 expression and intrinsic subtypes with poor prognosis. As a result, these women need to be treated by a multidisciplinary team.

Study question Are there any differences in implantation, cytoskeleton and ultrastructure of embryos biopsied on day5 vs day3 and how endometrial damage/inflammation may affect receptivity and implantation? Summary answer No differences are observed in implantation rates but vitrification following day5 biopsy led to more cytoskeletal/ultrastructural anomalies. Infections and epithelial damage severely affected endometrial receptivity. What is known already Successful implantation is dependent on the correct synchronization of the window of implantantation with the transfer of chromosomally/genetically normal embryos, in a well prepared receptive endometrium. This is the first study to examine the effects of day5 vs day3 embryo biopsy by comparing implantation/pregnancy rates and by analysing cytoskeleton using Confocal Laser Scanning Microscopy (CLSM), and ultrastructure by Transmission Electron Microscopy (TEM). In addition, Scanning Electron Microscopy (SEM) was used on endometrial biopsies to assess possible uterine pathologies/inflammation that may be responsible for the failed implantation after PGT-A/M and if subsequent treatment can increase implantation/pregnancy rates in succeeding PGT-A/M cycles. Study design, size, duration 470 embryos were biopsied on day5 for PGT-A (n = 152–37 cycles) or on day3 for PGT-A (n = 162–29 cycles) and PGT-M (n = 156–22 cycles). Following transfer of normal embryos, spare embryos, rejected for transfer following day5 or day3 biopsy were processed for Cytoskeletal analysis (n = 30 fresh day3 biopsied, n = 30 day5 biopsied/vitrified) or TEM (n = 20 fresh day3 biopsied, n = 20 day5 biopsied/vitrified). Also, patients with a –ve hCG test, underwent endometrial biopsy to detect infection/inflammation and assess receptivity. Participants/materials, setting, methods Cytoskeletal analysis was performed by embryo immunostaining with α-tubulin, γ-tubulin, acetylated-tubulin antibodies and DAPI or/ PI to visualise DNA. TEM analysis was carried out following embryo fixation in gluteraldehyde, incubation in osmium, aqueous uranyl acetate, dehydration through ethanol series, and immersion in Epon. Endometrial biopsies were fixed in gluteraldehyde solution and processed for SEM using standard methods. The study was conducted in an academic hospital with an IVF/PGD laboratory and 3 private IVF Units. Main results and the role of chance 162 embryos were biopsied on day 3 for PGT-A (29 cycles), 10 cycles had no normal embryos for transfer, 30 normal embryos were transferred in 19 cycles leading to 12/19 (63.2%) +vehCG/ET and 11/19 (57.9%) Ongoing pregnancy rate/ET. 156 embryos were biopsied on day 3 for PGT-M (22 cycles), 2 cycles had no normal embryos for transfer, 34 normal or carrier embryos were transferred in 20 cycles leading to 15/20 (75.0%) +vehCG/ET and 13/20 Ongoing pregnancy rate/ET (65.0%). 152 embryos were biopsied on day 5 for PGT-A (37 cycles), 8 cycles had no normal embryos for transfer, 34 normal embryos were transferred in 29 cycles leading to 18/29 (62.1%) +vehCG/ET and 16/29 (55.2%) Ongoing pregnancy rate /ET. Analysis of endometrial biopsies with SEM revealed bacterial infections, inflammation and epithelial damage. So far, 33.3% of patients who received intracavitary infusions-antibiotic treatment per os achieved a +vehCG/ET in their next PGT-A/M cycle. Cytoskeletal analysis showed that the majority of spindles examined in both day3 and day5 biopsied embryos were normal (85/114(74.6%) and 87/137(63.5). However vitrification following day5 biopsy led to more cytoskeletal/ultrastructural anomalies which included multipolar/abnormally shaped spindles, chromosome-bridging, chromosome-lagging and more vacuoles, lipofuscins. and distension of mitochondria. Limitations, reasons for caution Patients undergoing PGT-A have various aetiologies (heterogeneous group). The embryos used for cytoskeletal and ultrastructural analysis in this study were all diagnosed with either chromosomal abnormalities or single gene defects following PGT-A or PGT-M. Wider implications of the findings: This is the first study to compare implantation/pregnancy rates, cytoskeleton and ultrastructure of day5 vs day3 biopsied embryos. The similarities observed in implantation/pregnancy rates, and the limited ultrastuctural and cytoskeletal anomalies identified confirm the procedures’ safety and indicate in certain cases endometrial factors/inflammation responsible for failed implantation following PGT-A/M. Trial registration number Not applicable

Study question Does radioactive iodine (RAI) treatment in premenopausal women with differentiated thyroid cancer (DTC) affects ovarian reserve, as evaluated by anti-Müllerian hormone (AMH), antral follicle count (AFC) and follicle-stimulating hormone (FSH)? Summary answer AMH concentrations decreased at three, six and 12 months following RAI treatment in women with DTC, whereas no difference was observed regarding FSH. What is known already Thyroid cancer is the third most common type of female malignancy and DTC is the most common histopathological type. Thyroidectomy constitutes the mainstay of treatment for DTC, followed by administration of RAI, which acts as an adjuvant therapy to destroy residual cancerous thyroid tissue. However, the effect of RAI on ovarian reserve of these women, as assessed by AMH, AFC and FSH, remains controversial. Study design, size, duration A systematic review and meta-analysis was performed aiming to identify studies evaluating the effect of RAI treatment on ovarian reserve in women with DTC. For this purpose, a literature search in the electronic databases PubMed, Scopus and CENTRAL was carried out until 06/12/2020. The primary outcome measure was the effect of RAI on ovarian reserve, as evaluated by AMH, AFC and FSH. Participants/materials, setting, methods Studies were eligible if they included premenopausal women with DTC, treated with a single RAI dose and assessed for at least one marker of ovarian reserve repeatedly within 12 months post-RAI.Meta-analysis of weighted data was performed using random effects model. Results were reported as weighted mean difference (WMD) with 95% confidence interval (CI). Main results and the role of chance Four prospective eligible studies, published between 2005 and 2020, were eligible for the meta-analysis, evaluating a total of 154 women. The number of participants ranged from 24 to 50. The single dose of RAI used to treat DTC ranged from 50 to 150 mCi. AMH concentrations decreased at three (WMD -1.66 ng/ml, 95% CI -2.42 to -0.91, p Limitations, reasons for caution The small number of studies and patients included, as well as the lack of data on AFC may have compromised the validity of the conclusions drawn. Moreover, subgroup analysis according to female age was not feasible, due to the lack of relevant data. Wider implications of the findings The negative effect of RAI on ovarian reserve in premenopausal women with DTC, as indicated by the decreased AMH, should be confirmed by data on AFC, which are currently not available. These findings necessitate close monitoring of ovarian reserve in such women, counselling them regarding the need for fertility preservation. Trial registration number N/A

Study question Does oral antioxidant supplementation improve sperm quality in infertile men with varicocele who have not undergone surgical repair? Summary answer Oral antioxidant supplementation improves sperm concentration and motility in infertile men with varicocele who have not undergone surgical repair. What is known already: Benefit from oral antioxidant supplementation has been shown in infertile men with varicocele following surgical repair. Similarly, oral antioxidant supplementation has been suggested in infertile men with varicocele who have not undergone surgical repair. However, its effect currently remains controversial. Study design, size, duration A literature search was performed until January 2021 aiming to identify prospective studies evaluating the use of oral antioxidant supplementation alone or in combination in men with varicocele who have not undergone surgical repair. Participants/materials, setting, methods Seven prospective studies were identified, published between 1987 and 2018, including 278 infertile men with varicocele who had not undergone surgical repair. The number of patients included ranged from 20 to 65. Sperm analysis, evaluating sperm concentration, motility and morphology was performed in these studies before and after oral antioxidant supplementation. Meta-analysis of weighted data was performed using random effects model. Results are reported as weighted mean difference (WMD) with 95% confidence interval (CI). Main results and the role of chance Seven studies were included in the systematic review. Oral antioxidant supplementation was performed by a combination of pentoxifylline, zinc and folic acid (single study), a combination of l-carnitine, fumarate, acetyl-l-carnitine, fructose, CoQ, vitamin C, zinc, folic acid and vitamin B12 (single study), a combination of L-Carnitine, vitamin C, coenzyme Q10, vitamin E, vitamin B9, vitamin B12, zinc , and selenium, l-carnitine (single study), or sole treatment with acetyl-l-carnitine (single study), L-Carnitine (single study), Coenzyme Q10 (single study) or zinc sulfate (single study). For the purpose of meta-analysis, the effect of oral antioxidant supplementation was evaluated after three months of treatment. Oral antioxidant supplementation significantly increased sperm concentration (WMD +5.65x106/ml 95% CI: +1.11 to + 10.12 p = 0.01, random effects model) and motility (WMD +4.30%, 95% CI: +0.86 to + 7.74 p = 0.01, random effects model) in infertile men with varicocele who had not undergone surgical repair. On the other hand, no significance difference was observed in sperm morphology (WMD +3.9%, 95% CI: –0.16 to + 8.04 p = 0.06, random effects model) and volume (WMD +0.53ml, 95% CI: 0.0 to + 1.0 p = 0.052, random effects model). Limitations, reasons for caution The number of relevant trials and that of patients included is small to allow for solid conclusions to be drawn. Moreover, although different oral antioxidants have been administered in infertile who had not undergone surgical repair, subgroup analysis was not feasible. Wider implications of the findings: Currently, limited evidence supports the use of oral antioxidants in the treatment of men with varicocele, who have not undergone surgical repair. Although the benefit in sperm concentration and motility appears to be modest, it might be important regarding achievement of pregnancy in these men. Trial registration number Not applicable

Aim Radioactive iodine (RAI) is frequently used as adjuvant therapy in patients with differentiated thyroid cancer (DTC). However, its effect on ovarian reserve has not been fully elucidated, with studies yielding inconsistent results. The aim of this study was to systematically review and meta-analyze the best available evidence regarding the effect of RAI on ovarian reserve in premenopausal women with DTC. Methods A comprehensive literature search was conducted in PubMed, Cochrane and Scopus, through to December 6th, 2020. Data were expressed as weighted mean difference (WMD) with a 95% confidence interval (CI). The I2 index was used to assess heterogeneity. Results Four prospective studies were included in the qualitative and quantitative analysis. Anti-Mullerian hormone (AMH) concentrations decreased at three (WMD -1.66 ng/ml, 95% CI -2.42 to -0.91, p Conclusions AMH concentrations are decreased at three months and remain low at 6 and 12 months following RAI treatment in women with DTC. No difference in FSH concentrations post-RAI is observed.

Laparoscopy can be used for almost all gynecological procedures and is considered as the indicated method for specific procedures. This is especially true for adnexal surgery. Of course, while it is considered a method of choice for the treatment of benign ovarian tumors, the same does not apply to malignant ones, although treatment of ovarian cancer either at an early or even at a more advanced stage is feasible with laparoscopy. Finding malignancy, when not suspected, during laparoscopic treatment of an ovarian cyst is a situation raising several issues, depending on whether the identification of malignancy is intra- or post-operative, which involve inadequate surgical staging, peritoneal spread of cancer cells, intraoperative rupture of a malignant ovarian cystic tumor, and port site metastasis. This chapter analyzes the possible adverse events related to the use of laparoscopy in the treatment of adnexal masses considered as benign but turn out to be malignant, and how they can be mitigated with careful preoperative patient selection and with adequate surgical experience.

Objectives Multiple pregnancies sustain the high pace of extreme prematurity. Little evidence is available about triplet gestation given the evolution in their management during the last decades. The aim of the study was to compare the neonatal outcomes of triplets with those of matched singletons in a cohort study. Methods An observational retrospective cohort study of triplets and matched singletons born between 2004 and 2017 matched by gestational age was conducted. Additionally, the investigation performed in regard to data from the overall Greek population of interest. The primary outcome was mortality or severe neonatal morbidity based on pregnancy type. Results A total of 237 triplets of 24–36 weeks’ gestation and 482 matched singletons were included. No differences in the primary outcome between triplets and singletons were found. Rates of severe neonatal morbidities did not differ significantly between triplets and singletons. A threshold of 1000 gr for birthweight and 28 weeks’ gestation for gestational age determined survival on triplets [OR: 0.08 (95% CI: 0.02–0.40, p=0.0020) and OR: 0.13 (95% CI: 0.03–0.57, p=0.0020) for gestational age and birthweight respectively]. In Greece stillbirths in triplets was 8 times higher than that of singletons (OR: 8.5, 95% CI: 6.9–10.5). From 3,375 triplets, 94 were stillborn, whereas in singletons, 4,659 out of 1,388,273. In our center 5 times more triplets than the expected average in Greece were delivered with no significant difference in stillbirths’ rates. Conclusions No significant differences were identified in mortality or major neonatal morbidities between triplets and matched singletons highlighting the significance of prematurity and birthweight for these outcomes.

Introduction/Background Ovarian cancer is usually diagnosed in advanced stage. The goal of primary debulking is to achieve no residual disease (RD). Proper selection of candidates for complete debulking is crucial for the avoidance of suboptimal laparotomies. The aim of this study is to compare ‘Fagotti’ diagnostic laparoscopy and preoperative ‘Suidan’ criteria (age, ASA score, CA125, CT results) in the selection of patients for primary debulking. Methodology We retrospectively reviewed the medical records of patients with advanced ovarian cancer that underwent ‘Fagotti’ diagnostic laparoscopy (January 2017 - January 2019) in our clinic. Results 25 patients with advanced ovarian cancer underwent ‘Fagotti’ diagnostic laparoscopy, in order to decide their treatment plan. 7 patients were excluded from the study, because they did not meet the inclusion criteria. According to the preoperative predictive score, half of the patients (n=9) were assigned for primary debulking (PDS) (Group A) and the other half (n=9) for neoadjuvant chemotherapy (NACT) followed by interval debulking (IDS) (Group B). After ‘Fagotti’ diagnostic laparoscopy, the treatment plan changed in a total of 9 patients: 4 from Group A (from PDS to NACT+IDS) and 5 from Group B (from NACT+IDS to PDS), but with no statistically significant difference. From all patients (n=16) that underwent PDS or IDS, no case of suboptimal cytoreduction was documented (13 RD=0 and 3 RD Conclusion ‘Fagotti’ diagnostic laparoscopy continues to be the method of choice for the proper selection of patients for primary debulking, despite being an invasive technique. Disclosure Nothing to disclose

Introduction/Background Adenomyosis often co-exist in the pathological reports, after surgery for endometrial cancer. The aim of this study is to describe the clinicopathological and oncological characteristics of these patients and further investigate the malignant transformation of the adenomyotic tissue. Methodology We retrospectively reviewed the medical records of all patients that underwent hysterectomy for endometrial cancer (January 2012 - December 2017) in our clinic. The pathological reports were reviewed and when adenomyosis co-existed, the pathological slides were re-examined in order to discover any malignant change in the adenomyotic tissue. The clinicopathological characteristics and oncological results were described. Results Out of 229 cases of endometrial cancer, 64 (28%) patients had concurrently endometrial cancer and adenomyosis. Among these 64 patients, 7 (11%) had malignant transformation of adenomyosis. The mean age of patients suffering from both endometrial cancer and adenomyosis was 63.2 years old and 57 (89%) of these patients, had early endometrial cancer (FIGO stage IA–IB). Out of these patients, 22 (34.4%) had grade I, 36 (56.2%) grade II and only 6 (9.4%) had grade III tumors. Moreover, in this special group of patients with concurrent endometrial cancer and adenomyosis, 25 (39%) patients presented in the pathological report fibroids and 2 (3%) endometriosis. Concerning the patients with malignant transformation of adenomyosis, their mean age was 65 years old with no premenopausal case. There was only 1 case of recurrence and none death due to cancer. Conclusion Adenomyosis, as a benign disease, is described in the last decades, but its malignant transformation is not fully researched, due to the low incidence of this entity and the relative diagnostic problems. Further investigation is needed in order to clarify the pathologic progression of adenomyotic lesions to endometrial cancer and the associated prognosis of this disease. Disclosure Nothing to disclose.

Introduction/Background In ovarian cancer, metastatic cardiophrenic lymph nodes are associated with FIGO stage IV disease. The goal of debulking surgery should be no residual disease and resection of those lymph nodes is mandatory. The aim of this case report is to present the subxiphoid approach, as an alternative for the exploration of both cardiophrenic spaces from one incision, in contrast to the transdiaphragmatic approach. Methodology The patient was a 45 years old female. Preoperative work-up revealed an elevated CA-125 of 2521 and a CT-scan showing a pelvic mass, ascites, omental cake, diaphragmatic disease and enlarged supradiaphragmatic cardiophrenic lymph nodes, without pleural effusion. The patient underwent primary debulking surgery. Cytoreduction included type II radical oophorectomy (en bloc modified radical abdominal hysterectomy, bilateral salpingo-oophorectomy, pan-pelvic peritonectomy, rectosigmoid colectomy), appendicectomy, cholecystectomy, radical omentectomy, paracolic gutters peritonectomy, small - large bowel mesentery electro-coagulation, right diaphragm full-thickness resection and subxiphoid resection of supradiaphragmatic cardiophrenic lymph nodes. Results The cardiophrenic incision surgical steps included: subxiphoid peritoneal dissection, cutting of the transverse abdominis muscle, dissection of the retrosternal peritoneum laterally from the midline, digital development of the cardiophrenic space and removal of the enlarged lymph nodes. Total operative time was 450 min and estimated blood loss 700 ml, with no residual disease. Post-operative intensive care unit (ICU) admission was necessary for three days due to mild hemodynamic instability and the patient was discharged from hospital on the 17th postoperative day. The pathological report showed a grade III serous adenocarcinoma, with metastases to six of seven resected cardiophrenic lymph nodes. Conclusion Subxiphoid resection of supradiaphragmatic cardiophrenic lymph nodes is a feasible alternative approach for the exploration of both cardiophrenic spaces with no direct diaphragmatic trauma. Disclosure Nothing to disclose.

Introduction/Background Lymphocyst is rare disease,and mainly reported in some case reports.Occurrence of lymphocyst has been described in relation to surgery in a wide variety of other areas including the mediastinum, axila, neck, aorta and peripheral vasculature.The pathophysiology is based in insufficient lymphatic stasis with gross postoperative lymph leakage which cannot be absorbed in the peritoneum. Methodology A 46-year-old woman, was admitted to the emergency department, with abdominal pain. The pain was located to the abdomen.Her vital signs were non-reassuring.A mass was palpated arising from the pelvis on the left side.Her medical history included aleft oophorectomy due to a cyst form about 13 centimeters. The tumor makers were within normal range. Moreover, an abdominal MRI scan was carried out, that described the presence of a cyst measured 10 x 8 cm in the left parametrium.She was scheduled for surgery a few days later. The cyst was above the division of iliac vessels cling to left ureter and left uterine artery. The operation was uncomplicated and her post-operative period was uneventful. Histology showed lymphocyst, without any signs of malignancy Fifteen days later after a routine check, an entrenched retention of fluid was found in the pouch of Douglas 5 cm which was aspirated by needle under guidance of Computed Tomografy. The cytological examination showed lymphpocytes as an inflammatory response. Results In 5 to 10% of patients, the lymphocyst become symptomatic, manifesting fever, pain, constipation, prolonged ileus, urinary frequency, obstructive uropathy, leg edema, erythema of overlying skin or deep vein thrombosis. Conclusion Most lymphocysts are asymptomatic and are only diagnosed accidentally. A symptomatic lymphocyst may compress adjacent structures, for example, ureter, the urinary bladder, rectum or the iliac vein. Pelvic lymphocysts may be treated conservatively or surgically, by laparoscopy or laparotomy as well as using the methods of intervention radiology. Disclosure Nothing to disclose

Introduction/Background Ovarian cancer is usually diagnosed in advanced stage. The goal of debulking surgery should be no residual disease. This may lead to severe postoperative complications, prolonging hospital stay and delaying chemotherapy initiation. The aim of this study is to identify possible predictive factors and minimize the occurrence of postoperative complications. Methodology We retrospectively reviewed the medical records of all patients that underwent primary (PDS) or interval (IDS) debulking surgery for advanced epithelial ovarian cancer (January 2018–December 2018) in two medical clinics. The clinicopathological characteristics, oncological and surgical results were described. Results Out of total 79 patients with ovarian cancer, 49 met the eligibility criteria. The mean age was 61±12 years old and the majority of them, 44 (90%), had FIGO stage III serous adenocarcinoma. The median hospitalization was 8±3 days and the postoperative complications ranged from 0 to 100, with one death within 30days. A univariate analysis was conducted: There was a statistically significant difference (p-value=0.002) between primary and interval debulking surgery: PDS showed increased postoperative complications. Furthermore, Aletti score, prolonged surgery duration (>300 min), elevated preoperative CA-125 and postoperative intensive care unit (ICU) admission were statistically significant associated with increased postoperative complications (p-value Conclusion Aletti score, prolonged surgery duration, elevated CA-125, postoperative ICU admission and primary debulking surgery were statistically significant associated with more postoperative complications.‘Fagotti’ diagnostic laparoscopy could be a possible way to decrease postoperative complication but further investigation with more patients is needed. Disclosure Nothing to disclose.

Research question Is body-mass index (BMI) associated with oocyte maturation in women at high risk for developing severe ovarian hyperstimulation syndrome (OHSS) who are triggered with gonadotrophin releasing hormone (GnRH) agonist? Design Prospective observational cohort study. A total of 113 patients at high risk for severe OHSS (presence of at least 19 follicles ≥11 mm) pre-treated with gonadotrophin releasing hormone (GnRH) antagonists and recombinant FSH were administered 0.2 mg triptorelin to trigger final oocyte maturation. Patients were classified in two groups depending on their BMI: ΒΜΙ less than 25 kg/m2 (n = 72) and ΒΜΙ 25 kg/m2 or over (n = 41). Baseline, ovarian stimulation and embryological characteristics, as well as luteal-phase hormone profiles, were compared in patients classified into the two BMI groups. The main outcome measure was the number of mature oocytes. Results A significantly higher number of mature (metaphase II) oocytes (19 [18–21] versus 16 [13–20], P = 0.029) was present in women with BMI less than 25 kg/m2 compared with those with BMI 25 kg/m2 or greater. The number of retrieved oocytes, the number of fertilized oocytes, oocyte retrieval, maturation and fertilization rates were similar in the two groups. A significantly higher dose of recombinant FSH was required for patients with BMI 25 kg/m2 or greater compared with patients with BMI less than 25 kg/m2 (1875 [1650–2150] IU versus 1650 [1600–1750] IU, P = 0.003) and the two groups displayed different luteal phase hormonal profiles. Conclusions Among women at high risk for developing severe OHSS who are triggered with a standard dose (0.2 mg) of the GnRH agonist triptorelin, women with BMI 25 kg/m2 or greater had significantly fewer mature oocytes, required a higher total dose of recombinant FSH compared with women with BMI less than 25 kg/m2.

Study question Does the outcome of the comparison of live birth rates between the first frozen embryo transfer (ET) (in a freeze-only cycles strategy, i.e. frozen ET group) and a fresh embryo transfer (fresh ET group) differ considering the type of ovarian response? Summary answer Α significantly higher probability of live birth is present in high, but not normal, responders, after the first frozen ET in a freeze-only cycle strategy as compared to a fresh ET. What is known already It has been hypothesised that freezing all good embryos in a fresh in-vitro fertilisation (IVF) cycle and deferring embryo transfer in subsequent cycles may provide a more physiological endometrial environment for embryo implantation when compared to a fresh ET. However, currently, three relevant meta-analyses have been published with conflicting results, while none of them has taken into consideration the type of ovarian response. Recently, the publication of additional, large relevant randomised controlled trials (RCTs) in patients with different types of ovarian response makes possible the comparative evaluation of the first frozen ET (in a freeze-only cycle strategy) versus fresh ET, considering the type of ovarian response. Study design, size, duration A systematic review and meta-analysis was performed aiming to identify RCTs comparing the first frozen ET (in a freeze-only cycle strategy) to a fresh ET. The main outcome was live birth, while secondary outcomes included ongoing pregnancy, clinical pregnancy, moderate/severe ovarian hyperstimulation syndrome (OHSS) and miscarriage. Participants/materials, setting, methods We identified eight eligible RCTs, including 5265 patients, which evaluated the first frozen ET in a freeze-only cycle strategy versus a fresh ET either in high responders (n = 4) or in normal responders (n = 4). No relevant RCTs were present in poor responders. Meta-analysis of weighted data using fixed and random effects model was performed. Results are reported as relative risk (RR) with 95% confidence interval (CI). Main results and the role of chance Eligible RCTs were published between 2011 and 2018. Four RCTs (n = 3255 patients) compared the first frozen ET (in a freeze-only cycle strategy) to a fresh ET in normal responders and four RCTs (n = 2010 patients) did the comparison in high responders. In high responders, a significantly higher probability of live birth was observed in the frozen ET group when compared with the fresh ET group (RR: 1.18, 95% CI: 1.06-1.31; fixed effects model; heterogeneity: I2 = 0%; three studies; n = 3398 patients). However the probability of live birth was not significantly different between the frozen ET group and the fresh ET group in normal responders (RR: 1.13, 95% CI: 0.90-1.41; random effects model; heterogeneity: I2 = 77%; three studies; n = 1608 patients). The risk of moderate/severe OHSS was significantly lower in the frozen ET group when compared with the fresh ET group both in high (RR: 0.19, 95% CI: 0.10-0.37; fixed effects model; heterogeneity: not applicable; a single study; n = 1508 patients) and normal responders (RR: 0.39, 95% CI: 0.19-0.80; fixed effects model; heterogeneity: I2 = 0%; two studies; n = 2939 patients). Limitations, reasons for caution Considerable heterogeneity was present among the studies, regarding ovarian stimulation protocols and the triggering signal used for inducing final oocyte maturation as well as the cryopreservation methods, while the quality of evidence was poor for the live birth rate in high responders. Moreover, the analysis did not apply a standard for determining 'high' or 'normal' responders since the type of ovarian response followed the characterisation of populations as reported by the authors of the eligible studies. Wider implications of the findings A freeze-only cycle strategy should be the preferred option in high responders since it enhances the probability of live birth, while reducing the chance of moderate/severe OHSS. In normal responders, the same strategy could be applied, in the interest of patient safety or clinic convenience, without compromising the chances of live birth. Study funding/competing interest(s) No external funding was used and there were no competing interests. Prospero registration number PROSPERO registration number: CRD42018099389.

Kisspeptins are multifunctional peptides; it has been shown that they act as inhibitors of tumor metastasis in a range of cancers and that they are also involved in cell invasion through regulation of matrix metalloproteinases (MMPs). The aim of this study was to investigate the expression of KISS-1 protein in adenomyosis lesions compared with matched eutopic endometrium, as well as with endometrium from patients without adenomyosis.In this comparative, non-interventional study, adenomyosis and corresponding eutopic endometrium samples from women with histologically proven adenomyosis after hysterectomy, and eutopic endometrium samples from women without adenomyosis were analysed. Expression of KISS-1 protein was analyzed immunohistochemically in formalin-fixed, paraffin-embedded adenomyotic tissue specimens (n=29), matched eutopic endometrium from the same patients (n=29) and normal endometrium from patients without adenomyosis (n=29).Using a semi-quantitative immunohistochemical score, we found that KISS-1 protein expression was higher in the adenomyotic as compared with matched eutopic glandular endometrium (p0.05), in which in turn KISS-1 protein expression was higher than those from patients without adenomyosis (p0.001). The inverse correlation was found in the stroma, between adenomyosis lesions and matched eutopic endometrium (p0.01), while no statistically significant correlation was found in KISS-1 protein expression in the stroma between patients with and without adenomyosis.KISS-1 protein expression appears to be up-regulated in adenomyotic as compared with eutopic glandular endometrium of patients with, as well as women without adenomyosis. These findings are suggestive of the involvement of KISS-1 protein in the pathogenesis and maintenance of adenomyosis. Future studies should investigate whether KISS1 protein could be used as a marker for early and minimally invasive detection of adenomyosis, based on its differential protein expression pattern in the eutopic endometrium of patients with and without adenomyosis.

Objective To analyze the expression pattern of metastasis suppressors KAI1 and KISS1 in the endometrium of patients with and without endometriosis. Study design In this pilot study, tissue samples were prospectively collected from 38 patients with endometriosis and 29 without endometriosis, undergoing operative laparoscopy in the proliferative phase of the menstrual cycle; diagnosis or absence of endometriosis was confirmed histologically. Protein expression of KAI1 and KISS1 were analyzed immunohistochemically in endometriotic lesions and the eutopic endometrium of patients with endometriosis and without endometriosis. Results KAI1 expression was significantly decreased in the glandular eutopic endometrium of endometriosis patients as compared with that of patients without endometriosis ( p = 0.008). On the other hand, in endometriosis patients, KAI1 expression was significantly increased in the ectopic as compared with the eutopic endometrial stroma ( p = 0.021). There were no other significant differences in KAI1 expression between different groups. KISS1 expression in the ectopic glandular endometrium was significantly increased as compared with the eutopic glandular endometrium from patients with ( p = 0.004) and without endometriosis ( p = 0.008). There was no significant difference in KISS1 protein expression in the stromal endometrium between the three groups. Conclusions KAI1 and KISS1 are implicated in the pathogenesis and maintenance of endometriosis. Future studies should investigate whether KAI1 and KISS1 could be used as markers for early and minimally invasive detection of endometriosis based on their differential protein expression pattern in the eutopic endometrium of patients with and without endometriosis.

The aim of the present study was to assess changes in thyroid function and thyroid autoimmunity (TAI) throughout ovarian stimulation (OS) for intracytoplasmic sperm injection (ICSI) and the association of these changes with ICSI outcome. A flexible gonadotrophin-releasing hormone (GnRH) antagonist protocol was used in 42 women and their thyroid function and TAI were assessed at baseline and five times during OS (Days 3 and 5 of the menstrual cycle, the day of hCG administration, the day of ovum pick-up and the day of the pregnancy test). The primary outcome measure was the change in thyroid function throughout OS. No overall change was recorded in thyrotropin-stimulating hormone (TSH) concentrations throughout OS (P = 0.066). In women who became pregnant (n = 8), an increase in TSH concentrations was noted on the day of the pregnancy test compared with Day 3 of the menstrual cycle (3.410 ± 1.200 vs 2.014 ± 0.950 μIU mL–1, respectively; P = 0.001; mean ± s.d.). TAI was present in 11 of 42 women. Biochemical pregnancy was negatively correlated with changes in TSH (r = –0.7, P = 0.004). No such association was noted regarding the live birth rate. The present study provides evidence that TSH concentrations could increase during OS, especially in women who become pregnant.

Poor response is not a rare occurrence in ovarian stimulation. Although not fully accepted, the most dominant criteria for poor ovarian response are small numbers of follicles developed or oocytes retrieved, and low estradiol (E2) levels after the use of a standard stimulation protocol. There is no ideal predictive test as the poor responder is revealed only during ovulation induction; however, increased levels of day 3 FSH and E2 as well as decreased levels of inhibin B can be used to assess ovarian reserve. Several protocols have been proposed for clinical management of low ovarian response in IVF. Although high doses of gonadotrophins have been used by the vast majority of authors, results have been controversial and prospective randomized studies have shown little or no benefit. The few available relevant studies do not indicate that recombinant FSH improves outcome. Flare-up GnRH agonist protocols (including all dosage varieties) produce better results than standard long luteal protocols. Luteal initiation GnRH agonist 'stop' protocols were shown to improve ovarian response according to prospective studies with historical controls, but this was not confirmed by well-designed prospective, randomized, controlled studies. The few available data obtained with GnRH antagonists have not shown any benefits. Adjuvant therapy with growth hormone (GH) or GH-releasing factors results in no significant improvement. The use of corticosteroids reduces the incidence of poor ovarian response in women undergoing IVF treatment. The limited data obtained with nitric oxide donors are encouraging. Pretreatment with combined oral contraceptives prior to stimulation may help ovarian response. No benefit was observed with standard use of ICSI or assisted hatching of zona pellucida. Finally, natural cycle IVF has produced results which are comparable with those obtained with stimulated cycles in true poor responders. Well-designed, large-scale, randomized, controlled trials are needed to assess the efficacy of these different management strategies.

To examine whether the concentrations of maternal serum TSH and free thyroxine (fT4) through pregnancy, the presence of thyroid autoimmunity (TAI) or the dose of levo-thyroxine (LT4) replacement can predict the occurrence of maternal or fetal/neonatal complications in pregnant women treated for maternal hypothyroidism. The study included 92 women with singleton pregnancies and primary hypothyroidism on LT4 replacement. Maternal serum TSH, fT4, thyroid auto-antibodies and doses of LT4 were monitored throughout pregnancy. All maternal and fetal/neonatal complications were recorded. The overall prevalence of maternal and neonatal complications was 24.1%. Neither maternal TSH/fT4 concentrations, presence of TAI nor dose of LT4 could predict the occurrence of complications. Pre-pregnancy body mass index (BMI) was higher in women who developed maternal complications [odds ratio (OR) 1.3, 95% confidence interval (CI) 1.1–1.5, p=0.007) and gestational week at delivery was lower in pregnancies complicated by neonatal (OR 0.5, 95% CI 0.3–0.8, p= 0.001) or any type of complications (OR 0.6, 95% CI 0.4–0.9, p=0.008). The occurrence of maternal or fetal/neonatal complications in pregnant women treated for hypothyroidism cannot be predicted by maternal TSH/fT4 through pregnancy, presence of TAI or dose of LT4 replacement.

The administration of two GnRH analogues (buserelin and leuprolide acetate) in long and short protocols was evaluated prospectively. In the long protocol, the analogues were given from day 1 of the cycle for at least 14 days and then hMG administration was started, while in the short protocol the analogues were initiated from cycle day 1, adding hMG from day 3. The patients were divided into four groups according to the protocol used: Group I, buserelin-long; Group II, buserelin-short; Group III, leuprolide-long; and Group IV, leuprolide-short. Serum E2 levels on the day of hCG injection and the number of follicles observed, oocytes retrieved, and embryos obtained, as well as implantation rates, were significantly higher (P0.001) in the long protocols than in the short ones.Pregnancy rates were similar in all groups, although a trend for better results was observed in buserelin-long compared to buserelin-short. There were no differences in the results achieved with buserelin or leuprolide.The administration of GnRH analogues (buserelin and leuprolide acetate) in long protocols induced a more intense ovarian response and was associated with significantly higher implantation rates and also a trend for higher pregnancy rates, although this difference was not statistically significant.

The aim of this study was to present a novel technique for the female pelvic organ prolapsed, an abdominal colpopexy at the lateral abdominal wall (ACLAW) using a tension-free tape and to compare it with the gold standard, the abdominal sacrocolpopexy (ASC). A retrospective comparative study was conducted consisting of 38 patients who underwent ACLAW and 40 patients who underwent ASC during the period 2007–2009. POP-Q data as well as PISQ-12 and POPDI-6 score values were recorded during a mean follow-up of 26.71 and 23.52 months for ACLAW and ASC groups, respectively. Parameters like operative time, blood loss and hospital stay time were evaluated as well. Except the 6-month point, anatomical outcome in terms of C point values and total vaginal length was comparable. Both score analyses did not demonstrate statistically significant differences between the groups. The novel technique was proved very much shorter (30 ± 10.2 vs. 125.93 ± 15.42 min, p

ObjEctIvE: Inhibin-b (Inh-b) is produced by sertoli cells and controls Follicle stimulating Hormone (FsH) secretion through a negative feedback mechanism. the primary aim of this study was to compare Inh-B with FSH as predictors of the recovery of sperm in testicular fine needle aspirate in men with azoospermia. DEsIGn: In 51 men with azoospermia basal values of Luteinizing Hormone (LH), FsH, prolactin and testosterone as well as Inh-b values before and 24 h and 48 h after the administration of 300 IU recombinant human F sH were determined. testicular Fine needle Aspiration (FnA) was also carried out. thirty-one young healthy men were also enrolled in the study as controls. rEsULts: there was significant difference between men with azoospermia and controls with regard to the basal Inh- b levels (median (interquartile range) 37.2 (36) vs. 103.0 (90) pg/mL, respectively, p=0.003) but not to the stimulated Inh-b levels (40.5 (41) vs. 73.0 (44) pg/mL, p=0.113 at 24 h and 34.3 (34) vs. 82.0 (50) pg/mL, p=0.098 at 48 h)). the Area Under curve in receiver Operating characteristic curves were similar for Inh-b and FsH (0.610 vs. 0.716, respectively, p=0.151) as far as prediction of sperm retrieval is concerned. cOncLUsIOns: basal serum Inh-b values are significantly lower in men with azoospermia compared to controls. However, Inh-b is not superior to FsH in predicting the presence of sperm in testicular fine needle aspirate .

Ovarian pregnancy is a rare variant of ectopic implantation. A case of an intrafollicular ovarian pregnancy after ovulation induction/intrauterine insemination is presented. The woman had primary infertility of 4 years. Diagnostic laparoscopy revealed endometriosis and adhesions. After adhesiolysis and laser vaporization of endometriotic implants, the patient underwent ovulation induction with artificial insemination by husband/intrauterine insemination; she conceived at her second attempt. The pregnancy proved to be an ovarian intrafollicular one. She was treated by right partial ovariectomy. Three months later she conceived spontaneously with an intrauterine pregnancy which is still ongoing. The diagnostic problems resulting from the coexistence of ovarian hyperstimulation and the intrafollicular development of pregnancy are discussed. A re-evaluation of the criteria for the diagnosis of ovarian pregnancy based on the currently available diagnostic methods is proposed. Moreover, the pathophysiology of ovarian and especially intrafollicular implantation is reviewed.

Intrapartum application of the continuous glucose monitoring system in pregnancies complicated with diabetes: A review and feasibility study

The aim of the study was to investigate the relation between cigarette smoking and urinary incontinence. A group of 80 women with incontinence (Group A) were tested urodynamically and compared with a group of 80 continent women (Group B). Patients were divided into smokers (S) and non-smokers (NS) with the incontinent ones classified as suffering from stress (SI) or motor in-continent (UI). The assessment of the smoking behavior of each individual focused upon the tar and nicotine content of each cigarette. The overall exposure to smoke was assessed as follows: tar/nicotine content in mg per cigarette x consumed cigarettes per day x duration of smoking intervals in years. According to the obtained data smokers were divided into current smokers (cs) and stop/start smokers (sss), whereas the current smokers were subdivided into heavy current smokers (hcs) and light current smokers (lcs). Significantly, more S were observed in Group A compared with Group B (48/80 vs. 11/32, P < 0.0005), whereas significantly more SI was found in NS compared with S (21/32 vs. 19/48, P < 0.0025). Particularly hcs developed more frequently UI than SI, although this difference had no statistical significance. According to our data smoking women are more likely to develop incontinence, especially motor incontinence, than non-smokers. Heavy smokers seem to tend more to UI.

One of the main endocrinological disturbances in patients with polycystic ovarian syndrome (PCOS) is the increased baseline concentrations of luteinizing hormone (LH) and consequently a high LH:follicle-stimulating hormone (FSH) ratio. The aim of this study was to assess the relationship between the baseline LH:FSH ratio with the stimulation response and the miscarriage risk in PCOS women stimulated for assisted reproduction techniques (ART) with and without gonadotrophin-releasing hormone analogue (GnRHa). Two groups of PCOS patients were analysed retrospectively. Group A (n = 20, 20 cycles) consisted of women stimulated with human menopausal gonadotrophin (HMG), and group B (n = 128, 162 cycles) comprised women stimulated with buserelin-long/HMG. LH and FSH concentrations were measured during the early follicular phase (days 4-6) in a preceding spontaneous or progestin-induced cycle. The following parameters were assessed: number of follicles developed, number of oocytes obtained and percentage of mature oocytes, as well as number of abortions and live births. In group A, the baseline LH:FSH ratio was correlated inversely with the number of follicles developed (P0.05), the number of oocytes obtained (P0.05) and the percentage of mature oocytes (P0.05). In group B, no correlation was found between the LH:FSH ratio and the number of follicles and oocytes, because their numbers were relatively constant irrespective of the baseline LH:FSH ratio, but a significant inverse correlation was noted with the percentage of mature oocytes (P0.001). However, a comparison of the slopes of the curve indicated a better correlation between the LH:FSH ratio and the percentage of mature oocytes in group A than in group B (P0.05). These findings were also confirmed when patients were subdivided according to the LH:FSH ratio (3 oror = 3). Furthermore, in women who miscarried, the mean LH:FSH ratio was significantly higher than in women having a live birth. In conclusion, in PCOS patients stimulated with HMG, a high basal LH:FSH ratio appears to have an adverse effect on the number of follicles and oocytes, as well as on oocyte maturity. On the other hand, the administration of GnRHa in the long protocol seems to reverse this detrimental effect on follicle and oocyte development. Furthermore, a higher LH:FSH ratio seems to predict a greater possibility for miscarriage, despite the use of GnRHa.

Increased interest has arisen recently about the possible association between ovarian stimulation and ovarian tumours. In this article, the current knowledge on the epidemiology, pathogenesis and aetiology of ovarian tumours is extensively reviewed in relation to the existing literature on the relationship between ovulation induction and ovarian neoplasia. The available data from epidemiological studies and case reports do not support a direct causal relationship between ovarian stimulation and ovarian cancer. However, it is possible that ovarian stimulants may have an augmenting role for special categories of tumours, e.g. sex-cord stromal tumours. A definite answer to this important issue may be reached through large prospective epidemiological studies or large retrospective well-designed case-control studies.

The combined administration of the gonadotrophin-releasing hormone (GnRH) agonist buserelin and human menopausal gonadotrophin (HMG) was evaluated in 527 cycles (428 patients) of an assisted reproduction programme. All women were randomly allocated according to the ovulation induction protocol into two groups: group I (short protocol; 318 cycles) was given buserelin (1 mg/day) intranasally from cycle day 1 and HMG (2 ampoules/day) from day 3 until human chorionic gonadotrophin (HCG) administration: group II (long protocol; 209 cycles) was given buserelin (1 mg/day) intranasally from cycle day 1 for at least 14 days and then 2 ampoules HMG/day were added, increasing progressively according to the ovarian response. The number (mean +/- SEM) of follicles developed was higher in group II than in group I (9.1 +/- 0.4 versus 7.7 +/- 0.3, respectively; P < 0.05). More oocytes were retrieved in group II (8.4 +/- 0.5) than in group I (6.5 +/- 0.3) (P < 0.001), as well as more embryos (6.3 +/- 0.5 and 4.0 +/- 0.3, respectively; P < 0.001). Moreover, in group II there was a better correlation between oestradiol and the total follicular volume (r = 0.5391) on cycle day 0 compared with group I (r = 0.458), while oestradiol values were similar between the two groups. No differences were observed in the cancellation rate, fertilization rate and maturity of the oocytes between the two groups. The pregnancy rate per transfer was slightly better in group II (25.8%) than in group I (19.4%), but this difference was not significant.(ABSTRACT TRUNCATED AT 250 WORDS)

2 A 25-year-old Caucasian nulliparous woman had right iliac ossa pain and dysuria that started approximately 10 months efore admission to our hospital. Bimanual examination reealed a palpable mass in the right parametrium that deviated he uterus to the left. Ultrasonographic examination revealed he presence of a solid mass (13.5 cm in diameter) with the chogenic characteristics of a leiomyoma. The most probable iagnosis was a pedunculated leiomyoma, and laparoscopic urgical intervention was proposed without preoperative gonaotropin-releasing hormone agonist treatment. During laparoscopy, a large myoma of the broad ligament as seen (Figure 1). The broad ligament was opened, and