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Gustavo Salata Romão,1 Sheyla Ribeiro Rocha,2 Milton Faria Junior,1 Marina de Toledo Durand,1 Reinaldo Bulgarelli Bestetti1 1Medical Course, University of Ribeirão Preto, Ribeirão Preto, São Paulo, Brazil; 2Department of Medicine, Federal University of São Carlos, São Carlos, São Paulo, BrazilCorrespondence: Gustavo Salata Romão; Reinaldo Bulgarelli Bestetti, Email gsalata@uol.com.br; rbestetti44@gmail.comPurpose: To evaluate medical students’ perceptions about using peer teaching (PT) in the online Clinical PBL (C-PBL).Materials and Methods: The C-PBL used in the Primary care Unit (PCU) of the medical course of the Ribeirao Preto University was adapted to the virtual environment. A PT session was included to enhance students’ intrinsic motivation. This cross-sectional study applied a 14-item survey to evaluate the perceptions of 378 medical students from the first to the seventh semester about the use of PT in this context.Results: According to participants’ perceptions, the use of PT in the online C-PBL allowed the interactive participation of students and produced satisfactory knowledge acquisition. Preparing and presenting a slideshow and being taught by peers contributed significantly to their learning. The survey used to collect information presented a high internal consistency measured by Cronbach’s alpha.Conclusion: From the students’ perspectives, the use of PT in the online C-PBL was satisfactory and improved learning for peer teachers and learners. This study contributes additional evidence suggesting that PT is an effective teaching strategy in online learning and can be associated with PBL. This finding has implications for curriculum development and the health system.Keywords: peer teaching, clinical PBL, problem based learning, virtual learning, educational technology

Reinaldo Bulgarelli Bestetti,* Marina de Toledo Durand,* Lucélio B Couto, Milton Faria-Jr, Helen Figueiredo Fumagalli, Vinicius M R Silva, Gustavo S Romão, Rosemary Furlan-Daniel, Marcelo E Garcia, Sônia M N Ferri, Ana Cláudia S Reis, Salim D Jorge-Neto, Tufik Jose M Geleilete Department of Medicine, University of Ribeirão Preto, Ribeirão Preto city, Brazil*These authors contributed equally to this workCorrespondence: Reinaldo Bulgarelli Bestetti, Universidade de Ribeirão Preto, Av, Costabile Romano, 2201, Ribeirão Preto city, Brazil, 14096-900, Tel/Fax +55 16 36037031, Email rbestetti44@gmail.comPurpose: The role of marks in the University Admission Test (UAT) plus the marks from pre-university academic records in predicting academic achievement at the end of the Medicine undergraduate degree program is not completely known. This study was undertaken to compare the performance of marks in the UAT alone with those of the UAT plus marks from the National High School Exam (ENEM in Brazil) regarding students’ outcomes at the end of the Medicine undergraduate degree program.Methods: Fifty-one (51) students from the last semester (12th) of our Medicine undergraduate degree program were included in the study. They were divided into a group of those who used the marks obtained in the UAT plus the marks obtained in the ENEM (ENEM group, n=9), and those who only used the marks in the UAT (non-ENEM group, n=42). We compared the academic achievement of the non-ENEM group with that of the ENEM group regarding the mean marks obtained in the clerkship, in the Progress Test (PT), and in the Objective Structured Clinical Examination (OSCE).Results: The mean scores obtained in the disciplines of the clerkship were higher in the non-ENEM group compared to the ENEM group (7.32 ± 0.41 vs 6.98 ± 0.31, p= 0.01). Both groups obtained similar mean marks in the OSCE and in the PT. A moderate correlation was observed between the marks in the clerkship with those of the UAT from the non-ENEM group (p=0.00006; r=0.45).Conclusion: Marks of the UAT alone appear to be associated with a higher academic achievement in the clerkship than marks of the UAT plus scores obtained from the ENEM at the end of the Medicine undergraduate degree program.Keywords: problem-based learning, medical school selection, medical education, clinical competency, university admission tests

Reinaldo B Bestetti, Lucélio B Couto, Priscila Roncato-Paiva, Gustavo S Romão, Milton Faria-Jr, Rosemary Aparecida Furlan-Daniel, Tufik José Magalhães Geleilete, Salim Demetrio Jorge-Neto, Fernanda Porfirio Mendonça, Marcelo Engracia Garcia, Marina Toledo Durand Department of Medicine, University of Ribeirão Preto, Ribeirão Preto City, BrazilCorrespondence: Reinaldo B BestettiUniversity of Ribeirão Preto, Avenida Costábile Romano, 2201, Ribeirão Preto City 14096-900, BrazilTel +55 16 36036795Email rbestetti44@gmail.comPurpose: Most studies assessing the value of the university admissions test (UAT) to predict academic performance at the end of a medical course were carried out on lecture-based medical courses. However, the association between performance in the UAT with academic achievement at the end of medical course in a problem-based learning (PBL) medical hybrid curriculum remains controversial. The aim of this study was to correlate marks in the UAT with those obtained in the Organized Structured Clinical Examination (OSCE), in the progress testing (PT), and in the final marks of the clerkship (FMC).Methods: We used data from 48 medical students. A single and a multiple dependency studies were performed to assess bivariate and multiple correlation between the UAT or the essay scores (dependent variables) and the OSCE, PT, and FMC (independent variables). Pearson test, multiple linear regression, and ANOVA tests were used and a p-value < 0.05 was considered significant.Results: In the bivariate analysis, only the UAT and FMC marks were correlated (r=0.34; p=0.02). However, the multiple dependency study showed a moderate correlation among UAT, OSCE, PT, and FMC marks (r=0.46; p=0.01). No correlation was found between the essay scores and PT, FMC, and OSCE scores.Conclusion: Our study shows that UAT marks, but not essay scores, can predict academic achievement, particularly in terms of clinical competence (FMC) at the end of a medical course in a PBL hybrid curriculum.Keywords: admissions test, clinical performance, problem-based learning, Organized Structured Clinical Examination, progress testing

Gustavo Salata Romão, Reinaldo Bulgarelli Bestetti, Lucélio Bernardes CoutoDepartment of Medicine, University of Ribeirão Preto, Ribeirão Preto, BrazilWe read with great interest the excellent paper by Pruitt et al1 who presented a problembased learning (PBL) approach to system-based practice medical education. Because a PBL medical teaching approach in primary care is rare, we would like to report our experience on this strategy as well. We have been using the PBL method in our medical course before the clerkship since 2003. In view of the fact that pre-university education is deficient and totally lecture-based,2 we have had to make some changes to adapt PBL to our educational reality, mainly testing application (multiple-choice questions) before, and some lectures following, the reporting phase of tutorial sessions.3,4 However, we had not used PBL in primary care until 2016. In Brazil, the Unified Health System provides universal health coverage for more than 170,000,000 people in a public decentralized and hierarchical network of primary, secondary, and tertiary health care services. A key part of this increasing access to health care is the Family Health Program (FHP). Unfortunately, the system is underfunded, and the health professionals are not sufficiently prepared to work in such a complex health system. Because of this, we have been implementing system-based practice in our medical course in a PBL environment since 2016.View the original paper by Pruitt and colleagues.

Reinaldo B Bestetti, Lucélio B Couto, Carolina BA Restini, Milton Faria Jr, Gustavo S Romão Department of Medicine, UNAERP Medical School, University of Ribeirão Preto, Ribeirão Preto, Brazil Purpose: In our context, problem-based learning is not used in the preuniversity environment. Consequently, students have a great deal of difficulty adapting to this method, particularly regarding self-study before the reporting phase of a tutorial session. Accordingly, the aim of this study was to assess if the application of an assessment test (multiple choice questions) before the reporting phase of a tutorial session would improve the academic achievement of students at the preclinical stage of our medical course.Methods: A test consisting of five multiple choice questions, prepared by tutors of the module at hand and related to the problem-solving process of each tutorial session, was applied following the self-study phase and immediately before the reporting phase of all tutorial sessions. The questions were based on the previously established student learning goals. The assessment was applied to all modules from the fifth to the eighth semesters. The final scores achieved by students in the end-of-module tests were compared.Results: Overall, the mean test score was 65.2±0.7% before and 68.0±0.7% after the introduction of an assessment test before the reporting phase (P0.05). Students in the eighth semester scored 71.8±2.3% compared to 70±2% when they were in the seventh semester (P>0.05).Conclusion: In our medical course, the application of an assessment test (a multiple choice test) before the reporting phase of the problem-based learning tutorial process increases the overall academic achievement of students, especially of those in the sixth semester in comparison with when they were in the fifth semester. Keywords: problem-based learning, self-directed learning, medical education, undergraduates, assessment

Lucélio B Couto, Gustavo S Romão, Reinaldo B Bestetti Department of Medicine, University of Ribeirão Preto, Ribeirão Preto, Brazil We have read with great interest the paper by Kassab et al, who have essentially shown that good teachers will be good tutors in a problem-based learning (PBL) environment. We have been facing great difficulties to select tutors because there has been no tradition in PBL in our region in the preuniversity teaching. Furthermore, the majority of our teachers have been formed in a discipline-based medical curriculum. Therefore, it is reassuring to learn from the work by Kassab et al that subject-matter mastery is the powerful independent predictor of tutoring skills. View the original paper by Kassab and colleagues.

Objective: To determine the prevalence of anxiety, depression and burnout in residents of Gynecology and Obstetrics during COVID-19 pandemic in Brazil and its associated factors., Methods: Cross-sectional study involving all regions of Brazil, through the application of a sociodemographic questionnaire, the Hospital Anxiety and Depression Scale (HAD) and the Maslach Burnout Inventory (MBI-HSS) instrument. Multivariate analysis was performed after adjusting the Poisson model., Results: Among the 719 participating medical residents, screening was positive for anxiety in 75.7% and for depression in 49.8% of cases. Burnout syndrome was evidenced in 41.3% of the physicians studied. Those with depression are more likely to have anxiety (OR 0.797; 95%CI 0.687 - 0.925) and burnout syndrome (OR 0.847 95%CI 0.74 - 0.97). Residents with anxiety (OR 0.805; 95%CI 0.699 - 0.928) and burnout (OR 0.841; 95%CI 0.734 - 0.963) are more likely to have depression., Conclusion: High prevalence of anxiety, depression and burnout were found in residents of Gynecology and Obstetrics in Brazil, in addition to important correlations between anxiety-depression and depression-burnout., Competing Interests: Conflicts to interest: none to declare., (© 2024. Federação Brasileira de Ginecologia e Obstetrícia. All rights reserved.)

Competing Interests: The authors have no conflict of interests to declare.

Breaking bad news is common in obstetrics and gynecology (ob-gyn). However, it is difficult, and few doctors receive training on how to deal with this situation. This narrative review aims to gather, analyze, and synthesize part of the knowledge on the area, focused on Ob-Gyn. Among the 16 selected articles, two are randomized controlled intervention studies, and most studies refer to obstetrics. The results found by us pointed out that simulation, feedback/debriefing, lectures, and protocols could improve doctors' performance in communicating bad news. For patients, the context and how the information is transmitted seem to impact more than the content of the news. Ob-Gyn doctors could benefit from specific protocols and education, given the specialty's particularities. There is a lack of evidence about the most effective way to conduct such training. Finding validated ways to quantify and classify studies' results in the area, which would allow for the objective analysis of outcomes, is one of the biggest challenges concerning this topic., Competing Interests: The authors have no conflict of interests to declare., (Federação Brasileira de Ginecologia e Obstetrícia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).)

Competing Interests: None to declare.

Competing Interests: The authors have no conflict of interests to declare.

Construct: The Communication Assessment Tool (CAT) is a 14-item instrument developed in English to assess medical trainees' interpersonal communication skills from the patient's perspective in clinical settings. Background: Using validated instruments and simulated patients constitutes good practice in assessing doctor-patient communication. The CAT was designed for use in real practice, but has not yet been applied to assessing OB-GYN residents' delivery of bad news in Objective Structured Clinical Examination (OSCE) stations. This study aims to provide validity evidence for using the CAT to assess residents' interpersonal communication skills under difficult circumstances in a simulated clinical setting in Brazil. Approach : Cross-cultural adaptation comprised translation into Portuguese, synthesis of translations, and back-translation. Next, a committee of 10 external and independent experts rated the items for linguistic equivalence and relevance to the overall scale. Researchers used the expert ratings to produce a preliminary Brazilian-Portuguese version. This version was applied by four simulated patients to assess 28 OB-GYN residents completing two, 10-minute OSCE stations focused on delivering bad news. Item and scale content validity indices and internal-consistency reliability were calculated. Simulated patients were interviewed to clarify any doubt regarding the content and usability of the tool and their response process. Findings: Thirteen of the 14 items in the Brazilian-Portuguese version were considered "equivalent" by at least 70% of the experts. All items were considered relevant by 100% of the experts. The Item Content Validity Index ranged from .9 to 1, and the Scale Content Validity Index was .99. The instrument showed good reliability for both scenarios (Cronbach's alpha > .90). Simulated patients considered the CAT easy to understand and complete. Conclusions: This study provides validity evidence for using the Brazilian-Portuguese CAT in a simulated clinical environment to assess OB-GYN residents' delivery of bad news. Based on this study's findings, the OB-GYN Department organized an annual formative assessment for residents to improve their interpersonal communication skills. This version of the CAT may also be applicable to other specialties.

Competing Interests: The authors have no conflict of interests to declare.

Background: Effective assessments programs are a challenge in problem-based learning (PBL). One of the main principles of this educational setting is the Formative Assessment (FA). We hypothesized that students' performance assessed by FA in tutorial sessions in a PBL curriculum is related to other summative assessments., Objective: To investigate the correlation among FA in tutorial sessions with grades obtained in Objective Structured Clinical Evaluation (OSCE) and Progress Testing (PT) to better understand the assessment process in PBL medical teaching approach and to predict student's future performance., Design: An observational cross-sectional study was conducted comparing FA, OSCE and PT scores from 4th to 8th semester medical students. Correlation analyses were performed using pooled and separate data from the 4th and 8th semesters., Results: From the 5th to 8th semester, OSCE scores were smaller compared to the FA, while PT scores were lower in all stages. In the pooled data, the correlation analysis showed a significant positive relationship between grades on FA and OSCE, FA and PT and OSCE and PT. A significant correlation among the three assessments strategies was also detected in the 8 th semester, but not in the 4th semester., Conclusions: Assessment strategies in PBL approach, including FA, OSCE and PT, have positive correlations, which increases as the medical course becomes more complex.

To investigate the relationship of birth weight (BW) of females born at full term with functional ovarian reserve (FOR) during menacme, based on serum level of anti-Müllerian hormone (AMH), among women who were 34-35 years old. This prospective birth cohort study assessed all women who were born in Ribeirão Preto City, State of São Paulo (Brazil) between June 1, 1978 and May 31, 1979. The primary endpoint was serum AMH, a marker of FOR, and its correlation with the BW of females classified as small for gestational age (SGA), appropriate for gestational age (AGA), and large for gestational (LGA). We included 274 women in this study, 19 were SGA, 238 were AGA, and 17 were LGA. The average of AMH concentration was not significantly different (p = 0.11) among women in the SGA group (2.14 ng/mL), AGA group (2.13 ng/mL), and LGA group (2.57 ng/mL). An analysis of variance indicated that the three groups also had no significant differences in the percentage of women who had adequate AMH levels (1 ng/mL; p = 0.11). There were no significant differences in the serum concentrations of AMH among 34 and 35 year-old women who were born at full term and classified as SGA, AGA, and LGA. Our sample size allowed detection of major differences between these groups (effect size of 0.8). Association of birth weight of females born at full term with functional ovarian reserve during menacme estimated by serum concentration of anti-Müllerian hormone.

This cross-sectional study aimed to identify factors related to coital frequency (CF) among 254 women in their 30s using a semistructured interview to collect sociodemographic, anthropometric, reproductive, clinical, and relationship data. CF was characterized as (a) never, (b) rarely (≤1 times/month), (c) occasionally (≤1 times /week), (d) regularly (2-3 times/week), or (e) frequently (>3 times/week). The mean age was 34.38 ± 0.43 years, mean body mass index (BMI) was 27.86 ± 6.52 kg, mean family income was US$1,044.18 ± 796.19, mean number of children was 1.71 ± 0.89, and mean relationship duration was 8.87 ± 5.11 years. Eighty-seven women (35.2%) were taking hormonal contraceptives, 143 (98.0%) were employed, 239 (96.48%) had a secondary or higher education, and 9 (3.62%) had primary schooling. CF was classified as >3 times/week in 22 (8.66%), 2-3 times/week for 98 (38.58%), ≤1 times/week in 40 (15.75%), ≤1 times/month in 14 (5.51%), and never in 5 (1.97%). Women who reported having coitus >3 times/week a week had significantly higher body mass index (BMI; 32.72 ± 7.42 kg/m(2)) than those who had coitus 2-3 times/week (28.45 ± 6.76 kg/m(2)) and ≤1 times /week (26.81 ± 5.39 kg/m(2)) (p < 0.01 for both comparisons). Thus, coital frequency varies in women in their 30s. Obese women had a higher CF than normal-weight and overweight women.

Background: In problem-based learning (PBL), the facilitator plays an important role in guiding the student learning process. However, although content expertise is generally regarded as a useful but non-essential prerequisite for effective PBL facilitation, the perceived importance of content knowledge may be subject to cultural, contextual, and/or experiential influences., Aim: We sought to examine medical students' perceptions of subject-matter expertise among PBL facilitators in a region of the world (Brazil) where such active learning pedagogies are not widely used in university or pre-university settings., Results: Of the 252 Brazilian medical students surveyed, significantly (p≤0.001) greater proportions viewed content expert facilitators to be more effective than their non-expert counterparts at building knowledge (95% vs. 6%), guiding the learning process (93% vs. 7%), achieving cognitive learning (92% vs. 18%), generating learning goals (87% vs. 15%), and motivating self-study (80% vs. 15%)., Discussion/conclusion: According to Brazilian medical students, subject-matter expertise among PBL facilitators is essential to the learning process. We believe this widespread perception is due, in large part, to the relative lack of prior educational exposure to such pedagogies.

Background: Despite being a well-established pedagogical approach in medical education, the implementation of problem-based learning (PBL) approaches hinges not only on educational aspects of the medical curriculum but also on the characteristics and necessities of the health system and the medical labor market within which it is situated., Aim: To report our experiences implementing a PBL-based approach in a region of Brazil where: 1) all pre-university education and the vast majority of medical courses are based on traditional, lecture-based instructions; and 2) students' career interests in primary care, arguably the prototypical PBL trainee, are heavily disfavored because of economics., Results: Brazilian guidelines require that clinical training take place during the last 2 years of the medical program and include intensive, supervised, inpatient and outpatient rotations in pediatrics, family medicine, obstetrics and gynecology, internal medicine, and surgery. Throughout the pre-clinical curriculum, then, students learn to deal with progressively more difficult and complex cases--typically through the use of PBL tutors in a primary care context. However, because of curricular time constraints in the clerkships, and students' general preoccupation with specialty practice, the continuation of PBL-based approaches in the pre-clinical years--and the expansion of PBL into the clerkships--has become exceedingly difficult., Discussion and Conclusion: Our experience illustrates the importance of context (both cultural and structural) in implementing certain pedagogies within one Brazilian training program. We plan to address these barriers by: 1) integrating units, whenever possible, within a spiral curriculum; 2) introducing real patients earlier in students' pre-clinical coursework (primarily in a primary care setting); and 3) using subject experts as PBL tutors to better motivate students.

The objectives of this prospective study were to evaluate the nuclear maturation stage and the presence and location of meiotic spindles of in vivo matured oocytes from infertile women with and without endometriosis (male or tubal causes of infertility) undergoing stimulated cycles for intracytoplasmic sperm injection (ICSI). We also compared the ICSI outcomes among groups. We analyzed the meiotic spindles of oocytes from 36 patients with endometriosis I/II, 24 with endometriosis III/IV, and 60 without endometriosis (male or tubal causes of infertility). The oocytes were imaged using polarization microscopy. There were no differences in the number of oocytes in telophase I (mean [standard deviation]: 0.1 [0.5], 0.2 [0.4], and 0.2 [0.5], respectively, in the endometriosis I/II, endometriosis III/IV, and control groups), in metaphase II with visible spindles (4.2 [2.5], 3.1 [2.0], and 3.6 [2.2], respectively, in the endometriosis I/II, endometriosis III/IV, and control groups), and in spindle location among groups. We can conclude from this study that noninvasive analysis of spindles from in vivo matured oocytes of infertile patients with endometriosis did not demonstrate significant differences in terms of the nuclear maturation stage, the percentage of oocytes in metaphase II with visible spindles, and the spindle localization when compared to the control group. However, it is important to state that there are no studies evaluating the accuracy of polarization microscopy for the detection of meiotic anomalies in human oocytes, which would need to be better evaluated in future studies using an appropriate methodology.

Anti-mullerian hormone (AMH) is a glycoprotein produced by granulosa cells of primary, pre-antral and small antral ovarian follicles and its clinical applicability has been recently demonstrated by several studies. Prediction of the response to ovarian stimulation for in vitro fertilization corresponds to the most frequent utilization of AMH in clinical practice, being routinely assessed in many services to identify subgroups of women susceptible to a poor response or to Ovarian Hyperstimulation Syndrome. There are great perspectives that AMH may be applicable to the individual determination of risk for iatrogenic gonadal injury in women with neoplasms who will be submitted to chemotherapy. It is also probable that AMH assessment will be included in protocols for the investigation of amenorrhea and oligomenorrhea, since AMH levels are increased in Polycystic Ovary Syndrome, reduced in premature ovarian failure and normal in other conditions such as hyperprolactinemia and hypogonadotropic hypogonadism. It is possible that AMH will be utilized in the future for the prediction of age at menopause and of reproductive prognosis, providing solid bases for pre-conceptive and contraceptive counseling.

Purpose: To compare serum anti-Mullerian hormone (AMH) levels on the seventh day of ovarian stimulation between normal and poor responders., Methods: Nineteen women aged ≥35, presenting with regular menses, submitted to ovarian stimulation for assisted reproduction were included. Women with endometriosis, polycystic ovarian syndrome or those who were previously submitted to ovarian surgery were excluded. On the basal and seventh day of ovarian stimulation, a peripheral blood sample was drawn for the determination of AMH, FSH and estradiol levels. AMH levels were assessed by ELISA and FSH, and estradiol by immunochemiluminescence. At the end of the stimulation cycle patients were classified as normal responders (if four or more oocytes were obtained during oocyte retrieval) or poor responders (if less than four oocytes were obtained during oocyte retrieval or if the cycle was cancelled due to failure of ovulation induction) and comparatively analyzed by the t-test for hormonal levels, length of ovarian stimulation, number of follicles retrieved, and number of produced and transferred embryos. The association between AMH and these parameters was also analyzed by the Spearman correlation test., Results: There was no significant difference between groups for basal or the seventh day as to AMH, FSH and estradiol levels. There was a significant correlation between seventh day AMH levels and the total amount of exogenous FSH used (p=0.02)., Conclusions: AMH levels on the seventh day of the ovarian stimulation cycle do not seem to predict the pattern of ovarian response and their determination is not recommended for this purpose.

Rationale: Chronic pelvic pain (CPP) is a common and complex disease whose cause is often clinically inexplicable, with diagnosis and treatment being more difficult. From a clinical viewpoint, CPP is defined as non-cyclic, non-menstrual pain lasting at least 6 months and sufficiently severe to interfere with habitual activities and requiring clinical or surgical treatment. Thus, CPP is a syndrome resulting from a complex interaction of the nervous, musculoskeletal and endocrine systems and also influenced by psychological and sociocultural factors. CPP is influenced by emotional aspects with an impact on quality of life, and involving high costs for health services. Its aetiology is not always clear and a cure or significant improvement of symptoms is not always obtained with the treatments employed, with constant frustration of the professionals involved. It can be seen that its treatment is often unsatisfactory, simply providing temporary relief of symptoms., Methods: In the present study, we reviewed the bibliography regarding pelvic pain, with emphasis on emotional aspects and on the importance of a multidimensional approach to the care for these patients., Results and Conclusions: New investigations are needed to clarify these relations and interventions in a more effective manner. Interdisciplinary care can minimize the impact of the disease, helping the patients to cope with symptoms and improving their quality of life., (© 2010 Blackwell Publishing Ltd.)

Purpose: to compare serum markers of oxidative stress between infertile patients with and without endometriosis and to assess the association of these markers with disease staging., Methods: this was a prospective study conducted on 112 consecutive infertile, non-obese patients younger than 39 years, divided into two groups: Endometriosis (n=48, 26 with minimal and mild endometriosis - Stage I/II, and 22 with moderate and severe endometriosis - Stage III/IV) and Control (n=64, with tubal and/or male factor infertility). Blood samples were collected during the early follicular phase of the menstrual cycle for the analysis of serum malondialdehyde, glutathione and total hydroxyperoxide levels by spectrophotometry and of vitamin E by high performance liquid chromatography. The results were compared between the endometriosis and control groups, stage I/II endometriosis and control, stage III/IV endometriosis and control, and between the two endometriosis subgroups. The level of significance was set at 5% (p < 0.05) in all analyses., Results: vitamin E and glutathione levels were lower in the serum of infertile women with moderate/severe endometriosis (21.7 ± 6.0 mMol/L and 159.6 ± 77.2 nMol/g protein, respectively) compared to women with minimal and mild endometriosis (28.3 ± 14.4 mMol/L and 199.6 ± 56.1 nMol/g protein, respectively). Total hydroxyperoxide levels were significantly higher in the endometriosis group (8.9 ± 1.8 µMol/g protein) than in the Control Group (8.0 ± 2 µMol/g protein) and among patients with stage III/IV disease (9.7 ± 2.3 µMol/g protein) compared to patients with stage I/II disease (8.2 ± 1.0 µMol/g protein). No significant differences in serum malondialdehyde levels were observed between groups., Conclusions: we demonstrated a positive association between infertility related to endometriosis, advanced disease stage and increased serum hydroxyperoxide levels, suggesting an increased production of reactive species in women with endometriosis. These data, taken together with the reduction of serum vitamin E and glutathione levels, suggest the occurrence of systemic oxidative stress in women with infertility associated with endometriosis. The reproductive and metabolic implications of oxidative stress should be assessed in future studies.

Objective: To assess the impact of the mean oocyte diameter (MOD) on occurrence of fertilization and embryo quality in assisted reproduction cycles., Design: Prospective observational study., Setting: Sector of Human Reproduction of the University Hospital, Faculty of Medicine of Ribeirão Preto, University of São Paulo (HCFMRP-USP)., Patient(s): Thirty-five women undergoing intracytoplasmic sperm injection (ICSI) at the University Hospital of Ribeirão Preto from May to October 2007., Intervention(s): MOD assessment., Main Outcome Measure(s): Occurrence of fertilization and qualitative embryo classification on 2nd and 3rd day after ICSI., Result(s): We divided 160 metaphase II oocytes according to MOD into groups A (MOD below the 25th percentile), B (MOD between 25th and 75th percentile), and C (MOD above the 75th percentile). There was no statistically significant association between MOD and the occurrence of fertilization or the qualitative embryo classification on days 2 and 3. There was no statistically significant difference between groups regarding number of cells or the qualitative embryo classification on days 2 and 3., Conclusion(s): The MOD of mature oocytes does not seem to be related to the occurrence of fertilization or to the developmental quality of human embryos on days 2 and 3 after ICSI., (Copyright 2010. Published by Elsevier Inc.)

Background: Chronic pelvic pain (CPP) is a common and complex disease whose cause is often clinically inexplicable, with consequent difficulty in diagnosis and treatment. Patients with CPP have high levels of anxiety and depression, with a consequent impairment of their quality of life., Aims: The objective of this study was to determine the prevalence of anxiety and depression and their impact on the quality of life of women with CPP., Materials and Methods: A cross-sectional controlled study was conducted on 52 patients with CPP and 54 women without pain. Depression and anxiety were evaluated by the Hospital Anxiety and Depression Scale, and quality of life was evaluated by the World Health Organization Quality of life Whoqol-bref questionnaire. Data were analysed statistically by the Mann-Whitney U-test, the Fisher exact test, chi-square test and Spearman correlation test., Results: The prevalence of anxiety was 73% and 37% in the CPP and control groups, respectively, and the prevalence of depression was 40% and 30% respectively. Significant differences between groups were observed in the physical, psychological and social domains. Patients with higher anxiety and depression scores present lower quality of life scores., Discussion: The fact that DPC is a syndromic complex, many patients enter a chronic cycle of search for improvement of medical symptoms. The constant presence of pain may be responsible for affective changes in dynamics, family, social and sexual. Initially the person is facing the loss of a healthy body and active, to a state of dependence and limitations. In this study, patients with higher scores of anxiety and depression scores had lower quality of life and patients with lower scores of anxiety and depression had scores of quality of life. These results show that perhaps the depression and anxiety may be related to the negative impact on quality of life of these patients., Conclusion: In view of this association, we emphasise the importance of a specific approach to the treatment of anxiety and depression together with clinical treatment to improve the quality of life of these patients.

Objective: To analyze comparatively the speaking fundamental frequency (F0) between women at menacme and women in the climacterium taking or not hormonal replacement therapy., Methods: A controlled transverse study was conducted on 45 women divided into three groups of 15 women each: Group A (women aged 20-40 years with regular menstrual cycles taking no hormonal contraceptives), Group B (women aged 45-60 years with a duration of menopause of at least 2 years taking 1mg estradiol valerate +90 microg norgestimate per day in a continuous treatment scheme lasting at least 6 months), and Group C (women aged 45-60 years with a duration of menopause of at least 2 years taking no HRT for at least 6 months). The mean age for Groups A, B and C was 30.3, 54.5 and 56.5 years, respectively. The groups were analyzed comparatively regarding F0 values for the sustained vowels /e/ and /i/., Results: Mean F0 for the sustained vowels /e/ and /i/ were 215.97 and 229.89 Hz, 206.21 and 221.79 Hz, 200.71 and 212.79 Hz for Groups A, B and C, respectively, with no significant differences between groups., Conclusions: Although there is evidence of a probable modulating effect of sex steroids on the larynx, in the present study no significant differences in speaking voice were observed regarding menopause or the use of HRT. The absence of such differences observed in F0 does not necessarily mean that there is no difference in vocal quality between these groups since F0 represents only a vocal parameter.

The aim of the present study was to measure the in vitro aromatase activity in granulosa cells of women with endometriosis submitted to assisted reproduction techniques. A case-control study was conducted on eight patients with endometriosis and eight with other infertility causes submitted to in vitro fertilization or intracytoplasmic sperm injection. Granulosa cells were obtained from pre-ovulatory follicles during oocyte retrieval and cultured for 24 h in the presence or absence of testosterone (2 x 10(-6) and 2 x 10(-5) M), follicle-stimulating hormone (FSH) and insulin-like growth factor-I (IGF-I) (both at 50 ng/ml). Estradiol (radioimmunoassay) was measured in the obtained culture fluids. The basal production of estradiol and its production under testosterone addition to the culture (aromatase activity) were analyzed. Reduced aromatase activity was detected in cultured granulosa cells in endometriosis cases, compared with controls, when testosterone was added at the concentration at 2 x 10(-6) M (p = 0.0303). The basal production of estradiol was also reduced in endometriosis patients (p = 0.0390). The effect of addition of FSH and IGF-I did not differ between groups. In conclusion, the in vitro basal production of estradiol and aromatase activity in granulosa cells were reduced in women with endometriosis submitted to assisted reproduction techniques, compared with the control group.

Purpose: To assess the presence of insulin resistance as well as the incidence of polycystic ovary syndrome (PCOS) in adolescents with menstrual disorders., Methods: A case-control study was conducted with 34 adolescents during the period of 2 to 4 years after menarche. The patients were divided into two groups: group I (G I) with 22 patients with menstrual irregularity, and group II (G II) with 12 patients with regular menstrual cycles. Body mass index and Ferriman-Gallway index were calculated for all patients, who also received a pelvic ultrasound. We measured DHEA-S, 17 hydroxyprogesterone, testosterone, TSH, LH, FSH, and prolactin in serum sample and conducted the glucose tolerance test with 75 mg dextrose with measurement of glucose and insulin., Results: Mean +/- SD ovary volume was larger in G I (11.38 +/- 4.06 cm(3)) than in G II (7.72 +/- 5.59 cm(3)); P < 0.05. DHEA-S (G I = 47.23; G II = 38.38 microg/dl) and testosterone (G I = 54.19; G II = 32.53 ng/dl) levels were higher in patients with menstrual irregularity. In G I we detected two patients with diabetes mellitus and one patient with glucose intolerance. Sixteen patients in this group had clinical or hormonal characteristics of PCOS. The mean values of the area under the insulin curve (AUIC) were higher in patients with menstrual irregularities (8,556.52 muIU/mL/2 h) than in controls (5,743.38 microIU/mL/2 h); P < 0.05., Conclusions: The presence of PCOS was detected in 95% of the adolescents with menstrual irregularity. Patients with menstrual disorders presented higher AUIC values than controls.

Mitochondria are organelles responsible for oxidative phosphorylation, the main energy source for all eukaryotic cells. In oocytes and embryos, it seems that mitochondria provide sufficient energy for fecundation by supporting spindle formation during meiosis II, and for implantation. Since mitochondria are inherited from mother to child, it is important that oocyte mitochondria should be intact. Older women seem to have more mitochondrial DNA mutations, which can be responsible for poor implantation and aneuploidy, two conditions that occur more often in this group. In the present report we propose a new model to explain why older women have poor implantation rates.

The purpose of this prospective and non-randomized study was to identify prolactin (PRL) isoforms in the follicular fluid (FF) of patients undergoing in vitro fertilization (IVF). The FF from 19 patients was obtained during oocyte retrieval at the University Hospital, Ribeirão Preto Medical School. The molecular weight of FF PRL was determined by column chromatography on Sephacryl S-200 HR combined with an immunometric assay. The only PRL isoform detected in FF exhibited a molecular weight of 20.5 kD. The molecular weights of FF PRL and small PRL are essentially identical. The 20.5-kD PRL accounted for 93.1 +/- 9.1% (mean +/- SD) of the recovered PRL after gel chromatography. Total PRL recovery was 74.2 +/- 19%. Thus, the only PRL detected in the FF was the small PRL, the most potent one., (Copyright 2002 S. Karger AG, Basel)