COGI 2011 7 nero.indd

NOVEMBER 17-20, 2011 PARIS, FRANCE

Editors

14TH WORLD CONGRESS ON CONTROVERSIES IN OBSTETRICS, GYNECOLOGY & INFERTILITY (COGI)

Z. Ben-Rafael B.C.J.M. Fauser R. Frydman

ISBN 978 88 6521 054 3 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or internet communication system or transmitted in any form, or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission, in writing, from the publisher. © Copyright 2012 MONDUZZI EDITORIALE S.r.l. Via Meucci, 15/17 – 43015 Noceto (PR) – Italy MONDUZZI EDITORIALE S.r.l. Via B. Eustachi, 12 – 20129 Milano – Italy Phone (+) 39-02-20404031 – Fax (+) 39-02-20404044 www.monduzzieditore.it e-mail: [email protected] Layout: ESN – Rastignano – Bologna – Italy Printed in February 2012 by EB.O.D. – Milano – Italy

Contents Preface .............................................................................................................. 11 INFERTILITY & ART ........................................................................................... 13 The effectiveness of immunotherapy with paternal lymphocytes in patients with at least two IVF cycles .......................................... 15 R. Barini, I.N. Machado, Y. Klimesch, S.B.S. Lima, M.C. Vicentini

Robotic coelioscopy versus vaginal route for simple hysterectomy .................... 19 M. Carbonnel, S. Roy, H.T. N’guyen, H. Abbou, J.M. Ayoubi

A novel approach for treating infertile patients with diminished ovarian reserve (DOR) ............................................................. 23 G. Carlomagno, S. Roseff, S. Harter, RN, S. Murphy Cohen, ARNP, V. Unfer

Impact of rh-FSH on sperm DFI in idiopathic oligoasthenospermia.................... 27 N. Colacurci, M.D. D’Eufemia, V. Auletta, P. De Franciscis, M.G. Monti, C. Trotta, E. La Verde, D. Mele

Pregnancy rate of gonadotrophin therapy and laparoscopic ovarian electrocautery in polycystic ovary syndrome resistant to clomiphene citrate: a comparative study ........................................................ 31 M. Ghafarnejad, N. Arjmand, Z. Khazaee

Premature ovarian failure in a woman with a balanced 15; 21 translocation – a case report ......................................................................... 37 S. Hosseini, M. Vahid Dastjerdi, Z. Asgari, H. Samiee

Male obesity and sperm parameters in infertility ................................................ 41 L. Jamshidi

Upper age limit for access to ART: never-ending discussions? ........................... 45 H. Konecna, T. Kucera, S. Suda

Classification of utero-vaginal malformations ................................................... 51 L.V. Adamyan, Z.N. Makiyan, A.A. Stepanian

Female genital organ's malformations: new hypothesis of embryo-morphogenesis ....................................................... 55 Z. Makiyan


Association of expanded Natural Killer cells subsets in women with recurrent gestational failure ....................................................... 59 R. Ramos-Medina, Á. García-Segovia, M. Tejera-Alhambra, Á. Aguarón, B. Alonso, M. Rodríguez-Mahou, J. Gil , J. A. León, P. Caballero, S. Sánchez-Ramón

The effect of bromocriptine and cyclodynon on the clinical symptoms and prolactin levels in women of reproductive age with hyperprolactinemia ..................................................... 65 L. Suturina, L. Kolesnikova, L. Popova

Sperm recovery in patients with non-mosaic Klinefelter syndrome: a comparative study ......................................................................... 69 H. Terada, T. Sugiyama, S. Mugiya, S. Ozono

Co-occurrence of polycystic ovary syndrome with depression and anxiety symptoms ..................................................................... 73 Xin Li, Fulong Wang, Johnna Wu, Fang Fang,Yi Jin

Cryopreservation of a small number of human spermatozoa with home-made Strawtop: 3 years experience ................................................. 77 Songguo Xue, Qiuping Peng, Shaofeng Cao, Qiao Yu, Jiqiang Si, Yanping Kuang

Sucrose pretreatment vitrification yields 100% survival rate of mouse and human eggs ................................................................................. 81 Songguo Xue, Qiuping Peng, Qiao Yu, Qifeng Lyu, Shaofeng Cao, Yanping Kuang

FETOMATERNAL MEDICINE ............................................................................. 85 Types of fistula and their management in a referral center in Saudi Arabia .................................................................................................. 87 G. Al-Shaikh, K. Perveen, M. Moazin, A. Al-Badr

Determination of the early immunological changes in patients with pregnancy loss .......................................................................... 91 F. Aliyeva, A. Poletayev, A. Amirova, N. Shahbazova, X. Tahmazi

Challenges in implementing humanized birth practices in a highly specialized and university affiliated hospital .................................... 95 R. Behruzi, M. Hatem, L. Goulet, W. Fraser

Placenta praevia: our experience ......................................................................101 M. Brandão, J. Casanova, M.M. Sampaio, T. Oliveira, R.M. Rodrigues

The influence of bacterial vaginosis on preterm rupture of membranes ...............105 E. Bylykbashi, I.V. Bylykbashi, E. Kosturi, O. Janushaj, A. Zhaka, E. Treska

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November 17-20, 2011 Paris, France

The impact of periodontitis in the preterm birth and body size of newborns ...............................................................................109 L. Muhametaj, E. Bylykbashi, M. Muhametaj, A. Manaj, M. Xhelili

Pre-pregnant body mass indexin women with gestational diabetes mellitus and pregnancy outcome ......................................113 S. De Carolis, A. Botta, F. Macrì, F. Stifani, L. Casarella, S. Garofalo, C. Martino, V.A. Degennaro, S. Moresi, G. Del Sordo, E. Di Pasquo, D. Pitocco

Controversies in the introduction of antenatal ultrasonography in rural Tanzania ......................................................117 E. Firth, P. Mlay, R. Walker, P.R. Sill

Maternal status and recent patterns of double and triple deliveries in Spain .............................................................125 V. Fuster Siebert, J. Román-Busto

The influence of mode of delivery in neonatal complications in breech presentation ...............................................................129 S. Latifi-Hoxha, M. Hoxha, Sh. Bajraktari Ponosheci, N. Berisha, B. Skenderi

Waist circumference in relation to prediction of delivery outcomes ..................133 E. Mehrabi, M. Ebrahimi Mameghani, M. Kamalifard, P. Yavari Kia

Effect of melatonin on the oxidative metabolism of colostrum phagocytes of diabetic women .....................................................139 I. Calderon, G. Morceli, C. Hara, R. Volpato, M. Rudge, A. Honorio-França, E. França

The role of dydrogesterone in threatened abortion ............................................143 A. Bimbashi, E. Ndoni, R. Hoxhallari

Our experience in management of severe preeclampsia ...................................149 E. Ndoni, A. Bimbashi, A. Dokle

Fetal growth and birth weight: the need for clinical decision support software.....................................................................155 R. Santos, C. Santos, J. Bernardes, R. Cruz-Correia

Endothelin-1 system polymorphisms in preeclampsia and gestational hypertension .......................................................161 A. Seremak-Mrozikiewicz, M. Barlik, K. Drews

TNF-α concentrations in maternal and umbilical cord plasma and the perinatal outcome ....................................................................165 J. Zegarska, K. Borowska-Maćkowiak, J. Kłyszejko-Molska, M. Socha, M. Gruszka, P. Krepska, B. Wolski, W. Szymański, M. Grabiec

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GYNECOLOGY ................................................................................................171 The effect of armed conflict on spontaneous abortions in Benghazi – Libya .....................................................173 Z.A. Bodalal, K. Agnaeber

Peculiarities of HRT for women with obesity ....................................................181 G. Alimbayeva, I. Kuznetzova, M. Yakokutova

Complications of meshes in combination with surgery for uterovaginal prolapse ..............................................................185 E. Athanassiou, T. Tantanasis, X. Giannoulis, N. Tsambazis, A. Loufopoulos

Pregnancy after gigantic bilateral ovarian teratoma ...........................................189 M. Brandão, S.V. Soares, P. Reis, M. Rodrigues, T. Oliveira, R.M. Rodrigues

Primary bilateral Burkitt´s lymphoma of the ovary ............................................193 A.M. Coelho, A.M. Sousa, F. Passos, M. Bernardino, I. Santana, A.F. Jorge, J. Cabeçadas

Retrospective study of laparoscopic assisted vaginal hysterectomy (LAVH) for benign gynecological disorders..................................197 R. Condeço, L. Barros, S. Barreto, C. Leitão, M.C. Silva, R. Mira

The cyst of Nuck: clinical case and review of the literature ...............................203 A. Cubal, J. Carvalho, F. Azevedo

Body composition in users of levonorgestrel-releasing intrauterine system ...........................................................................................207 N. Dal´Ava, L. Bahamondes, M.V. Bahamondes, A. de Oliveira Santos, I. Monteiro

Can promestriene be used even in oncology patients? ......................................213 L. Del Pup, D. Postruznik

Postpartum echographic diagnosis of ganglioneuroblastoma – a case report ..................................................................................................219 O. Eremina, Y. Boykova, E. Shifman, I. Shevelev, V. Korolishin, A. Gus

Impact of capsule rupture in stage I clear cell carcinoma of the ovary ......................................................................223 H. Kajiyama, M. Mizuno, E. Yamada, H. Matsumura, F. Kikkawa

Improvement of postoperative care after major abdominal gynecologic surgery ..............................................................227 E. Kallfa, G. Hyska, E. Belaj , A. Delilaj , S. Xinxo, V. Grori, V. Mulliqi F. Lauszus, O. Gliozheni

Evaluation of the ovarian malignancies' occurrence in patients with previous IVF treatment .............................................................231 A. Koumousidis, A. Kotelis, A. Daskalakis, I. Kaniaris, M. Kontoyannis, V. Sanoulis, D. Ftoulis, Ch. Tsarmaklis, Ch. Katsetos

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Can inflammation take part in development and progression of endometrial hyperplasia? ....................................................237 Ye. Kovalenko, T. Tatarchuk, A. Kubyshkin, T. Filonenko

The expression and characterization of endoglin in uterine leiomyosarcoma ...............................................................................241 H. Matsumura, K. Shibata, E. Yamada, M. Mizuno, H. Kajiyama, T. Senga, F. Kikkawa

A rare case of invasive vaginal carcinoma associated with complete uterine prolapse ......................................................245 M.M. Melo, E. Gonçalves, A.R. Neiva, A. Almeida, J. Mesquita, A. Carvalho, D. Magalhães, J. Maia

Is adjuvant chemotherapy necessary for stage IA ovarian clear cell carcinoma? ...........................................................................251 M. Mizuno, H. Kajiyama, E. Yamada, H. Matsumura, F. Kikkawa

Comparing Metformin and Pioglytazone in polycystic ovary ...........................255 N. Navali, S.Tagavi

An explorative study upon factors that contribute to contraceptive-seeking behaviour among married Sudanese women in Khartoum, Sudan..............................................................261 T. Parekh, J. Parr

Lynch Syndrome – a case report .......................................................................267 A.M. Sousa, A.M. Coelho, M. Bernardino, A.S. Gomes, A.F. Jorge, I. Claro

An ovarian tumor with origin in an appendiceal cancer – a case report ..................................................................................................271 A.M. Sousa, A.M. Coelho, M. Bernardino, A.S. Gomes, A.F. Jorge, R. Rego

Breast cancer and hot flashes treatment ...........................................................275 C. Tomás, M. Rodrigues, A. Relva, L. Canelas, F. Romão, MJ. Botica, M. Vieira

Charged particle therapy for recurrence of gynecologic cancer, 9 case reports ..................................................................281 E. Yamada, K. Shibata, H. Kajiyama, M. Mizuno, H. Matsumura, F. Kikkawa

Single site laparoscopic surgery for complex cases in benign gynecology .......................................................................................285 J. Ybanez-Morano, R.P. Rivera, J.O. Fuentes, M.C. Vicencio, M. A. Panaligan

Physiologic and pathologic changes in veins during pregnancy. What to be afraid of? ...........................................................289 E. Yupatov, L. Maltseva, I. Ignatyev, E. Fomina, M. Nyukhnin, S. Sokolov, A. Zaitsev

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Preface Dear Friends and Colleagues Over the years, the field of Obstetrics, Gynecology & Infertility has undergone enormous expansion in clinical and basic data, as well as that of field-related technology. The intention of the 14th COGI Congress was to search for answers even when evidence is lacking, and to reach current conclusions to ongoing debates in the fields through evidence-based medicine. The Congress functions as an exclusive forum for international experts to share and compare experiences, in order to outline appropriate treatment. The 14th COGI in Paris had 2,200 participants from 101 countries (increase of 20%), 720 accepted abstracts and 18 supporting companies, which shows the growing importance of COGI in Europe and worldwide. In addition, a “Position Paper” on the treatment of osteoporosis in women under 70 years of age has been developed by a group of experts. We would like to thank the authors of these chapters for their contribution to the success of the Congress. Zion Ben-Rafael Editor Founder and Chairman of the COGI Congress

INFERTILITY & ART

The effectiveness of immunotherapy with paternal lymphocytes in patients with at least two IVF cycles R. Barini, I.N. Machado, Y. Klimesch, S.B.S. Lima, M.C. Vicentini Allovita – Laboratory Immunology of Reproduction, Campinas-SP, Brazil

SUMMARY Objective: To describe our experience with the immunotherapy with paternal lymphocytes (IPL) for couples with implantation failure in at two previous cycles of IVF. Materials/Methods: Retrospective analysis of all couples who were referred to our laboratory for IPL after two or more IVF cycles negative for serum levels of the hormone chorionic gonadotropin (βHCG). The rate of viable pregnancies after the IPL in further IVF cycles was considered success rate of pregnancy. Results: 25 couples were included in this study with a mean women age of 35.7 years (± 3.56). The number of cycles of IVF before immunotherapy with paternal lymphocytes ranged from 2 to 6 cycles. The success rate of pregnancy was 63% (14/22) after new IVF cycles and 68% (17/25) when spontaneous pregnancies were included. Conclusion: Couples who had undergone at least two previously failed IVF cycles before the IPL seemed to benefit with this immunotherapy, suggesting that IPL is a valuable adjuvant therapy for them.

INTRODUCTION Recent technological developments in assisted reproduction techniques have enabled many couples to accomplish the dream of having children. However, failure to conceive despite normal appearing embryo transfer cycles may still occur. Many underlying causes of this unsuccessful in vitro fertilization treatment were postulated. In 1953 Peter Medawar formulated the first hypothesis that embryo behaves like one graft since has both maternal and paternal antigens, being therefore likely theories rejection and immunological tolerance originated in maternal organism (alloim© 2012 Monduzzi Editoriale | Proceedings

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mune) (Guerin et al., 2009; Porcu-Buisson et al., 2007). In the embryo implantation process, cells of the villous cytotrophoblast has extra features to express nonclassical HLA molecules (HLA-G). Uterine natural killer cells recognize the HLA-G as the cytotrophoblast and the block does not own, promoting a Th2-type immune response favorable to successful pregnancy (Choudhury and Knapp, 2000; Van Mourik et al., 2009). Thus, there are some data suggesting that successful implantation may be directly linked to the balance between Th1 and Th2 (Kwak-Kim et al., 2003; Kalu et al.; Saito et al., 2010). According to these data, patients with repeated pregnancy loss and failure of embryo implantation in IVF cycles have abnormal immunological response (NG et al. 2002; Yokoo et al,. 2006; Kalu et al., 2008). Besides having a high level of natural killer cells (NK) and cytotoxic also have an inversion in the balance of Th1 and Th2 cytokines (NG et al., 2002; Kwak-Kim et al.,2003; Yokoo et al., 2006; Kalu et al.,2008; Chernyshov et al.,2010) The prevalence of Th1 immune response leads to the release of IL-2, IL - 12, interferon gamma (INF γ) and tumor necrosis factor alpha (TNF), induce inflammatory reactions and cytotoxic via IL - 2, IFN gamma and TNF alpha, promoting a deleterious effect on pregnancy, specifically in the cells of the villi primary trophoblast by inducing apoptosis and rejection of the embryo (Raghupathy et al., 2000; NG et al., 2002; Kwak-Kim et al., 2003; Kalu et al., 2008; van Mourik et al., 2009; Boomsma et al., 2009; Winger et al., 2010; Saito et al., 2010). In vitro fertilization (IVF) treatment is expensive and emotional stressing. Couples usually inquire as to what reason is for the implantation failures and if there is something else it can be done. Based on the above theoretical etiologies, one treatment option is to consider the immunotherapy with paternal lymphocytes (IPL). The ILP is available as adjuvant therapy as it appears to reverse the function of immunological changes to a predominance of Th2-type immune tolerance thereby allowing embryo implantation and subsequent development of gestational increasing rates in assisted fertilization. The aim of this study was to report our experience with the immunotherapy with paternal lymphocytes (IPL) for couples with implantation failure in at two previous cycles of IVF.

MATERIAL AND METHODS It was carried out a retrospective analysis of all couples who were referred to our laboratory from January 2009 to March 2011 for IPL after two or more IVF cycles negative for serum levels of the hormone chorionic gonadotropin (βHCG). The treatment (IPL) was administered intradermally every 21 days, totaling 3 doses. After a positive post-treatment crossmatch test, the couples were allowed to further attempts to pregnancy. The rate of viable pregnancies was considered success rate of pregnancy. 16


RESULTS A total of 25 couples were included in this study with a mean women age of 35.7 years (± 3.56). The number of cycles of IVF before immunotherapy with paternal lymphocytes ranged from 2 to 6 cycles. The success rate of pregnancy was 63% (14/22) after new IVF cycles and 68% (17/25) when spontaneous pregnancies were included.

CONCLUSIONS Our study demonstrated that couples who had undergone at least two previously failed IVF cycles before the IPL seemed to benefit with this immunotherapy, suggesting that IPL is a valuable adjuvant therapy for them. With the introduction of immunotherapy with paternal lymphocytes by Dr. Alan Beer in 1981 (Beer et al., 1981), it appears as a therapeutic option also in patients with repeated implantation failure in IVF cycles. In agreement with the results presented here, previous published results have reported that the rate of successful pregnancy could be increased by active immunotherapy – IPL (Check et al., 2005; Wegener et al., 2006; Margalioth et al., 2006).

REFERENCES 1. BEER AE,QUEBBEMAN JF, AYERS JW, HAINES RF. Major histocompatibility complex antigens, maternal and paternal immune responses, and chorionic habitual abortions in humans. Am J Obstet Gynecol 141:987- 999; 1981. 2. BOOMSMA CM, KAVELAARS A, EIJKEMANS MJC, LENTIES EG, FAUSER BCJM, HEIJNEN CJ, MACKLON NS. Endometrial secretion analysis identifies a cytokine profile predictive of pregnancy in IVF. Human Reproduction 24(6):1427 – 1435; 2009. 3. CHECK J H, LISS M L, DIANTINO A, DUROSEAU M. Lymphocyte immunotherapy can improve pregnancy outcome following embryo transfer (ET) in patients falling to conceive after two previous ET. Exp Obstret Gynecol 32 (1):21-2; 2005. 4. CHERNYSHOV PV, SUDOMA O I, DONS’KOI V B, KOSTYUCHYK A A, MASLIY V Y. Elevated NK Cell Cytotoxicity, CD 158a Expression in NK Cells and Activated T Lymphocytes in Peripheral Blood of Women with IVF Failures. American Journal of Reproductive Immunology; 64:58-67, 2010. 5. CHOUDHURY SR, KNAPP L A. Human Reproductive failure I: Immunological factors. Human Reproduction Update 7 (2): 113-134; 2000. 6. GUERIN LR, PRINS JR, ROBERTSON AS. Regulatory T – cells and immune tolerance in pregnancy new target for infertility treatment? Human Reproduction Update; 15 (5): 517- 535; 2009. 7. KALU E, BHASKARAN S, THUM MY, VISHWANATHA R, CROUCHER C, SHERRIFF E, FORD B, BANSAL AS. Serial Estimation of Th1:Th2 cytokines profile in Women undergoing In – Vitro fertilization – embryo transfer. American Journal of Reproductive Immunology; 59: 206 – 211; 2008. 8. KWAK-KIM JYH, CHUNG-BANG HS, NG SC, NTRIVALAS EI, MANGUBAT CP, BEAMAN KD, BEER AE, GILMAN-SACHS A. Increased T helper 1 cytokine responses by circulating T cells are present in women with multiple implantation failures after IVF. Human Reproduction 18 (4):767 – 773; .2003.

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9. MARGALIOTH EJ, BEN-CHETRIT A, GAL M, ELDAR-GEVA T. Mini Review – Developments in Reproductive Medicine. Investigation and treatment of repeated implantation failure following IVF-ET. Human Reproduction21 (12):3036 – 3043; 2006. 10. NG SC, GILMAN – SACHS A, THAKER P, BEAMAN KD, BEER AE, KWAK-KIM J. Expression of intracellular Th1 and Th2 cytokines in women with recurrent spontaneous abortion, implantation failures after IVF/ET or normal pregnancy. American Journal of Reproductive Immunology; 48: 77 – 86; 2002. 11. PORCU – BUISSON G, LAMBERT M, LYONNET L, LOUNDOU A, GAMERRE M, CAMOINJAU L, DIGNAT – GEORGE F, CAILLAT-ZUCMAN S, PAUL P. Soluble MHC Class I chainrelated molecule serum levels are predictive markers of implantation failure and successful term pregnancies following IVF. Human Reproduction; 22 (8): 2261 – 2266; 2007. 12. RAGHUPATHY R, MAKHSEED M, AZIZICH F, OMU A, GUPTA M, FARHAT R. Cytokine production by maternal lymphocytes during normal human pregnancy and in unexplained recurrent spontaneous abortion. Human Reproduction; 15 (3):713 – 718; 2000. 13. SAITO S, NAKASHIMA A, SHIMA T, ITO M. Th1/Th2/Th17 and regulatory T-cell paradigm in pregnancy. American Journal of Reproductive Immunology; 63: 601 – 610; 2010 14. VAN MOURIK MSM, MACKLON NS, HEIJNEN CJ. Embryonic implantation: cytokines, adhesion molecules, and immune cells in establishing an implantation environment. Journal of Leukocyte Biology; 85; 2009. 15. WEGENER S, SCHNURSTEIN K, HANSCH S, BOLZ M, BRIESE V, SUDIK R, WEGENER R, BUSECKE A, MÜLLER H. Immunotherapy with paternal lymphocytes for recurrent miscarriages and unsuccessful in vitro fertilization treatment. Transfus Med Hemother 33: 501 – 507; 2006. 16. WINGER EE, REED JL, ASHOUSH S, AHUJA S, EL-TOUKHY T, TARANISSI M. Treatment with adalimumab (Humira®) and intravenous immunoglobulin improves pregnancy rates in women undergoing IVF. American Journal of Reproductive Immunology; 61: 113 – 120; 2009. 17. YOKOO T, TAKAKUWA K, OOKI I, KIKUCHI A, TAMURA M, TANAKA K. Alteration of Th1 and Th2 cells by intracellular cytokine detection in patients with unexplained recurrent abortion before and after immunotherapy with husband’s mononuclear cells. Fertility and Sterility; 85 (5): 1452 – 1458; 2006.

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Robotic coelioscopy versus vaginal route for simple hysterectomy M. Carbonnel, S. Roy, H.T. N’guyen, H. Abbou, J.M. Ayoubi Service de Gynécologie Obstétrique, Hôpital Foch, Suresnes. Faculté de Médecine Paris Ouest, Paris, France

ABSTRACT This prospective study carried out from March 2010 to August 2011 has been designed to compare two techniques used for simple hysterectomy: vaginal hysterectomy (HV) and robot-assisted coelioscopic hysterectomy (RH). Thirty-four patients were included in the RH group, and 22 in that undergoing HV. Compared with the VH group, both anaesthesia and intervention durations were significantly longer in the RH group while the duration of hospital stay was shorter; blood loss and D1 and D2 pain assessed by visual analogue scale were also significantly reduced. No difference between groups was found 8 weeks post-surgery regarding complications, duration of work leave, return to normal life, and sexual life. Robotic coelioscopy in simple hysterectomy may provide some benefits over vaginal access. Randomized prospective studies and definition of specific indications are necessary, however, to confirm these results.

INTRODUCTION Laparoscopic hysterectomy is the easiest and the most frequently used technique for simple hysterectomy; but this procedure is also invasive and may have complications (1). Vaginal hysterectomy (VH) is less invasive and adequate in obese patients but it presents some difficulty in nulliparas or in patients with large uterus or adherences (1). Coelioscopy is less invasive and easier than the vaginal route in patients with adherences and nulliparas; in addition, compared with the vaginal or the coelio-assisted vaginal procedure, it causes less pain and reduces the length of postoperative hospital stay (1-3). Robotic hysterectomy (RH) is a novel technique that potentializes the benefits of coelioscopy. Considering the widespread use of the vaginal procedure in our country, we decided to perform a comparative evaluation of the two techniques. © 2012 Monduzzi Editoriale | Proceedings

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METHODS This was a single-centre prospective study comparing all vaginal and robot-assisted coelioscopic simple hysterectomies carried out from March 2010 to August 2011 in Foch Hospital (Suresnes, France). Population characteristics, durations of anaesthesia, surgical procedure and hospital stay, per- and postoperative complications, blood loss, and analgesic consumption were extracted from patients’ medical files. Immediately post-surgery, patients were given a questionnaire meant to record the intensity of pain using a visual analogue scale (VAS), and the time of colonic transit restoration. A questionnaire was also to be completed at Month 2 for the evaluation of the duration of work leave, return to normal activity, sexual life, satisfaction, complications, and mid-term pain.

RESULTS Fifty-six patients were included: 34 in the RH group and 22 in the VH group. Patients were comparable in terms of age, BMI, history of laparotomy, conserva-

Anaesthesia duration (min)

RH (=34) mean ± SD 208 ± 8.8

VH (=22) mean ± SD 114.5 ± 10.1

< 0,0001

Operative duration (min)

137.9 ± 7.9

73.2 ± 9.7

< 0,0001

Console management duration (min)

106 ± 7.2

Blood loss (ml)

44 ± 8.9

135.3 ± 30

< 0,01

Laparoconversion

0 (0%)

1 (4.5%)

NS

Transfusion

0 (0%)

1 (3CGR) (4.5%)

Total morphine consumption (mg)

9.4 ± 1.7

6.9 ± 1.5

0,3

Hospital stay duration (days)

3.5 ± 0.2

4.3 ± 0.2

0,01

VAS D0

4 ± 0.4

4.7 ± 0.6

0.3

VAS D1

2.7 ± 0.4

4.5 ± 0.5

0.002

VAS D2

1.9 ± 0.4

3.5 ± 0.5

0.007

Tab. 1 - Results.

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p


tive and non-conservative hysterectomy, and uterine weight. Indications were also comparable (fibroma, adhenomyosis) except for Benjamin’s syndromes (14RH / 1 VH). The number of lifetime pregnancies was higher in the VH group (2.9 ± 0.7 vs. 1.7 ± 0.4). Compared with data of VH group, the results displayed in Table I show longer operative and anaesthesia durations, reduced blood loss and pain at D1 and D2, and a shorter hospital stay in the RH group. No difference between groups was observed in terms of complications: 1 case of pain related to arm compression, and 1 of digestive injury in the RH group; 2 haemorrhages in the VH group. Duration of work leave, return to normal activity, satisfaction and sexuality were not different at Month 2. More pain was reported however in the group having undergone VH.

CONCLUSION Benefits of RH versus coelioscopy have been described previously (4,5), especially regarding blood loss, complications and duration of hospital stay. But few studies have compared this technique to the vaginal route (6-8). Our observations are in accordance with their results (reduced blood loss, shorter hospital stay, less complications). Our study is the first with an evaluation of postoperative pain; this parameter appears to be improved by the robotic technique. Nevertheless, the use of such surgical procedure remains restricted due to its related cost and duration of installation

REFERENCES 1. Nieboer TE, Johnson N, Lethaby A, Tavender E, Curr E, Garry R, van Voorst S, Mol BW, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev, Jul 8(3), 2009. 2. Ghezzi F, Uccella S, Cromi A, Siesto G, Serati M, Bogani G, Bolis P. Postoperative pain after laparoscopic and vaginal hysterectomy for benign gynecologic disease: a randomized trial. Am J Obstet Gynecol, Aug; 203(2):118.e1-8, 2010. 3. Gendy R, Walsh CA, Walsh SR, Karantanis E. Vaginal hysterectomy versus total laparoscopic hysterectomy for benign disease: a metaanalysis of randomized controlled trials. Am J Obstet Gynecol, May; 204(5):388.e1-8, 2011. 4. Payne TN, Dauterive FR. A comparison of total laparoscopic hysterectomy to robotically assisted hysterectomy: surgical outcomes in a community practice. J Minim Invasive Gynecol,15(3):286-91, 2008. 5. Boggess JF, Gehrig PA, Cantrell L, Shafer A, Mendivil A, Rossi E, Hanna R. Perioperative outcomes of robotically assisted hysterectomy for benign cases with complex pathology. Obstet Gynecol, 114(3):585-93, 2009. 6. Matthews CA, Reid N, Ramakrishnan V, Hull K, Cohen S.Evaluation of the introduction of robotic technology on route of hysterectomy and complications in the first year of use. Am J Obstet Gynecol, 203(5):499.e1-5. 2010. 7. Landeen LB, Bell MC, Hubert HB, Bennis LY, Knutsen-Larson SS, Seshadri-Kreaden U. Clinical and cost comparisons for hysterectomy via abdominal, standard laparoscopic, vaginal and robotassisted approaches.S D Med, 64(6):197-9, 201, 203 passim. 2011-10-17. 8. Wright KN, Jonsdottir GM, Jorgensen S, Einarsson JI. A Comparison of Abdominal, Laparoscopic, Vaginal, and Robotic Hysterectomies: Surgical Outcomes and Operative Cost in a Single Institution Journal of Minimally Invasive Gynecology, Volume 17, Issue 6, Supplement, Page S23, 2010,

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A novel approach for treating infertile patients with diminished ovarian reserve (DOR) G. Carlomagno1, S. Roseff2, S. Harter, RN2, S. Murphy Cohen, ARNP2, V. Unfer1 Palm Beach Center for Reproductive Medicine, Florida USA; 1AGUNCO Obstetrics and Gynecology Center, Rome Italy 2

SUMMARY Ovarian reserve (OR) decreases throughout life and has a physiological limit around the age of 50. The diagnosis of diminished ovarian reserve (DOR) is based on menstrual cycle day 2-4 follicle-stimulating hormone (FSH) and estradiol levels, antral follicle counts, and anti-mullerian hormone (AMH) titers. In particular, FSH levels increase and AMH levels decrease with age, providing diagnostic criteria across the reproductive spectrum. In the clinical IVF practice, it is crucial to improve stimulation protocols in order to obtain higher quality oocytes and embryos, and this is of the utmost importance especially for DOR patients. In the present study, we aimed to evaluate the effect of two well-known compounds, myo-inositol and melatonin, on serum AMH levels. Indeed, several studies have suggested that AMH is a predictor of IVF outcome. 11 patients (35.40± 5.1 years old, mean±SD) diagnosed with DOR were selected and treated with a combination of 2g of myoinositol and 3mg of melatonin (Inofolic®Plus, Lo.Li.pharma, Roma; Italy) once daily for one month. After treatment, patients showed a significant increase in AMH levels. AMH levels increased from 0.58±0.16 ng/ml at baseline to 1.24±0.25ng/ml (p12% presente more frequently pregnancy losses (p< 0.0001) than those with ≤12% NK cells. Multivariate analysis disclosed that NK is an independent risk factor for RGF. A cut-off of 12% baseline NK defines a subgroup of RGF women of putative immune alterations.

INTRODUCTION Spontaneous pregnancy loss is a surprisingly common occurrence. Whereas approximately 15% of all clinically recognized pregnancies result in spontaneous loss, there are many more pregnancies that fail prior to being clinically recognized. Only 30% of all conceptions result in a live birth (1).This clinical problem affecting up to 10% of couples in occidental countries. Recurrent spontaneous abortion (RSA), © 2012 Monduzzi Editoriale | Proceedings

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defined by three or more consecutive spontaneous abortions, which has numerous causes and clinical presentations and may occur during any stage of pregnancy, have been frequently explained with an immunological pathomechanism (2). At present, there exist a small number of etiologies for recurrent gestational failure (RGF). These include parental chromosomal abnormalities, anatomic factors, autoimmune diseases, endocrine disorders, infections, etc. After evaluation for these causes, approximately half of all cases remain unexplained (1). There are two known independent risk factors for RGF: the age of the mother and the number of previous pregnancy losses (3). However, there is no surrogate marker that could help to define those women at risk of pregnancy loss in the next gestation. Thus, the search of biological predictive markers is critical. Natural killer (NK) cells constitute the predominant leukocyte population in uterine mucosa from embryo implantation and considerable effort has been made to investigate the phenotype and functions of NK cells at implantation and during pregnancy. Dysregulation of NK cells has been associated with reproductive pathologies, such as recurrent miscarriages (RM), infertility, and pre-eclampsia. In women with these conditions, NK cell parameters, either in absolute numbers or in proportion (%), subsets, functional activity such as cytotoxicity or secretory cytokine profile, receptor or gene expression, have been extensively investigated in peripheral, endometrial or decidual NK cells (4).

MATERIALS AND METHODS Study population Women with a history of repeated implantation failure (IF) (n=110) and recurrent miscarriage (RM) (n=84) who were consecutively studied at the Clinical Immunology Unit at Hospital General Universitario Gregorio Marañón and Clinica Tambre comprise the study group. Normal fertile women (n=55) here included as controls (Table 1). All medical charts were reviewed prospectively by the same person on the

Age (years)

Control Group

Study Group

(n=55)

RM (n=84) RIF (n=110)

P value*

30.14±6.2

35.92±3.62

37.60±3.36

12% than the control group. Using ROC curves, statistically chosen cut-off value for NK cells in our population was 12% of total lymphocytes, with sensitivity for the occurrence of pregnancy loss of 34%, and specificity: 76%. Using this level, a greater numbers of subjects with NK>12% presented pregnancy loss (p12% had 2.7-fold (hazard ratio, HR 95% CI: 1.38-5.48) higher risk for having pregnancy loss. We show for the first time that %NK is an independent risk factor for RGF. We concluded that a cut-off of 12% baseline NK cells defines a subgroup of RGF

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Fig. 1 - Proportion of NK cells at baseline in women with recurrent gestational failure (RGF) and control group. Statistical analysis was made by Student´s t-Test between the study and the control groups. Each box plot represents the median (thick band) and the 25th and 75th centiles. The error bars represent the smallest and largest values that are not outliers. P < 0.05 was considered to be statistically significant.

women with putative immune alterations related to pregnancy loss. We show for the first time that %NK is an independent risk factor for RGF. Putative immune alterations related to pregnancy loss. Finally we propose that NK cells could be used as surrogate marker of recurrent gestational failure.

Acknowledgements We wish to thank the healthy volunteers who participated in this study. This work was funded by grants from the Spanish Ministry of Health, Social Policy and Equality (grant EC10-026) and from the Fundación Tambre.

Disclosures The authors declare that they have no competing financial interest.

REFERENCES 1. FORD HB, SCHUST DJ. Recurrent pregnancy loss: etiology, diagnosis, and therapy. Rev Obstet Gynecol. 2(2):76-83; 2009. 2. DE CAROLIS C, PERRICONE C, PERRICONE R. NK cells, autoantibodies, and immunologic infertility: a complex interplay. Clin Rev Allergy Immunol. 39(3):166-75; 2010.

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3. Professor L REGAN, Miss M BACKOS, and DR R RAI. The Investigation and Treatment of Couples with Recurrent First-trimester and Second-trimester Miscarriage. Green-top Guideline No. 17Royal College of Obstetricians and Gynaecologists. April 2011. 4. KWAK-KIM J, GILMAN-SACHS A. Clinical implication of natural killer cells and reproduction. Am J Reprod Immunol. 59(5):388-400; 2008.

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The effect of bromocriptine and cyclodynon on the clinical symptoms and prolactin levels in women of reproductive age with hyperprolactinemia L. Suturina1,2, L. Kolesnikova1, L. Popova2 Scientific Centre of the Family Health and Human Reproduction Problems, Siberian Branch, Russian Academy of Medical Sciences, Irkutsk, Russia; 2Irkutsk State Medical Academy of Postgraduate Education, Irkutsk, Russia 1

SUMMARY This article presents the findings of a three month prospective open-label controlled trial comparing the efficacy of bromocriptine (2,5 mg twice daily) (group 1, n=24) with the cyclodynon (40 mg 1 once daily) (group 2, n=24) efficacy in 48 women of reproductive age who have non-neoplastic hyperprolactinemia. As a result of treatment, in both groups of women there was significant decrease in serum prolactin concentration compared with the baseline values. In addition to this a comparable decrease in the frequency of psycho-emotional and menstrual disorders was observed. In the cyclodynon group we registered higher efficacy in the management of mastalgia and less frequent adverse effects.

INTRODUCTION Hyperprolactinemia is one of the increasingly common problems of gynecological endocrinology. It is found in 15 - 30% of women with secondary amenorrhea and oligomenorrhea. Besides, hyperprolactinaemia is present in 30-70% of female patients with galactorrhea and/or infertility. Dopamine receptor agonists (eg, bromocriptine, quinagolide, cabergoline) are the main agents used to manage pathological hyperprolactinemia, and their efficacy has been thoroughly studied. For example, prolactin decreasing is achieved in 60-100% of female patients used dopamine agonists, and normalization of menstrual cycles - in 70-100%. Ovulatory function was restored in 52-80% of hyperprolactinemic women, followed by pregnancy in 80-91% of patients. On the other hand, use of one of the first genera© 2012 Monduzzi Editoriale | Proceedings

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tion dopamine agonists—bromocriptine, a semisynthetic ergot alkaloid derivative, which is the "gold standard" of treatment,-- is also associated with a series of side effects (up to 65%) that are the reason for discontinuation of treatment in 5-10% of female patients [3,5,6]. Data from previous studies show that, as a rule, there is a lower incidence of adverse reactions in the use of phytotherapeutics, than in the use of pharmaceuticals. It is known that the extract of Vitex agnus-castus, also called Vitex, Chasteberry, or Monk's Pepper, has dopaminergic properties. Clinical efficacy of a Vitex agnus castus-based phytotherapeutic agent (Cyclodynon®) in women with non-neoplastic hyperprolactinemia, premenstrual syndrome, and mastopathy has been shown in a number of uncontrolled trials [1, 4]. However, there is insufficient data on the comparative effectiveness of phytotherapeutical agents and synthetic dopamine agonists in women with hyperprolactinemia [2]. The objective of the study was to compare the effects of bromocriptine and Vitex agnus castus-based phytotherapeutic agent (Cyclodynon®) on prolactin secretion and clinical symptoms in women of reproductive age with non-neoplastic hyperprolactinemia.

MATERIAL AND METHODS The study involved a total of 48 female patients of reproductive age with nonneoplastic hyperprolactinemia. The exclusion criteria were as follows: a pituitary micro and macroadenoma, thyroid dysfunction, pregnancy, lactation, obesity and use of medicines that effect prolactin levels within three months prior to this trial. To achieve the objective women were assigned to two treatment groups: one group received Bromocriptine (Gedeon Richter, Hungary) (2.5 mg twice daily) (group 1, n=24), the other group - Cyclodynon (Bionorica AG, Germany) (40 mg once daily) (group 2, n = 24) for 3 months. The patients of both groups were comparable in the incidence and the structure of the causes of primary and secondary infertility, menstrual disorders, galactorrhea, age (26.6 ± 3.7 years in group 1 and 26.3 ± 2.9 years in Group 2, р > 0.05), body mass index (21.7 ± 3.0 and 22.6 ± 3.9 kg/mg, respectively, р > 0.05) and the severity of hyperprolactinemia (782 ± 55 and 600 ± 55 mU/ml, respectively, р > 0.05, while the reference range was 72—480 mU/ml). A questionnaire survey, analysis of medical documentation, and overall clinical and gynecological examination of female patients were carried out in both groups. Instrumental methods included pelvic ultrasound scan performed by the Aloka-650 ultrasound scanner, and thyroid and breast ultrasound scans. All women underwent either computed tomography or magnetic resonance imaging of the pituitary gland and nearby area. Blood samples for hormonal testing were collected in the morning, between 8-9 a.m., on the 5- 9th days of the menstrual cycle or if there was a delay of menstruation, at any time. The concentrations of PRL (prolactin) were measured by

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radioimmunoassay using a Dias radioimmunoassay kit (Russia) and an ImmunoTest analyser. Clinical symptoms and signs were assessed and hormonal testing was performed before therapy and at 3 months after therapy initiation. The significance of the difference was measured using the nonparametric Mann– Whitney test for the quantitative parameters in the independent groups, the Wilcoxon test was used for linked samples and χ2 test or Fisher exact test for qualitative parameters. The level of significant differences was evaluated at 5%. This study was approved by the Ethical Committees of the Scientific Centre of the Family Health and Human Reproduction Problems and Irkutsk State Medical Academy of Postgraduate Education (Irkutsk, Russia).

RESULTS The study revealed that at 3 months after initiation of bromocriptine and Cyclodynon® therapy there was a significant decrease (all р0.05

After treatment

217±32*

303±29**

>0.05

*p=0.0001 (for group 1, before and after treatment ) **p=0.0029 (for group 2, before and after treatment ) Tab. 2 - Dynamics of serum prolactin concentration (M±m) of female patients during therapy.

the study confirm a hypothesis about the adequate prolactin-inhibiting activity of Cyclodynon®, a phytotherapeutic agent, comparable with the effect of ergocriptine, in women with moderate non-neoplastic hyperprolactinemia.

CONCLUSIONS A significant decrease in serum prolactin levels after treatment compared with baseline values, as well as a decrease in the incidence of psycho-emotional disorders and menstrual disorders in women with non-neoplastic hyperprolactinemia is observed both during the use of the "gold standard" of treatment -- bromocriptine -- at a dose of 2.5 mg twice daily for 3 months and during the therapy with a phytotherapeutic drug based on the extract of Vitex agnus castus-- Cyclodynon® – administered at a dose of 40 mg once daily for 3 months. The study revealed that in the group of patients who received Cyclodynon® the incidence of side effects was lower and the effectiveness of the management of mastalgia was higher.

REFERENCES 1. He Z, Chen R, Zhou Y et al. Treatment for premenstrual syndrome with Vitex agnus castus: A prospective, randomized, multi-center placebo controlled study in China. Maturitas. 2009 63(1): 99103. 2. Kiligdag E B, Tarim E, Bagis T et al. Fructus agni casti and bromocriptine for treatment of hyperprolactinemia and mastalgia. Int J Gynaecol Obstet. 2004 85(3): 292-293. 3. Melmed S, Casanueva FF, Hoffman AR et al. Diagnosis and treatment of hyperprolactinemia: An Endocrine Society Clinical Practice Guideline. J. Clin. Endocrinol. Metab. 2011 96: 273-288. 4. Milewicz A, Gejdel E, Sworen H et al. Vitex agnus castus extract in the treatment of luteal phase defects due to latent hyperprolactinemia. Results of a randomized placebo-controlled double-blind study. Arzneimittelforschung. 1993 43(7):752-756. 5. Pascal-Vigneron V, Weryha G, Bosc M, Leclere J Hyperprolactinemic amenorrhea: treatment with cabergoline versus bromocriptine. Results of a national multicenter randomized double-blind study. Presse Med 1995 24:753–757. 6. Webster J, Piscitelli G, Polli A et al. A comparison of cabergoline and bromocriptine in the treatment of hyperprolactinemic amenorrhea. Cabergoline Comparative Study Group. N Engl J Med 1994 331:904–909.

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Sperm recovery in patients with non-mosaic Klinefelter syndrome: a comparative study H. Terada, T. Sugiyama, S. Mugiya, S. Ozono Department of Urology, Hamamatsu University School of Medicine, Shizuoka, Japan

SUMMARY We investigated factors that predict successful microdissection sperm extraction (MD-TESE) in men with non-mosaic Klinefelter syndrome and the influence of preoperative hormonal therapy on the sperm retrieval rate. From June 2008 to October 2010, 78 MD-TESE attempts were made in 16 patients. Patients with serum follicle stimulating hormone (FSH) and luteinizing hormone (LH) levels 300 ng/dl received hormonal therapy with human chronic gonadotropin. The success rate for retrieval was 25% (4/16 patients) using MD-TESE, and this procedure followed by intracytoplasmic sperm injection led to one birth. Age, hormonal therapy, and LH, FSH and testosterone levels were not predictors of sperm retrieval. We conclude that MD-TESE is an effective technique in men with non-mosaic Klinefelter syndrome and that these men can father a child, despite concerns regarding genetic risks.

KEY WORDS Chromosomal anomaly, Klinefelter syndrome, TESE-ICSI

INTRODUCTION Klinefelter syndrome is a common genetic condition that was first described in 1942.1. Affected non-mosaic men are azoospermic and have been labeled as infertile. Men with Klinefelter syndrome account for 3% of infertile men and 11% of men with azoospermia and one in 500-1000 male newborns 1,2. The finding that men with non-mosaic Klinefelter syndrome have potential fertility has been aided by developments in assisted reproduction techniques. We investigated the preopera© 2012 Monduzzi Editoriale | Proceedings

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tive factors that predict successful microdissection sperm extraction (MD-TESE) in men with non-mosaic Klinefelter syndrome and the influence of hormonal therapy on the sperm retrieval rate. Herein, we present our experience in 16 patients with Klinefelter syndrome who underwent TESE procedures.

MATERIALS AND METHODS From June 2008 to October 2010, a total of 78 MD-TESE attempts were made in 16 patients with non-mosaic Klinefelter syndrome. Patients with serum follicle stimulating hormone (FSH) and luteinizing hormone (LH) levels 300 ng/dl received hormonal therapy with human chronic gonadotropin (hCG). Treatment with hCG was initiated at a dose of 3000 IU once a week for eight weeks and titrated upward until a response of serum testosterone before TESE. The influences of hormonal therapy and age on sperm retrieval were analyzed.

RESULTS The overall success rate for retrieval was 25% (4/16 patients) using MD-TESE. Combined with ICSI, this led to the birth of one child. Attempts at ICSI are continuing in the 3 other cases. Hormonal therapy using hCG did not affect sperm retrieval rates, with normal baseline testosterone ³250 ng/dl. The 4 patients with successful sperm retrieval were 26-42 years old and the 12 patients in whom retrieval was unsuccessful were 25-42 years old. Therefore, age had no effect on the success rate. Clinical parameters such as LH, FSH and testosterone levels were also not predictive of the success of sperm retrieval in patients with non-mosaic Klinefelter syndrome.

CONCLUSIONS Klinefelter syndrome have hypergonadotropic hypogonadism with a sex-chromosome anomaly. Affected non-mosaic men are azoospermic and have been labeled as infertile. The genotypic abnormality results from a meiotic nondisjunction event that results in a 47,XXY genotype in up to 80% of non-mosaic cases; however, up to 3% of men with this syndrome are mosaic 46,XX/47,XXY.4 The extra chromosome is inherited from the mother or father at an approximately equal rate.5 The phenotypic appearance of a male with Klinefelter syndrome varies widely, but enlarged breasts, sparse facial and body hair, and small, firm testes are common. Mosaic patients occasionally have sperm in their ejaculate,6 but men with nonmosaic Klinefelter syndrome have been considered to be sterile.1 The first pregnancy using surgical sperm retrieval in a patient with non-mosaic Klinefelter syndrome was published in 1996 7 and the first birth using ICSI was reported in 1997 8. Physical features, biochemistry (serum testosterone, FSH, LH),

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and testicular volume have been investigated as factors associated with the success rate of surgical sperm retrieval. A study in 20 patients found that a significantly larger testicular volume and the serum testosterone level were markers of success 7 . However, in the current study, serum testosterone levels and age did not differ between patients with and without successful sperm retrieval. Theoretically, the potential for sperm retrieval should decrease with age as hyalinization of seminiferous tubules progresses. Thus, the concern for maintenance of fertility in young men with Klinefelter syndrome must be balanced with the possible psychosocial benefits of testosterone replacement through early androgen replacement therapy. We conclude that MD-TESE for men with non-mosaic Klinefelter syndrome followed by ICSI is a viable assisted reproduction technique, and does not depend on the age of the man.

REFERENCES 1. FORESTA C, GALEAZZI C, BETTELLA A, MARIN P, ROSSATO M, GROLLA A, FERLIN A. Analysis of meiosis in intratesticular germ cells from subjects affected by classic Klinefelter’s syndrome. J Clin Endocrinol Metab 84, 3807-3810, 1999. 2. KLINEFELTER JR HF, REIFENSTEIN JR EC, ALBRIGHT F. Syndrome characterized by gynecomastia, aspermatogenesis without A-Leydigism and increased excretion of follicle stimulating hormone. J Clin Endocrinol Metab 2, 615-627, 1942. 3. FRIEDLER S, RAZIEL A, STRASSBURGER D, SCHACHTER M, BERN O, RON-EL R. Outcome of ICSI using fresh and cryopreserved-thawed testicular spermatozoa in patients with nonmosaic Klinefelter’s syndrome. Hum Reprod 16, 2616-2620, 2001. 4. HARARI O, BOURNE H, BAKER G, GRONOW M, JOHNSTON I. High fertilization rate with intracytoplasmic sperm injection in mosaic Klinefelter’s syndrome. Fertil Steril 63, 182-184, 1995. 5. THOMAS NS, HASSOLD TJ. Aberrant recombination and the origin of Klinefelter syndrome. Hum Reprod Update 9, 309-317, 2003. 6. COZZI J, CHEVRET E, ROUSSEAUX S, PELLETIER R, BENITZ V, JALBERT H, SELE B. Achievement of meiosis in XXY germ cells: study of 543 sperm karyotypes from an XY/XXY mosaic patient. Hum Genet 93, 32-34, 1994. 7. STAESSEN C, COONEN E, VAN ASSCHE E, TOURNAYE H, JORIS H, DEVROEY P, VAN STEIRTEGHEM A, LIEBAERS I. Preimplantaion diagnosis for X and Y normality in embryos from three Klinefelter's patients. Hum Reprod 11, 1650-1653, 1996. 8. BOURNE H, STERN K, CLARKE G, PERTILE M, SPEIRS A, BAKER HW Delivery of normal twins following the intracytoplasmic injection of spermatozoa from a patient with 47,XXY Klinefelter’s syndrome. Hum Reprod 12, 2447-2450, 1997.

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Co-occurrence of polycystic ovary syndrome with depression and anxiety symptoms Xin Li1, Fulong Wang2, Johnna Wu2, Fang Fang1,Yi Jin1 Obstetrics and Gynecology Hospital of Medical Center, Fudan University, Shanghai, China; 2Institute for Nutritional Sciences, Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, Graduate School of the Chinese Academy of Sciences, Shanghai, China

1

SUMMARY Objective:We studied the psychological characteristics in PCOS women and whether its endocrinometabolic profiles are associated with depressive and anxiety symptoms. Methods:100 PCOS aged 19-40 years were recruited in and performed anthropometric measurements,endocrinometabolic profiles,self-Rating Depression Scale(SDS) and self-Rating Anxiety Scale(SAS). Results:The SDS and the SAS scores of the PCOS women were both significantly higher than norm. 27% PCOS women were ascertained depressive symptoms and 15% were ascertained anxiety symptoms. 14% PCOS women had both depression and anxiety symptoms. However,no relationship was found between the SDS or SAS scores and body mass index, HOMA-IR and free androgen index (p3800g was excluded from the study. The outcomes were analysed by t-test and the risk scale was expressed through Odds Ratio, with confidence interval 95%. The study was done in the Clinic of Obstetrics and Gynaecology of the University Clinical Centre of Kosovo. It included 801 pregnancies with breech presentation delivered between the year 2008 and 2009. The cases with congenital anomalies, multiple pregnancies, foetuses >3800g was excluded from the study. All patients who met the selection criteria (n=801) were divided in to groups: pregnancy who delivered by cesarean section (study group, n=415) and pregnancy who delivered by vaginal delivery (control group, n=388). The study was designed as retrospective study for comparison of neonatal complications between study and control group. Obstetrics files were reviewed and data from breech pregnancies was collected. Depending on the mode of delivery, the following parameters were recorded: gestational age, average APGAR-score at first and fifth minutes, birth weight, and parity. From the neonatal parameters we analyzed: intraventricular hemorrhage (IVH), perinatal asphyxia, early neonatal infection, sepsis, respiratory distress syndrome (RDS), the requirement for continuous positive airway pressure (CPAP), birth trauma and neonatal death. Gestational age was determined from the first day of last menstruation and confirmed by an expert of neonatology after birth. Apgar score was evaluated and care given by an expert neonatologist. Perinatal asphyxia was determined based on the APGAR-score in 5 min., gas-analysis of the newborn, neurological signs - convulsions in the first 24 hours, multi-systemic dysfunction of vital organs. Early neonatal infection was diagnosed based on clinical criteria and laboratory tests (blood analysis, C-reactive protein - CRP, positive blood culture) in first 3 days of life. Sepsis was diagnosed based on clinical criteria and laboratory confirmation. IVH 130


was diagnosed by cranial ultrasound and, in particular, with lumbal puncture. RDS was determined as presence of characteristic radiographic finding and clinical criteria (cyanosis, tachypnea, thoracic retraction and roars). Analysis was performed by using statistical package SPSS-Sigma Stat 2.03 version software. The neonatal outcomes were analysed by t-test of proportions while the risk scale was expressed through Odds Ratio, with confidence interval 95% (95% CI). Statistical significance was considered if the value of the factor alpha ≤ 0.05.

RESULTS AND CONCLUSIONS In breech presentation for fetuses with birth weight up to 3800g planned cesarean section significantly reduced the risk of IVH (OR 95% CI [11.7-46.8], p