266. Hum Reprod Update. 2008 Jul-Aug;14(4):393. doi: 10.1093/humupd/dmn020. Epub 2008 Jun 2. Pre-hCG elevation of plasma progesterone: good, bad or otherwise. de Ziegler D, Bijaoui G, Chapron C.
OBJECTIVE: A recent meta-analysis covering 21 studies shows that, when taken in isolation, the basal FSH level (commonly used to assess the ovarian reserve) is a poor indicator of successful in vitro fertilization (IVF) outcome. PATIENTS AND METHODS: We present a personal series of 3592 IVF procedures. Analysis of the results compares the age and basal FSH values, based on a statistical analysis that is essentially descriptive. RESULTS: When FSH levels are high, the pregnancy rate remains acceptable in young women (<38 years); it drops sharply, however, in older women. In each age group, the rate of spontaneous miscarriage does not increase according to FSH level. The pregnancy rate is better in young women with high FSH levels than in older women with normal FSH levels. DISCUSSION AND CONCLUSION: The results presented agree with the studies published in the literature, which suggest that FSH is a prognostic factor for the quantity of oocytes obtained (ovarian reserve) while age defines the quality of the oocyte: it is this difference in quantity, and not in quality, which makes the difference between cases of poor and normal response to IVF. In young women at least, a high FSH level is not a contra-indication in principle for IVF.
Endometriosis is a frequent pathology for which the dominant signs and symptoms are pelvic pain and infertility. The physiopathology remains the subject of controversy. Four physiopathological hypotheses have been put forward: regurgitation, metaplasia, induction and (vascular and lymphatic) embolization. The anatomical distribution of endometriotic lesions would appear to be fundamental for a better understanding of Sampson's menstrual regurgitation theory of endometriosis. Analysis of the results in the literature and comparison with our experience clearly shows that the distribution of endometriotic lesions is asymmetrical in several respects. Abdominopelvic anatomy and peritoneal fluid flow can explain this asymmetrical distribution of endometriotic lesions in the great majority of cases. These observations are a very strong argument in favour of the crucial role played by tubal regurgitation and the peritoneal fluid in the physiopathology of endometriosis. The similarity in anatomical distribution of endometriomas, superficial and deeply invasive endometriotic lesions would tend to indicate a common origin for these different types of lesions.
BACKGROUND: Matrix metalloproteinases (MMPs) may contribute to endometriosis. We tested whether eight functional polymorphisms of these genes could modify the risk of endometriosis. METHODS: In this case-control study, 227 endometriosis and 241 controls were genotyped for MMP1 -1607 1G/2G, MMP2 -1575 G/A (MMP2.1), -1306 C/T (MMP2.2), MMP3 -1612 5A/6A, MMP7 -153 C/T (MMP7.1), -181 A/G (MMP7.2), MMP12 -82 A/G and MMP13-77 A/G. Association between MMP genotypes and superficial (SUP), deep infiltrating (DIE) and endometriomas (OMA) was tested for each polymorphism separately, using unconditional logistic regression and then for combined genotypes, using the combination test. RESULTS: When considering all cases, MMP2 polymorphisms were found to be significant, mainly due to DIE (P = 0.023). A small difference between SUP and controls was found for MMP7.2 (P = 0.032) and MMP12 (P = 0.035), in the absence of correction for multiple testing. Using the combination test, the best association when comparing SUP with controls was obtained for MMP12-MMP13 (P = 0.004) for the combined genotype A/G-A/A (odds ratio = 27.60, 95% confidence interval: 2.80-272.40). CONCLUSIONS: These data show a potential role for MMP12 -82 A/G and MMP13 -77 A/G combined polymorphisms in superficial endometriosis. As no association was found with deep infiltrating endometriosis, this combination of polymorphisms might protect from a more in-depth penetration of tissues.
OBJECTIVE: To analyze the lymph node involvement by endometriotic foci in rectosigmoid endometriosis and to correlate it with clinical and histological parameters including the presence of lymphovascular invasions, which could explain this lymph node involvement. DESIGN: A prospective study of 26 consecutive cases of rectosigmoid endometriosis between January 2005 and January 2007. SETTING: A multidisciplinary study including clinical and pathological data. PATIENT(S): Twenty-six patients with symptomatic rectosigmoid endometriosis. INTERVENTION(S): Laparoscopic surgery with pathological analysis of each specimen. MAIN OUTCOME MEASURE(S): Involvement of lymph nodes by endometriotic foci was correlated with the size and the wall layers affected by endometriotic lesions, the number of lymph nodes retrieved, and the presence of lymphovascular invasions demonstrated by D2-40, a specific antibody to lymphatic vessels. RESULT(S): Lymph node involvement by endometriosis was observed in 11 of the 26 patients (42.3%) and correlated with the size of the lesions, the number of lymph nodes retrieved, and the presence of lymphovascular invasions, which were observed in 36.3% of cases. CONCLUSION(S): Our data confirm that lymph node involvement by endometriotic foci is a frequent event in rectosigmoid endometriosis and may result at least partially from a lymphatic spread of the disease.
A 25-year-old woman with unoperated deep endometriosis of the uterosacral ligament suddenly experienced severe abdominal pain, hematuria, hemoperitoneum, and intrauterine death at 31 weeks' gestation. Surgical intervention revealed active hemorrhage arising from right uterine artery and interruption of the ureter in an area of previously documented but not treated endometriotic nodule. Histologic examination confirmed presence of decidualized endometriosis at this site. Urohemoperitoneum during pregnancy is a rare but possible complication in women carrying deep peritoneal endometriotic nodules.
Müllerianosis may be defined as an organoid structure of embryonic origin; a choristoma composed of müllerian rests--normal endometrium, normal endosalpinx, and normal endocervix--singly or in combination, incorporated within other normal organs during organogenesis. A choristoma is a mass of histologically normal tissue that is -'not normally found in the organ or structure in which it is located-' (Choristoma, 2006). Müllerian choristomas are a subset of non-müllerian choristomas found throughout the body. Histologically, endometrial-müllerianosis and endometriosis are both composed of endometrial glands and stroma, but there the similarity ends. Their pathogenesis is different. Sampson faced the same difficulty with pathogenesis and nomenclature when he wrote: -'The nomenclature of misplaced endometrial or müllerian lesions is a difficult one to decide upon.-' -'The term müllerian would be inclusive and correct, but unfortunately it suggests an embryonic origin.-' Sampson then divided -'misplaced endometrial or müllerian tissue-' into -'four or possibly five groups, according to the manner in which this tissue reached its ectopic location-' (Sampson, 1925). Sampson's classification of heterotopic or misplaced endometrial tissue is based on pathogenesis: 1) -'direct or primary endometriosis-' [adenomyosis]; -'a similar condition occurs in the wall of the tube from its invasion by the tubal mucosa-' [endosalpingiosis]; 2) -'peritoneal or implantation endometriosis;-' 3) -'transplantation endometriosis;-' 4) -'metastatic endometriosis;-' and 5) -'developmentally misplaced endometrial tissue. (I admit the possibility of such a condition, but have never been able to appreciate it.)-' (Sampson, 1925). It is precisely this condition -'developmentally misplaced endometrial tissue,-' [müllerianosis] that is the subject of this review.
The diethylstilbestrol (DES) is a synthetic estrogen which was prescribed from 1941 onwards for the prevention of miscarriage. As well as a possible risk of cancer, another side effect of this treatment was the possible abnormality of the genitalia in the female issue of the prescribed user. Apart from possibly having a hypoplasic uterus, the patient is also prone, in the case where she has an undersized uterus, to having a much narrower than normal cavity. Consequently, there is a tendency for an excess of muscle tissue on the uterus walls. This can be observed on a RMN. The most significant characteristics of this abnormality are: constriction rings around the proximal uterine segment, a T shaped uterus, uterus with an arched base. The idea of the plastic enlargement operation (metroplasty) is to widen the cavity by making careful incisions of the excess muscle tissue located on the uterus wall. The objective of this is to obtain a triangular shaped cavity taking care though to weaken the walls themselves. 61 patients were treated. We observed 37 pregnancies after 16 months with 30 ongoing pregnancies. Generally, the anatomic results are excellent but it is difficult to measure the functional results of the success rate in future pregnancies. The reason for this is the enlarging of the cavity alone does not guarantee successful fertility. There are other problems to take into account e.g. implantation, miscarriage and premature labor. There are risks with this operation, such as placenta percreta, a possible rupture of the uterus, though this can happen at any time with DES patients. This operation can only be recommended once a thorough examination of the patient has been made.
We show that cytosolic aspartate aminotransferase (cAspAT) is involved in adipocyte glyceroneogenesis, a regulated pathway that controls fatty acid homeostasis by promoting glycerol 3-phosphate formation for fatty acid re-esterification during fasting. cAspAT activity, as well as the incorporation of [(14)C]aspartate into the neutral lipid fraction of 3T3-F442A adipocytes was stimulated by the thiazolidinedione (TZD) rosiglitazone. Conversely, the ratio of fatty acid to glycerol released into the medium decreased. Regulation of cAspAT gene expression was specific to differentiated adipocytes and did not require any peroxisome proliferator-activated receptor gamma (PPARgamma)/retinoid X receptor-alpha direct binding. Nevertheless, PPARgamma is indirectly necessary for both cAspAT basal expression and TZD responsiveness because they are, respectively, diminished and abolished by ectopic overexpression of a dominant negative PPARgamma. The cAspAT TZD-responsive site was restricted to a single AGGACA hexanucleotide located at -381 to -376 bp whose mutation impaired the specific RORalpha binding. RORalpha ectopic expression activated the cAspAT gene transcription in absence of rosiglitazone, and its protein amount in nuclear extracts is 1.8-fold increased by rosiglitazone treatment of adipocytes. Finally, the amounts of RORalpha and cAspAT mRNAs were similarly increased by TZD treatment of human adipose tissue explants, confirming coordinated regulation. Our data identify cAspAT as a new member of glyceroneogenesis, transcriptionally regulated by TZD via the control of RORalpha expression by PPARgamma in adipocytes.
The aim of the study was to determine Monarc (American Medical Systems) sling position after surgical treatment of stress urinary incontinence (SUI) through the transobturator approach. A total of 54 consecutive women with SUI were evaluated post-operatively with transvaginal ultrasound. A concomitant hysterectomy was performed in ten cases and a concomitant prolapse surgery in six cases. Ultrasound measurements include urethral length, the distance between the upper edge of the sling and the bladder neck (BN-S) and the BN-S/U ratio. The mean distance between the transobturator tape and the bladder neck was found to be 12.6 +/- 3.2 mm in the group of patients who underwent the transobturator procedure alone, 13 +/- 3.1 mm in the transobturator plus hysterectomy group and 12 +/- 2.8 mm in the transobturator plus prolapse group. The superior tape margin was at the mid-urethra in 81.5% of patients and always at a distance greater than 7 mm from the bladder neck. Eight patients did not have satisfactory results after the surgery. Only in one out of these eight patients was the transobturator sling not found to be at the mid-urethra. The superior tape margin of the Monarc sling remained at the level of mid-urethra in the majority of cases. It was never located too proximally beneath the bladder neck.
