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Malignant disease complicates pregnancy in up to 1 per 1,000-2,000 cases. Pregnancy itself does not constitute a predisposing factor for malignancy. Management and treatment of patients suffering from a malignancy during pregnancy still represents a challenge in everyday clinical practice. Recent advances in imaging, diagnostic and overall treatment modalities have tailored the management of patients, specifically those who wish to maintain the pregnancy. The aim of this review was to provide clinicians with concise information on the management of the most common malignancies during pregnancy. We performed a review of the current literature including review articles, original research articles and guidelines, which are used for the management of the most common malignancies during pregnancy. Breast, cervical and ovarian malignant tumours are the most common during pregnancy. However, the overall outcome and survival per stage for these cancers do not appear to be influenced by pregnancy. Ethical, emotional and treatment dilemmas may be encountered during treatment planning. Individualization of treatment planning should be made by a multidisciplinary team but the final decision rests with the parents.

Local anesthetics combined with opioids are commonly used in labor epidural analgesic schemes. This study investigated if the addition of fentanyl to epidural ropivacaine can affect cervical dilation and progress of vaginal delivery.Sixty-two nulliparous parturients were randomized to receive epidurally 8 ml ropivacaine 0.2% combined with fentanyl 20 μg (F/R-group, n = 31) or with normal saline 0.4 ml (R-group, n = 31), every hour. Rescue doses of 5 ml ropivacaine 0.2% were also administered. Measurements were performed every 60 min until full cervical dilation. The primary end-point was the time to reach 10-cm cervical dilation. Secondary outcomes were Bishop scores, mode of delivery, total ropivacaine dose, pain, and satisfaction scores (numerical scale, 0-10).Data from 60 parturients (29 in the F/R and 31 in the R-group) were analyzed. The F/R-group had 26 vaginal deliveries (four instrumentally assisted), and three cesarean deliveries. The R-group had 27 vaginal deliveries (six instrumentally assisted) and 4 cesarean deliveries. Time to 10-cm cervical dilation did not differ between the groups (4 ± 2.4 h in the F/R-group vs 4.4 ± 2.1 h in the R-group, p = .341). The number of women remaining in the study every hour until full cervical dilation and Bishop scores for a 4-h period did not differ between the groups (p = .617). Total ropivacaine dose was comparable between the groups, but the F/R-group reported significantly lower pain (p = .01) and higher satisfaction scores (p = .001).The addition of fentanyl to ropivacaine 0.2% solution did not affect cervical dilation and progress of the first stage of labor, but improved both analgesia and satisfaction.

The needs of the uterus and the fetus for the provision of nutrients and oxygen, supplied by the blood flow, are understandably extremely high, with the circulatory system playing the most important role in this action. Abnormal vascular growth and transformation that create a high vessel resistance network have been associated with various pregnancy pathologies, including miscarriage, small for gestational age (SGA) fetuses with or without preeclampsia and intrauterine growth restriction (IUGR). Placental growth factor (PlGF) has a major role in vasculogenesis and angiogenesis in human placenta. Low concentrations of PlGF and high concentrations of its inhibitor-soluble Fms-like tyrosine kinase-1 (sFlt-1) are linked with impaired angiogenesis and placental development, leading to the above pregnancy complications. The activity of vascular endothelial growth factor (VEGF), which is the most potent of all angiogenic mediators, is partly modulated by PlGF. Although the mechanisms via which PlGF exerts its various effects are still under investigation, we herein discuss the known actions exerted by this major mediator together with its results on fetal growth.

To evaluate the efficacy of misoprostol administrated vaginally on cervical priming and its complications prior to diagnostic or operative hysteroscopy in women who have undergone at least one cesarean section and who have never delivered vaginally before and/or had other transcervical procedure.A total of 55 patients undergoing hysteroscopy for various intra-uterine lesions were included in this study and were randomly allocated to two groups finally. Thirty patients in the study group were given 200 μg misoprostol vaginally 12 h before the procedure, whereas 25 patients in the control group did not receive any cervical priming. The countered outcome included the cervical width detected with Hegar dilatators and complication rates.Mean cervical width was greater in the study group (6.6 ± 1.3) than in the control group (5.1 ± 0.9). Complications and failure rates were lower in the study group.Application of 200 μg misoprostol vaginally 12 h before hysteroscopy softens the cervix, reduces cervical resistance and consequently the need for cervical dilatation, with only mild side effects.

To determine whether in vitro fertilization (IVF), frozen replacement cycles offer better outcomes than fresh cycles in order to support, or not, a possible shift towards total replacement of fresh IVF/intracytoplasmic sperm injection (ICSI) cycles from frozen elective transfers (FETs).Systematic review; opinion paper.Initial results seem to support a shift in current practice towards frozen cycles.Initial results may support replacement all fresh IVF/ICSI cycles with FETs, as this could be a safer and equally effective strategy. However, robust evidence from randomized controlled trials is needed if this will be generally applied.

To evaluate the effect of the presence of endometrial polyps (EP) on pregnancy rates and how polypectomy could affect pregnancy rates in women scheduled for intrauterine insemination (IUI).The study included patients who had attended the Second Department of Obstetrics and Gynecology of the University of Athens from April 2003 to October 2008 for infertility treatment and were candidates for IUI. In these women the presence of an endometrial polyp had been already diagnosed during the infertility evaluation. The study group consisted of 86 women who, following the diagnosis of endometrial polyp, had agreed to have the polyps removed hysteroscopically prior to the IUI. The control group consisted of 85 women, who despite the fact that the presence of an endometrial polyp had been previously diagnosed and its removal suggested, elected not to have the polyp removed. We used statistical analysis to check what effect the removal of the polyp had on the total number of pregnancies.There was a statistically significant difference in cumulative pregnancy rates between the two groups. The group that underwent polyp removal had higher pregnancy rates as compared to the one that the polyps were left intact.We propose that hysteroscopic polypectomy of any size appears to improve fertility in women with otherwise unexplained infertility.

An ectopic pregnancy is defined as cesarean scar pregnancy (CSP) when the products of conception are implanted within the myometrium in the area of a cesarean section scar. CSP can be a life-threatening condition and to date there is no clear consensus for CSP management. A medical approach joining high treatment rates with fertility preservation could be a safer and less invasive method of therapy.We present a case of CSP with a viable embryo that was successfully treated with a novel medical therapy combining multidose methotrexate (MTX) and mifepristone.No further additional invasive procedure was required since pregnancy products were dissolved and no major complications were experienced.Multidose MTX and mifepristone can be considered a safe and effective treatment for CSP.

It is with great interest that we have read the paper published in your journal by Kerimoglu et al. [1] which addresses an important clinical question: the decrease of daily administered Cetrorelix dose in controlled ovarian hyperstimulation (COH) cycles to avoid premature LH surge while improving pregnancy rates mainly by the subsequent modifications at a cellular level. However, the article reports somewhat precipitate ‘conclusions’, which have the potential for misinterpretation and are in contrast, in several ways, with some important studies published in the past (see Table 1). Firstly, a ‘dose-finding’ study cannot be, by definition, ‘‘retrospective’’. Therefore, it is premature to state that ‘there is no difference...’ between the two regimens, as there have been studies in the past (even referred in Kerimoglu’s et al. [1]), with a prospective and, sometimes, even with a randomized design that clearly state that the lowest daily effective dosage for pituitary down-regulation with Cetrorelix is 0.25 mg/day. Furthermore, in an important—because of its design— randomized controlled trial (RCT) (not mentioned in Kerimoglu’s et al. [1]), Chang and colleagues [2] compared efficacy and efficiency of Cetrorelix and found to be 0.2 and 0.15 mg, respectively; they concluded that even for Asian women (for whom BMI is known to be lower than the Caucasian population), the lowest daily dose of Cetrorelix (in achieving satisfactory pituitary down-regulation) was 0.2 mg, and thus stated that daily administration of 0.15 mg ‘is not suitable’ for pituitary down-regulation. In addition to this, Chen et al. [3] also suggest that for Asian population ‘the lowest effective daily dosage is that of 0.2 mg’ and not 0.25 mg; even if one disregards the design of the study (non-randomized observational), that dose is closer to the ‘established’ one (0.25 mg) than the dosage of 0.125 mg suggested by Kerimoglu et al. [1]. Closely related to this are the findings of a more recent and larger retrospective study by Hsieh et al. [4]. That study concludes that ‘even for individuals with lower body weight (\50 kg), participants required 0.25 mg Cetrorelix daily. Furthermore, Tzeng’s study protocol [5], mentioned in Kerimoglu’s et al. [1], is quite different from daily Cetrorelix administration of 0.125 mg as it depends on leading follicular size; however, even with that protocol, the mechanism for LH-surge avoidance (which is used in 3 patients to end with the one LH surge that is mentioned in the paper) was the increase of the Cetrorelix dose to 0.25 mg/day. Finally, we should acknowledge the (potential) first ‘dose-finding’ study by Albano et al. [6], which concluded that ‘the minimal effective dose of Cetrorelix’ to prevent premature LH surge is 0.25 mg/daily. If a decrease in dosage is to be considered, further larger RCTs need to be conducted before we can move with confidence, to change in current clinical practice. T. Kalampokas Division of Applied Health Sciences, Assisted Reproduction Unit, University of Aberdeen, Aberdeen, UK

OBJECTIVE: To compare the pregnancy rates (PRs) between intrauterine insemination (IUI) and intraperitoneal insemination (IPI) in women receiving comparable ovarian stimulation in couples who were infertile for various infertility conditions. METHOD: Fifty-four couples were treated. Of these, 25 were diagnosed as having unexplained infertility, 21 as having male infertility and 8 as having cervical mucus hostility. RESULT: Nine pregnancies occured with 89 cycles of IUI and 6 pregnancies with 85 cycles of IPI, giving an overall PR of 28%. Twelve of the 15 pregnancies occured during the first treatment cycle and three during the second treatment cycle. There was no significant difference in the (PRs) between the IUI and IPI (P > 0.25). CONCLUSION: Both procedures combined with superovulation proved to be simple, inexpensive safe and worthwhile for infertile couples with unexplained infertility, male infertility and cervical mucus hostility.

This study refers to 50 couples treated for subfertility. Twenty five of these patients were treated with TU (Testosterone Ur econoate), the remaining 25 received placebo. Sperm characteristics, including ejaculate volume, pH, sperm density, morphology, motility, total testosterone, FSH, LH, DHT and E2 were evaluated both before and after treatment. A statistically significant increase of DHT levels was noticed after TU administration, whereas a marginally significant improvement of sperm morphology was present. Serum FSH concentrations, decreased significantly in the TU group whereas serum LH presented a slight but not statistically significant decrease; 4 pregnancies were achieved by the TU group whereas none were achieved by the patients belonging to the placebo group. The administration of TU per os to patients with idiopathic oligospermia presents a demonstrably positive effect.