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Purpose To evaluate the effectiveness, efficiency, and safety of a transnational gamete donation (TGD) programme based on the shipping of vitrified donor oocytes. Methods A retro-prospective observational study was conducted in the Assisted Reproductive Technology Center of the University Hospital of Florence, Italy. The study population included 622 consecutive donor oocyte cycles. A mean number of 6 vitrified oocytes per couple were shipped from two Spanish biobanks. In the receiving centre, gametes were warmed and inseminated and the subsequent embryo transfer (ET) was performed. The main outcome measurement was LBR. Secondary outcomes included oocyte survival rate, ICSI damage rate, normal fertilization, cleavage, and implantation rate (IR) in both ‘fresh’ and cryotransfer cycles. Results A total number of 3536 mature oocytes were warmed with 81.4% surviving oocytes. 2PN oocytes were 1941 with an ICSI normal fertilization rate of 70.4% and a cleavage rate of 93.4%; 857 day-3 embryos were transferred in 498 women, 63 blastocysts in 44. Couples with at least one vitrified embryo were 181 (32.3%). IR was 25.1% and 33.1% for day-3 ET and blastocyst stage respectively. Crude pregnancy rate and LBR after the first ET were 35.5% and 27% correspondingly with a conservative cumulative LBR of 34% and an optimal LBR of 51.4%. Conclusion Imported vitrified donor oocytes retain their competence and are capable of resulting in ongoing pregnancies and healthy babies in a proportion comparable to other existing systems as egg donation with vitrification/warming in the same laboratory and transnational fresh oocyte donation.

Endometriosis is a gynecological disease characterized by pain and infertility. The diagnosis is very often made during the infertility work-up, together with other reproductive diseases and uterine disorders. A retrospective cohort study was conducted on infertile women with clinical or ultrasound suspect of endometriosis, undergoing an ultrasound (US) evaluation by a team of expert sonographers (

Purpose On March 8, 2020, the Italian Government implemented extraordinary measures to limit viral transmission of COV-19/SARS-CoV-2. We evaluated the impact of COVID-19 lockdown on lifestyle and emotional state in women planning infertility treatments. Basic Procedures We performed a quantitative research study using a web-based survey, in 140 women referred to Assisted Reproductive Technologies Center. Main findings We observed changes in body weight during lockdown in 80 % of women, and a significant increase in BMI in comparison to that observed before (p = .001). We observed a high percentage of non-adherence to the Mediterranean pattern during lockdown due to higher frequency of consumption of sweet/pastries, cheese and meat, rather than fruit, vegetables and legumes. Before lockdown 36.4 % women were snack consumers while during lockdown 55 % (p = .002). By considering individuals’ attitude to snack consumption, we observed an increase related to boredom (p=

BACKGROUND: Hormonal fertility treatments are associated with increased coagulation factors inducing procoagulant milieu and possibly thrombotic risk. OBJECTIVE: To assess coagulation by ROTEM and coagulation tests in apparently healthy infertile women before oocyte donation procedure. METHODS: We enrolled 51 women (Assisted Reproductive Technology Centre, Florence). ROTEM and coagulation parameters were assessed before the start of infertility treatment. RESULTS: We divided women in 3 groups according to the number of cardiovascular risk factors: Group A (n = 10), Group B (n = 16), and Group C (n = 25). By considering ROTEM Extem test, a significantly increased of MCF, TPI, and G were observed in groups B (p = 0.005, p = 0.03, and p = 0.007) and C (p = 0.01, p = 0.05, and p = 0.005) in comparison to group A. As regards ROTEM Intem test, the TPI and G values were significantly higher in groups B and C in comparison to group A (p

Appendiceal Neoplasm is a rare tumour with a vague and nonspecific clinical presentation. Delayed or missed diagnosis could result in mucin spill into the peritoneal cavity because of cancer infiltration or spontaneous rupture of appendix. This condition is called Psuedomyxoma Peritonei (PMP) and has a very poor prognosis if not treated properly. We present 4 cases of Appendiceal Neoplasm misdiagnosed as adnexal masses of different origin: Dermoid cyst of the right ovary; stump of the previously removed tube; ectopic pregnancy; ovarian malignancy. It is important for gynaecologists to recognize mucinous appendiceal neoplasm in the differential diagnosis of right adnexal masses in order to reduce the risk of misdiagnosis. Keywords: Appendiceal Neoplasm, Adnexal Masses, Transvaginal Ultrasound, Misdiagnosis.

Laparoscopic surgery was originally considered the gold standard in the treatment of endometriosis-related infertility. Assisted reproductive technology (ART) was indicated as second-line treatment or in the case of male factor. The combined approach of surgery followed by ART proved to offer higher chances of pregnancy in infertile women with endometriosis. However, it was highlighted how pelvic surgery for endometriosis, especially in cases of ovarian endometriomas, could cause iatrogenic damage due to ovarian reserve loss, adhesion formation (scarring), and ischemic damage. Furthermore, in the last few years, the trend to delay the first childbirth, recent technological advances in ultrasound diagnosis, and technological progress in clinical and laboratory aspects of ART have certainly influenced the approach to infertility and endometriosis with, ART assuming a more relevant role. Management of endometriosis should take into account that the disease is chronic and involves the reproductive system. Consequently, treatment and counselling should aim to preserve the chances of pregnancy for the patient, even if it is not associated with infertility. This review will analyse the evolution of the management of infertility associated with endometriosis and propose an algorithm for treatment decision-making based on the most recent acquisitions.

Background: The last two decades have seen a growing number of pregnancies in women who needed the donation of oocytes. With oocyte donation pregnancies, studies on obstetric outcomes among these w...

Our objective was to investigate whether the chronic cytomegalovirus (CMV) infection can affect semen parameters in men with couple infertility and to assess the impact of male CMV infection on the reproductive outcomes of CMV-seronegative women suffering from tubal factor. Group 1 included CMV IgG-seropositive men, Group 2 CMV IgG-seronegative patients. Seminal parameters, two-pronuclear (2PN) fertilization rate (FR), 1-2-3PN FR, cleavage rate (CR), miscarriage rate (MR), pregnancy rate (PR) and live birth rate (LBR) were collected. Two hundred and twenty-two men were included: 115 (51.8%) in Group 1 and 107 (48.2%) in Group 2. There was reported a low trend towards higher sperm concentration/ml, total sperm count and viability in CMV IgG-seronegative males, compared to CMV IgG-seropositive (p > .05). Semen volume, pH, motility and normal sperm morphology were similar among groups. Considering the subgroup of men, partners of CMV IgG-seronegative females, 65 couples (29.2%) were selected. Median 2PN FR was 67%, total FR 83%, CR 100%, PR/cycle 26.2%, MR 10.8%, LBR/cycle 15.4%. No significant differences were found regarding the reproductive outcomes between CMV IgG-seropositive men and those seronegative. CMV did not seem to play a key role in male reproductive function, as well as in influencing sperm fertility potential in the assisted reproductive outcomes.

To investigate the incidence of adverse pregnancy outcomes in couples with an unexplained Recurrent Pregnancy Loss (RPL) history, a retrospective cohort study was conducted between 2014 and 2015. The study group (A) included couples with an unexplained RPL, and the control group (B) was composed of couples who attended the Low-Risk Antenatal Unit during the same period. On the other hand, 53 couples were included in the study group (A) and on the other hand, 65 in the control group (B). Women with previous unexplained recurrent pregnancies loss had a significantly increased risk of gestational diabetes with 12 cases (22.6%) in the study group and 3 cases (4.6%) in the control (OR: 6.048; 95% CI: 1.607-22.762

Artemisia annua L. is a herbaceous plant belonging to the Asteraceae family, known for producing, although at low levels, the sesquiterpene lactone artemisinin (AN), which is highly effective against malaria. In this study, an in vitro regeneration process of A. annua L. using ‘Artemis’ progeny was established and the potential of tissue culture for inducing new variability in terms of AN metabolism of in vitro regenerated plants was investigated. Among the plant growth regulators tested, the cytokinin 6-benzyladenine (BA) at 4.4 μM in combination with the auxin indole-butyric acid (IBA) at 0.35 μM yielded the greatest frequency of shoot induction. The optimal multiplication medium contained BA at 0.9 μM and naphthaleneacetic acid (NAA) at 0.05 μM. Regenerated plants (RPs), after transferring to the greenhouse and subsequently to the field, were analyzed during the growth cycle at different sampling times, showing a peak of AN content 20 days before blossom. Variability among different RPs and sampling times, in terms of AN and its precursors dihydroartemisinic acid (DHAA) and artemisinic acid (AA) was observed. This suggests that adventitious shoot induction could provide a useful strategy to induce variability influencing artemisinin metabolism as a consequence of in vitro manipulation.

Objectives The objective of the study was to evaluate the correlation between endometrioma-associated pain and lesion vascularization as measured with 3-dimensional power Doppler transvaginal sonography. Methods Endometriomas were examined, and 4 indices were obtained: mean grayness, flow index, vascularization index, and vascularization-flow index. Dysmenorrhea, chronic pelvic pain, and dyspareunia were analyzed in terms of severity, presence/absence, and duration. Results Twenty-nine women were selected. The univariable association of painful symptoms in terms of presence/absence and duration was low with the exception of mean grayness with the presence of chronic pelvic pain (β = –0.106; P = .047; 95% confidence interval, 0.810 to 0.998). The R2 value increased to 0.226 for dysmenorrhea (β = –0.475; P = .029) when analyzing the association between the vascularization index and the severity of painful symptoms. The visual analog scale scores for chronic pelvic pain and dyspareunia were higher (R2 = 0.300; β = –0.547 and –0.548, respectively; P = .028 and .053). Conclusions We observed an inverse association between the severity of pain and endometrioma vascularization. Further larger studies are required to confirm our findings.

Monitoring follicular growth usually involves a combination of hormonal assays and ultrasonic measurements of follicle size (Fig. 8.1). Nowadays, Transvaginal Ultrasound (TVUS) is the “gold standard” for monitoring ovarian ovulation in both spontaneous and stimulated cycles.

To evaluate pre-existing comorbidities, obstetric risk factors and adverse obstetric and neonatal outcomes in pregnancies conceived by oocyte donation, compared with naturally conceived pregnancies or by conventional IVF/intracytoplasmic sperm injection (IVF/ICSI).This retrospective single-centre contemporary cohort study reviewed data from singleton deliveries at the University Hospital of Careggi, Florence, from 2009 to 2017. Maternal and perinatal outcomes were analysed.The study included 25,851 pregnancies and newborns: 276 (1.1%) children were conceived after oocyte donation, 925 (3.6%) after IVF/ICSI and 24,650 (95.4%) after natural conception. Women in the oocyte donation group were significantly older compared with IVF/ICSI and natural conception groups (P 0.0001) and had a higher prevalence of chronic hypertension compared with the natural conception group (P = 0.0090). They were administered anticoagulant medications more frequently during pregnancy. The incidence of gestational hypertension was significantly higher than in natural conception (aOR 3.6) and IVF/ICSI pregnancies (aOR 2.7). The incidence of Caesarean section in oocyte donation pregnancies was higher than in natural conception and IVF/ICSI groups (aOR 3.4 and 2.3, respectively). An 11-fold increased risk of post-partum haemorrhage (PPH) was found in oocyte donation versus natural conception and an almost four-fold increased risk was found in oocyte donation versus IVF/ICSI; prematurity and low birthweight were more frequent after oocyte donation versus natural conception (aOR 2.4 and 1.8, respectively).Patients undergoing oocyte donation represent a group with increased comorbidities and risk factors for adverse obstetric outcomes. Oocyte donation seems to be independently associated with gestational hypertension and PPH. Pregnancies after oocyte donation warrant clinical surveillance with proper screening and, possibly, preventive strategies.

The pathophysiology of severe endometriosis in young women remains unknown. Menorrhagia, or heavy and prolonged menstrual bleeding, is the most common symptom experienced by women with von Willebrand disease (vWD) and represents a possible risk factor for developing endometriosis. A 17-year-old woman affected by vWD presented with severe dysmenorrhea and heavy menstrual bleeding. After being diagnosed with multiple ovarian endometriomas, the patient underwent repeated surgeries due to suspicious appearance of recurrent pelvic masses. vWD may be a risk factor for developing severe endometriosis, and patients with endometriosis should be screened for vWD and other bleeding disorders. Ovarian endometriomas in such patients might present a more severe progression and unique ultrasound findings, mimicking malignancies.

BACKGROUND Nowadays, serodiscordant couples (SDCs) with human immunodeficiency virus (HIV) or hepatitis C virus (HCV)-infected men have the chance to conceive safely, giving birth with a minimum risk of cross-infection. OBJECTIVE To assess the impact of male HIV and HCV infection on the assisted reproductive technologies (ART) outcomes in SDCs, with HIV or HCV seropositive men and negative partners. MATERIALS AND METHODS Of 153 couples: 24 in Group 1 (HIV-seropositive men), 60 in Group 2 (HCV-seropositive men) and 69 in Group 3 (controls). Sperm-washing procedure was performed using a three-step system. Fresh ICSI cycles were carried out in HIV SDCs, HCV SDCs and controls. Seminal parameters, fertilization rate (FR), cleavage rate (CR), pregnancy rate per cycle (PR/C), miscarriage rate, implantation rate (IR) and live birth rate were evaluated. RESULTS All the seropositive men have undetectable viral loads at the time of insemination, and both partners were free from co-morbid infections. The median number of embryos transferred was 2.0 (IQR 1.0-3.0), with no differences among groups. FR was significantly reduced in HIV and HCV SDCs compared to the controls (66%, 61% and 75%, respectively; p

We assessed the outcome of pregnancy in women with a history of recurrent pregnancy loss (RPL) following treatment with low-dose human menopausal gonadotropin (HMG)+progesterone or progesterone alone. This single-center retrospective cohort study included data from women diagnosed with RPL and treated between February 2005 and December 2012 with one cycle of HMG + progesterone or progesterone alone. Primary endpoint was the rate of ongoing pregnancies and losses by treatment, age (38 vs. ≥38 years) and in the subgroup with unexplained RPL. Of 169 RPL patients, 35.5% (n = 60) received HMG + progesterone and 64.5% (n = 109) progesterone alone. Compared to progesterone alone, HMG + progesterone led to a lower, although not significant, frequency of losses (3.3% vs. 11.9%, p = .09) and a twofold higher rate of ongoing pregnancies (41.7% vs. 19.3%, p = .002). Similar results were obtained in the subgroup of patients with unexplained RPL (ongoing pregnancies: 48.1% upon HMG + progesterone vs. 21.3% upon progesterone, p = .03; losses: 0% vs. 8.5%, respectively, p = .29) and in those 38 years (ongoing pregnancies: 47.4% vs. 18.8%, respectively, p = .003; losses: 5.3% vs. 10.9% respectively, p = .47). These findings suggest that HMG in women with RPL may reduce the rate of miscarriages and increase that of live births regardless of RPL cause and in women aged 38 years.

Oxidative stress negatively affects folliculogenesis and embryo development. However, a reliable and biologically accurate indicator of oxidative stress does not yet exist. On these bases, the aim of this study was to assess -and compare- blood and follicular fluid (FF) redox status in 45 infertile subjects (and 45 age-matched controls) undergoing in vitro fertilization (IVF) and to establish its connection with the outcome of IVF. Blood and FF were obtained at the time of egg retrieval and immediately analyzed. Firstly, ROS production in blood leukocytes and in granulosa cells was assessed. Oxidative stress markers in blood and in granulosa cells resulted significantly (p

Oxidative stress plays a major role in critical biological processes in human reproduction. However, a reliable and biologically accurate indicator of this condition does not yet exist. On these bases, the aim of this study was to assess and compare the blood and follicular fluid (FF) redox status of 45 infertile subjects (and 45 age-matched controls) undergoing in vitro fertilization (IVF), and explore possible relationships between the assessed redox parameters and IVF outcomes. Reactive Oxygen Species (ROS) production, assessed by flow cytometry analysis in blood leukocytes and granulosa cells, significantly increased (p < 0.05) in infertile patients. Also, oxidative stress markers—ThioBarbituric Acid-Reactive Substances (TBARS) as an index of lipid peroxidation, and Oxygen Radical Absorbance Capacity (ORAC) to account for total antioxidant capacity, both assayed by fluorometric procedures—in blood and FF were significantly (p < 0.001) modified in infertile patients compared to the control group. Moreover, a significant correlation between blood redox markers and FF redox markers was evident. An ORAC/TBARS ratio, defined as the redox index (RI), was obtained in the plasma and FF of the patients and controls. In the patients, the plasma RI was about 3.4-fold (p < 0.0001) lower than the control, and the FF RI was about six-fold (p < 0.0001) lower than the control. Interestingly, both the plasma RI and FF RI results were significantly correlated (p < 0.05) to the considered outcome parameters (metaphase II, fertilization rate, and ongoing pregnancies). Given the reported findings, a strict monitoring of redox parameters in assisted reproductive techniques and infertility management is recommended.

Plant cell cultures as valuable tools for the production of specific metabolites can be greatly improved by the application of elicitors including cyclodextrins (CDs) for enhancing the yields of the desired plant compounds. Here the effects of 2,6-dimethyl-β-cyclodextrins (DIMEB) on the production of carotenoids and quinones from Artemisia annua L. cell suspension cultures were investigated. The addition of 50 mM DIMEB induced an early increase of intracellular carotenoid and quinone contents, which could be observed to a higher extent for lutein (10-fold), Q9 (3-fold) and Q10 (2.5-fold). Real Time PCR analysis revealed that the expression of 1-deoxy-d-xylulose-5-phosphate reductoisomerase (DXR) gene in DIMEB treated cell cultures after three days was 2.5-fold higher than in untreated samples, thus suggesting that the DIMEB induced increase of carotenoids and quinones could be due to the induction of the plastidial isoprenoid biosynthetic route. In addition, the DIMEB treatment induced an enhanced release of carotenoids and quinones into the culture medium of A. annua cell suspension cultures possibly due to the ability of CDs to form inclusion complexes with hydrophobic molecules.

We report a rare case of rectus abdominis muscle endometriosis excised under ultrasound guidance. A 36-year-old woman came to our observation presenting an abdominal nodule located in the right side of the umbilical area. Ultrasound of the abdominal wall showed two hypoechogenic nodules in the context of the right rectus abdominis muscle and a fine-needle aspiration, performed under ultrasound guidance, confirmed the diagnosis of endometriosis. The patient underwent surgical excision of the lesions. Intraoperative localization was performed through ultrasonography. In our case, the diagnosis was essentially based on ultrasound scan. Computed tomography and magnetic resonance imaging were not performed. A high-resolution ultrasound is a simple, inexpensive and safe method and is sufficient for indicating surgery. Furthermore, the use of intraoperative ultrasound allowed adequate margins of excision.

Adnexal masses represent a common finding among both premenopausal and postmenopausal women. This article will concentrate on the importance of an accurate preoperative diagnosis of adnexal masses that may be encountered in the course of an assessment of the female pelvis. The ultrasonographic modalities including two-dimensional, Doppler, three-dimensional and real-time four-dimensional approach, the accuracy of the technique, and the role of second-level exam will be discussed. In this review, we searched for the most relevant articles on the topic with a special focus on the importance of an accurate preoperative diagnosis of adnexal masses, the different ultrasonographic modalities, and the role of second-level exam. The primary goal of diagnostic evaluation is to exclude malignancy. Furthermore, differentiation among pelvic masses with non-malignant features is relevant as well since suitable counseling and treatment depend on the suspected histology. Ultrasound represents the first-line modality for assessing adnexal masses and showed a very accurate examination. Ultrasound, performed by experienced operators, is effective in the morphologic evaluation of the adnexal masses and is useful in discriminating between benign and malignant lesions. Second-level exams may include assessment by an experienced ultrasound examiner, magnetic resonance imaging, and computed tomography. Ultrasound represents the first-line modality for assessing adnexal masses. Predicting the nature of an adnexal mass is essential regarding counseling, clinical management and surgical planning in such patients. Pattern recognition can accurately diagnose the majority of the benign masses and malignancies.

The objective of the study was to evaluate the correlation between endometrioma-associated pain and lesion vascularization as measured with 3-dimensional power Doppler transvaginal sonography.Endometriomas were examined, and 4 indices were obtained: mean grayness, flow index, vascularization index, and vascularization-flow index. Dysmenorrhea, chronic pelvic pain, and dyspareunia were analyzed in terms of severity, presence/absence, and duration.Twenty-nine women were selected. The univariable association of painful symptoms in terms of presence/absence and duration was low with the exception of mean grayness with the presence of chronic pelvic pain (β = -0.106; P = .047; 95% confidence interval, 0.810 to 0.998). The RWe observed an inverse association between the severity of pain and endometrioma vascularization. Further larger studies are required to confirm our findings.

Plant cell cultures are valuable tools for the production of bioactive compounds. Recently, many efforts have been made in order to develop and optimize strategies for increasing the yields of the desired plant metabolites by eliciting their biosynthesis or improving the efficiency of product recovery. We established Artemisia annua L. (Asteraceae) cell suspension cultures to investigate the biosynthesis of the antimalarial artemisinin (AN) [1] and other healthful phytochemicals such as carotenoids and quinones. The use of culture supplementation with cyclic oligomers ?-cyclodextrins was successful to significantly increase intracellular and extracellular levels of AN, lutein, Q9 and Q10 [2, 3]. In order to investigate the mechanism underlying these effects, other oligosaccharides having a linear structure were explored as putative elicitors in A. annua cell suspension cultures. For this purpose, oligogalacturonides (OGA) were obtained by hydrolysis of polygalacturonic acid with pectolyase from Aspergillus japonicus. Various OGA fractions were used for culture medium supplementation at different concentrations. The results showed that the 4-5 OGA fraction induced significant increases of AN and the intermediate dihydroartemisinic acid. These results suggest that the ability of ?-CDs to elicit the production of bioactive compounds in A. annua cell cultures could be due to their chemical similarity to pectic oligosaccharides often occurring in plants after fungal infection.

Objective. Endometriosis is a frequent indication for in vitro fertilization and embryo transfer (IVF-ET). Its influence on IVF-ET cycles remains controversial. We evaluated the impact of the severity of endometriosis on IVF-ET cycles in young women. Design. Retrospective cohort study. Setting. Academic tertiary referral centre. Sample and Methods. In a retrospective cohort analysis, 164 IVF-ET cycles in 148 women with endometriosis-associated infertility were analyzed. Eighty cycles performed during the same period on 72 consecutive women with tubal infertility were considered as controls. All patients were younger than 35 years old.Main Outcome Measures. Response to controlled ovarian hyperstimulation (COH), number of oocytes retrieved, fertilization, implantation and pregnancy rate (PR). Results. Clinical PR was lower in the group with endometriosis (all stages) in comparison with the tubal factor group. Higher total gonadotropin requirements, lower response to COH and lower oocyte yield were also found in the endometriosis group.Stage-stratifiedanalysisshowedalowerfertilizationrateinstageI‐II(52.6% stageI‐II,70.5%stageIII‐IVand71.9%tubalfactor).InstageIII‐IVendometriosis there was a higher cycle cancellation rate, a reduced response to COH and a lower PR compared with both the stage I‐II and the tubal infertility groups (PR 9.7, 25 and 26.1%, respectively). Conclusions. Stage III‐IV was strongly associated with poor IVF outcome. A decreased fertilization rate in stage I‐II might be a cause of subfertility in these women, owing to a hostile environment caused by the disease. Abbreviations: ASRM, American Society for Reproductive Medicine; COH, controlled ovarian hyperstimulation; E2, estradiol; FSH, follicle-stimulating hormone; hCG, human chorionic gonadotropin; IVF, in vitro fertilization; IVF-ET, in vitro fertilization and embryo transfer; PR, pregnancy rate

Modern imaging techniques allow for the noninvasive diagnosis of endometriosis. Preoperative staging of pelvic endometriosis helps the gynecologist plan therapy and offer a prognosis to patients. The challenge of creating a satisfactory classification of endometriosis remains. The ability of the current classification schemes to predict pregnancy outcome, or aid in the management of pelvic pain, is recognized to be inadequate. The study of deeply infiltrating endometriosis and adenomyosis is greatly hampered by a lack of clear terminology and the absence of a consensus classification of the lesions. A reviewed consensus classification of endometriosis in general, with a more detailed consideration on deep endometriosis, is urgently required. We suggest a new staging system for deep, infiltrating endometriosis based on ultrasonographic findings. Prospective data collection and review in large centers may provide a larger clinical base from which to derive empirical point scores and breakpoints in the classification scheme.

Purpose The awareness of possible risk of damage to ovarian reserves after surgical treatment of ovarian endometriomas supports a more conservative approach in infertile women with ovarian endometrioma. A growing number of patients with ovarian endometrioma undergo In Vitro Fertilization and Embryo Transfer (IVF-ET) prior to surgery. The aim of this study was to assess the effect of ovarian endometrioma on IVF-ET cycles. Methods In a retrospective cohort pilot study, IVF-ET cycles performed by our group during the period 2000–2004 were assessed. One hundred and forty-four women with a history of surgery for endometriosis or endometriosis at the time of the cycle were included in the ‘study group'. Seventy infertile patients because of tubal factor constituted the ‘control group'. IVF-ET outcome was assessed. Results Patients with endometriosis required a higher total dosage of FSH/hMG and attained lower peak E2 levels, and fewer follicles and oocytes were obtained. Clinical pregnancy rate per patient was lower in the endometriosis group (24/144, 16.7%) when compared with tubal factor (20/70, 28.6%), clinical pregnancy rate per embryo transfer was similar (24/117, 20.5% and 20/61, 32.8% respectively). When stratifying results in the endometriosis group, patients with a history of prior surgery for ovarian endometrioma required a higher dosage of FSH/ hMG and attained a lower peak of estradiol. A trend with a consistent reduction in pregnancy rate in women with a history of prior surgery for ovarian endometrioma (5/37, 13% in patients with previous cystectomy and no recurrence; 2/17, 11.8% in patients with prior surgery and recurrence of endometrioma at pick-up; 2/10, 20% in women never operated with endometrioma at pick-up; 15/53, 28.3% in the minimal-mild endometriosis group; 20/61, 32.8% for tubal factor) was observed. Conclusions Both surgery for ovarian endometrioma and the existence of endometrioma during pickup appear to affect IVF-ET outcome. Patients with prior surgery and endometrioma recurrence at the time of pick-up revealed a further decrease in pregnancy rate.

Endometriosis is a common estrogen-dependent disease. The aim of this study was to assess whether controlled ovarian hyperstimulation (COH) for assisted reproductive technology (ART) was associated with an increased incidence in endometriosis recurrence as documented by transvaginal ultrasound (TV-US).In a retrospective cohort study of 592 patients submitted to laparoscopy for endometriosis, 177 with infertility-related endometriosis who underwent a periodic ultrasound follow-up after laparoscopy were selected. Women who started ART after laparoscopy (n = 90) were compared with the control group, who did not undergo ART (n = 87). Recurrence of endometriosis was defined as the presence of endometriotic lesions observed through TV-US.During a long-term TV-US follow-up (1-15 years), 40 (22.6%) recurrences were observed. Patients submitted to ART showed a cumulative recurrence rate similar to that of the control group (28.6% and 37.9% respectively, p = 0.471). Recurrent lesions were ovarian cysts (47.5%), ovarian nodules (37.5%), and rectovaginal disease (15%). The stratified analysis based on stages of endometriosis and pelvic pain did not show differences.Gonadotropin treatments do not seem to affect the natural history of endometriotic lesions. The most important prognostic factors in recurrent disease observed by TV-US seem to be the stage of endometriosis and the presence of pelvic pain at the time of the first laparoscopic treatment.

Objectives Laparoscopy is considered the gold standard for treatment of endometriosis. In vitro fertilization and embryo transfer (IVF–ET) is often used to treat women with infertility associated with endometriosis. The objective of the study was to evaluate the pregnancy rate after surgical treatment and to assess whether a combined approach with laparoscopic surgery followed by IVF–ET can improve the “overall” pregnancy rate. Study design A retrospective observational study was carried out on 107 infertile patients who underwent laparoscopic surgery for endometriosis and came at follow-up for a period of time between 1 and 11 years. Sixty-seven patients who did not become pregnant after surgery subsequently underwent IVF–ET. Results The pregnancy rate achieved after the integrated laparoscopy-IVF approach was 56.1%. The pregnancy rate after surgery, was significantly lower (37.4%). The fecundity rate for spontaneous conceptions within 6 months of laparoscopy (23.2%) was significantly higher ( P Conclusions In patients with endometriosis-associated infertility, surgery followed by IVF–ET is more effective than surgery alone. When patients fail to conceive spontaneously, after a maximum of 1 year from laparoscopic surgery, IVF should be suggested.

With the increasing demand for assisted reproductive techniques (ARTs), it is important to consider how to manage infection. Three main positive factors that contribute to successful in vitro fertilization (IVF) cycles are maternal age, the ovarian hyperstimulation protocol used, and the number and quality of transferred embryos. Negative factors include contamination and infection. This paper describes the issues relating to infection during IVF and proposes guidelines to control infection and to increase laboratory safety.

To assess the accurate dating of the cessation of pregnancy in patients with recurrent pregnancy loss (RPL) and to evaluate the incidence and recurrence rate of pregnancy losses in similar gestational age. In a retrospective cohort study, couples with history of RPL and availability of precise documentation regarding previous pregnancy losses were included. The vast majority of losses occurred within the first trimester. In patients experiencing more than 2 miscarriages in the same gestational stage, a tendency for recurrent losses around the same period of gestation was observed. Overall, the probability of losses at different gestational stages goes down with increasing number of miscarriages at the same stage. The study supports the need to ascertain data regarding the timing of pregnancy loss as accurately as possible for prognosis of future pregnancies and management of couples. A classification for unexplained RPL based on gestational age of miscarriages could help researchers to better investigate RPL.

Plants are ideal bioreactors for the production of macromolecules but transport mechanisms are not fully understood and cannot be easily manipulated. Several attempts to overproduce recombinant proteins or secondary metabolites failed. Because of an independent regulation of the storage compartment, the product may be rapidly degraded or cause self-intoxication. The case of the anti-malarial compound artemisinin produced by Artemisia annua plants is emblematic. The accumulation of artemisinin naturally occurs in the apoplast of glandular trichomes probably involving autophagy and unconventional secretion thus its production by undifferentiated tissues such as cell suspension cultures can be challenging. Here we characterize the subcellular compartmentalization of several known fluorescent markers in protoplasts derived from Artemisia suspension cultures and explore the possibility to modify compartmentalization using a modified SNARE protein as molecular tool to be used in future biotechnological applications. We focused on the observation of the vacuolar organization in vivo and the truncated form of AtSYP51, 51H3, was used to induce a compartment generated by the contribution of membrane from endocytosis and from endoplasmic reticulum to vacuole trafficking. The artificial compartment crossing exocytosis and endocytosis may trap artemisinin stabilizing it until extraction; indeed, it is able to increase total enzymatic activity of a vacuolar marker (RGUSChi), probably increasing its stability. Exploring the 51H3-induced compartment we gained new insights on the function of the SNARE SYP51, recently shown to be an interfering-SNARE, and new hints to engineer eukaryote endomembranes for future biotechnological applications.

This study investigated the relationships between ovarian endometrioma size, ovarian responsiveness and the number of retrieved oocytes following ovarian stimulation. A prospective study was conducted in a public clinical assisted reproduction centre. A total of 64 infertile women with monolateral endometriomas undergoing IVF or intracytoplasmic sperm injection were included in the study. The total number of follicles, number of follicles ≥ 16 mm and number of oocytes retrieved of ovaries containing endometrioma and normal ovaries were compared. Multivariate linear regression was used to assess whether number of follicles and collected oocytes varied by endometrioma size, age, basal FSH concentration. Significantly lower numbers of follicles ≥ 16 mm (P = 0.024) and oocytes retrieved (P = 0.001) in the ovaries containing endometrioma were observed. In patients with endometriomas ≥ 30 mm, endometrioma size was the most influential contributor to the total number of follicles and oocytes retrieved. Ovarian endometriomas result in reduced response to ovarian stimulation, compared with the response of the contralateral normal ovary in the same individual. In case of endometriomas

We read with great interest the paper by Gizzo et al. about surgery effectiveness in treatment of endometriosis-related infertility [1]. In a group of 181 infertile patients operated on by the same surgeon the authors reported an overall high pregnancy rate within both the first and second year after surgery. A higher pregnancy rate (64.6 %) was observed among patients operated on when the surgeon achieved the specialization in laparoscopic treatment of endometriosisrelated infertility, while patients treated by the same skilled, but not still specialized surgeon, obtained a lower pregnancy rate of 35.4 %. The mechanisms linking endometriosis and infertility are poorly understood, and aetiology is not established [2, 3]. Laparoscopic surgery is considered the gold standard among treatments for endometriosis-associated infertility. The mean pregnancy rate reported in the literature of 50 % following surgery is scientific proof that operative treatment should first be undertaken in order to give patients the best chance of conceiving naturally [4]. In experienced hands, this procedure is a valuable surgical tool for the treatment of ovarian endometrioma larger than 3 cm [5]. We agree that laparoscopic surgery for endometriosis should only be performed by well-experienced surgeons to avoid unnecessary trauma to ovarian tissue or vascular injury while restoring normal pelvic anatomy and function. Ideally, surgeons dedicated to endometriosis-related infertility should also have a know-how in reproductive medicine in order to adopt a very conservative and anatomical– functional approach to preserve function of reproductive organs. However, even with surgeons experienced in laparoscopy for endometriosis-related infertility, we are now aware that any type of surgery could cause additional damage to already compromised ovarian function. Our data show that in women previously submitted to surgery for endometriosis, mean age at menopause is significantly lower than mean age of menopause observed in a reference population of Italian women (45.3 ? 4.3 years versus 51.2 ? 3.8). Patients with history of surgery for bilateral endometriomas showed a very young age at menopause (42.1 ? 5.1 years) and a higher percentage of premature ovarian failures (36.4 %) [6]. On the other hand, also in women with no history for ovarian surgery for endometriomas, we observed a very young age of menopause onset (45.1 years). It is not clear yet how endometriosis alone can influence the onset of the menopause [6]. Thus the debate about surgery effectiveness in treatment of endometriosis-related infertility is still open. The most recent European Society of Human Reproduction and Embryology (ESHRE) guidelines stated that there is no evidence that cystectomy prior to treatment with assisted reproductive technologies (ART) improves pregnancy rates in cases of infertile patients with endometrioma larger than 3 cm [7] (Level of evidence A). On the other hand, for the same type of patients, they invite to consider cystectomy prior to ART to improve endometriosis-associated pain or the accessibility of follicles (Level of evidence GPP) [7]. This comment refers to the article available at doi:10.1007/s00404014-3591-z and an author’s reply to this comment is available at doi:10.1007/s00404-015-3792-0.

We report a rare case of rectus abdominis muscle endometriosis excised under ultrasound guidance. A 36-year-old woman came to our observation presenting an abdominal nodule located in the right side of the umbilical area. Ultrasound of the abdominal wall showed two hypoechogenic nodules in the context of the right rectus abdominis muscle and a fine-needle aspiration, performed under ultrasound guidance, confirmed the diagnosis of endometriosis. The patient underwent surgical excision of the lesions. Intraoperative localization was performed through ultrasonography. In our case, the diagnosis was essentially based on ultrasound scan. Computed tomography and magnetic resonance imaging were not performed. A high-resolution ultrasound is a simple, inexpensive and safe method and is sufficient for indicating surgery. Furthermore, the use of intraoperative ultrasound allowed adequate margins of excision.

To compare the accuracy of five different classification systems for interpreting electronic fetal monitoring (EFM) when predicting neonatal status at birth, as determined by the umbilical cord arterial pH.Ninety-seven cardiotocography traces were retrospectively interpreted according to five classification systems for EFM: Dublin Fetal Heart Rate Monitoring Trial (DFHRMT), Royal College of Obstetricians and Gynecologists (RCOG), Society of Obstetricians and Gynaecologists of Canada (SOGC), National Institute of Child Health and Human Development (NICHD) and ParerIkeda's. For each classification system, sensitivity, specificity, positive and negative predictive values were calculated. The capacity of the classifications to predict neonatal pH was also evaluated by receiver-operating characteristic (ROC) curves. Agreement between the five systems was estimated using weighted kappa statistic.Considering pH ≤7.15 as the cutoff for low pH, the sensitivity and specificity values were 100 and 18% (DFHRMT); 100 and 15% (RCOG); 88 and 37% (SOGC); 67 and 92% (NICHD); 55 and 67% (ParerIkeda). The ROC curves showed that all classifications analyzed had a low discriminative capacity when predicting umbilical artery pH ≤7.15. An excellent agreement was observed between DFHRMT and RCOG (weighted κ value: 0.860).ParerIkeda and NICHD classifications had the highest specificity in detecting umbilical cord arterial pH ≤7.15. The high specificity of the NICHD classification is hindered by a high percentage of "intermediate" traces (80%). ParerIkeda classification is the one that best classify as pathological only the traces of fetuses that are truly at risk of acidemia, thus avoiding unnecessary intervention. It also showed the best trade-off between sensitivity and specificity and the lowest rate of traces considered "intermediate."

Background Deep infiltrating endometriosis (DIE) is associated with severe painful symptoms and represents a complex management challenge. Objective To analyse the effect of pregnancy on deep infiltrating lesions and related symptomatology. Study design As part of a longitudinal study performed over the past 3 years to determine the efficacy of hormonal treatment in treating women with DIE, we identified three cases of advanced pelvic endometriosis, all with DIE (deep recto-vaginal and recto-sigmoid involvement) where patients achieved spontaneous pregnancies. They were followed up by transvaginal ultrasound (TV-US). The main outcome measures were analysis of the size and echographic pattern of deep infiltrating lesions of endometriosis and evaluation of clinical symptoms during pregnancy. Results We observed modifications in lesion size and pattern. In the two patients observed in the third trimester, the lesions were more homogeneous with less evident limits of nodules and band-like echoes, less fibrotic-like. All patients showed complete resolution of symptoms during pregnancy. Conclusions The hormonal environment produced by pregnancy might determine significant modifications of endometriotic lesions and reduce painful symptoms. As surgery for DIE is difficult, complex and can lead to major complications, the achievement of a pregnancy-specific hormonal state, through pregnancy or hormonal treatment, may be a valid option in selected cases.

Modern imaging techniques allow for the noninvasive diagnosis of endometriosis. Preoperative staging of pelvic endometriosis helps the gynecologist plan therapy and offer a prognosis to patients. The challenge of creating a satisfactory classification of endometriosis remains. The ability of the current classification schemes to predict pregnancy outcome, or aid in the management of pelvic pain, is recognized to be inadequate. The study of deeply infiltrating endometriosis and adenomyosis is greatly hampered by a lack of clear terminology and the absence of a consensus classification of the lesions. A reviewed consensus classification of endometriosis in general, with a more detailed consideration on deep endometriosis, is urgently required. We suggest a new staging system for deep, infiltrating endometriosis based on ultrasonographic findings. Prospective data collection and review in large centers may provide a larger clinical base from which to derive empirical point scores and breakpoints in the classification scheme.

Background Questions remain as to whether surgical excision of ovarian endometriomas might cause damage to ovarian function. To test the hypothesis that ovarian surgery for endometrioma compromises ovarian function and accelerates ovarian failure. Methods In a tertiary university Clinic, longitudinal prospective cohort study. Patients who underwent laparoscopy for endometriosis between March 1993 and November 2007 were assessed for inclusion in the study. A prospective follow-up at 3, 6 and 12 months then yearly was conducted. Evolution of menstrual pattern, symptoms and reproductive outcomes were investigated. Results From over the 14-year period, 302 patients were included in the study. The mean age (±SD) of patients was 32.6 ± 5.6 years; the median duration of follow-up was 8.5 years (range 2-17 years). Menopause was documented in 43 women (14.3%) at a mean age of 45.3 ± 4.3 years (range 32-52 years). Women previously submitted to bilateral cystectomy were younger at menopause than those with monolateral endometrioma (42.1 ± 5.1 years versus 47.1 ± 3.5 years, P = 0.003). Premature ovarian failure (POF) was observed in 7 of 43 (16.3%) menopausal patients; the majority (4, 57.1%) after bilateral cystectomy. The relationship between the preoperative ovarian endometriomas total diameter and menopausal age was significant in case of surgery for bilateral endometriomas (R(2) = 0.754, P = 0.002). Conclusions Patients who had been operated on for bilateral endometriomas have an increased risk of POF. Ovarian parenchyma loss at the time of surgery seems related to cyst diameter. In the case of unilateral ovarian endometrioma, the contralateral intact ovary might adequately compensate.

Objective: To investigate factors that might influence the recurrence of both painful symptoms and endometriotic lesions following laparoscopic treatment of endometriosis. Study design: Retrospective cohort study in a University teaching hospital. We reviewed data from patients referred for laparoscopy between March 1993 and November 2007. We selected women who were followed up throughout Transvaginal-ultrasound (TV-US) after a first conservative laparoscopy for endometriosis. After laparoscopy, all patients were followed up according to an internal protocol: a standard gynaecologic examination, the assessment of painful symptoms and a TV-US scan that were repeated at 3, 6, and 12 months, and subsequently on a yearly basis. Sixteen factors were assessed by univariable and multivariable Cox proportional hazards models to evaluate their associations with recurrence of endometriotic lesions and pain related-endometriosis. Results: 401 women were enrolled. A total of 154 (38.4%) experienced moderate or severe pain after laparoscopy; endometriotic lesions were observed by TV-US in 74 (18.4%) patients. In the multivariable model, age at menarche, severity of chronic pelvic pain (CPP) and dysmenorrhoea prior to surgery were significant risk factors for recurrence/occurrence of pain. Age at the first laparoscopy, stage of disease, pre-operative severity of CPP, and pregnancy were predictive factors of the recurrence for such lesions. Conclusion: The severity of CPP prior to the first laparoscopy showed the only significant factor in the overall prediction of recurrence of pain and endometriotic lesions. Patients with severe CPP at the time of their first surgery might represent a sub-group of women with a more aggressive form of endometriosis.

We present a rare case of endometriosis of the cervix. Transvaginal sonography showed a 35-mm cyst in the cervix with diffuse, low-level internal echoes. Transvaginal sonography-guided aspiration with a 17-gauge needle was performed, yielding a very thick chocolate-colored fluid. Cytological examination of the fluid revealed the presence of endometrial cells. Symptoms resolved after aspiration and no recurrence has developed. © 2010 Wiley Periodicals, Inc. J Clin Ultrasound, 2010