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Current Opinion in Obstetrics &... Aug 2023Vitamin D deficiency has been implicated as a contributing factor to a spectrum of reproductive health burden, including difficulty conceiving, pathogenesis of... (Review)
Review
PURPOSE OF REVIEW
Vitamin D deficiency has been implicated as a contributing factor to a spectrum of reproductive health burden, including difficulty conceiving, pathogenesis of gynaecological disorders such as uterine fibroids and endometriosis, to metabolic and endocrine burden of polycystic ovarian syndrome (PCOS).
RECENT FINDINGS
There have been recent publications showing that in infertile women who are supplemented with vitamin D, there are higher pregnancy rates; there are improved ovarian reserve parameters in women with diminished ovarian reserve; curtailed fibroid growth in those with uterine myomas; lessened dysmenorrhea in endometriosis patients; and improved menstrual regularity, lowered testosterone, AMH and insulin levels in women with PCOS. In infertile men, sperm parameters, especially motility, are positively correlated with vitamin D serum levels.
SUMMARY
Vitamin D status appears to be relevant to reproductive physiology, and to physiological processes underlying common gynaecological disorders as well as for reproductive success.
Topics: Pregnancy; Humans; Male; Female; Vitamin D; Infertility, Female; Endometriosis; Semen; Vitamins; Vitamin D Deficiency; Polycystic Ovary Syndrome; Leiomyoma; Anti-Mullerian Hormone
PubMed: 37266579
DOI: 10.1097/GCO.0000000000000887 -
Current perspectives on endometrial receptivity: A comprehensive overview of etiology and treatment.The Journal of Obstetrics and... Oct 2023Recurrent implantation failure (RIF) remains a challenging problem in assisted reproductive technology (ART). Further insights into uterine abnormalities that can... (Review)
Review
Recurrent implantation failure (RIF) remains a challenging problem in assisted reproductive technology (ART). Further insights into uterine abnormalities that can disturb embryo implantation should be obtained. This review provides an overview of the effects of organic and non-organic uterine disorders on endometrial receptivity. The results suggest that various uterine pathologies can lead to defective embryo implantation via multiple mechanisms. In particular, uterine adenomyosis dysregulates molecular and cellular interactions that are vital for successful embryo implantation with a background of chronic inflammation, which may be alleviated by pretreatment with a gonadotropin-releasing hormone agonist. Uterine myomas can cause endometrial deformation and adverse alterations in uterine contractility. Nonetheless, the effectiveness of myomectomy remains debated, and endometrial polyp removal may be considered, particularly in patients with RIF. Chronic endometritis abrogates the appropriate uterine immunological environment critical for embryo implantation. Abnormal endometrial microbiota have been suggested to influence endometrial receptivity; however, supporting evidence is currently scarce. Platelet-rich plasma therapy may be a potential treatment for thin endometria; nevertheless, further validation is required. Endometrial receptivity analysis can detect dysregulation of the window of implantation, and new non-invasive methods for predicting endometrial receptivity have recently been proposed. However, numerous issues still need to be fully clarified. Further clinical and basic studies are necessary to investigate the pathophysiology of defective endometrial receptivity and identify optimal treatments for patients undergoing ART, especially those with RIF.
Topics: Female; Humans; Endometrium; Embryo Implantation; Uterine Diseases; Uterus; Endometritis
PubMed: 37527810
DOI: 10.1111/jog.15759 -
Fertility and Sterility Jul 2024Fibroids are a common pathology and increasingly observed in women seeking medical treatment for infertility. The longer reproductive horizon because of improvements in... (Review)
Review
Fibroids are a common pathology and increasingly observed in women seeking medical treatment for infertility. The longer reproductive horizon because of improvements in medical care and current trend for women to postpone childbearing are making fibroid-related infertility increasingly common. This review aimed to critically analyze the association between uterine fibroids and infertility, mechanisms by which uterine fibroids may impair fertility, and management of myoma-related infertility. The association of fibroids with infertility is a source of controversy. As the focus of this review is infertility, it is crucial to analyze the mechanisms by which fertility may be impaired by the presence of fibroids. Current management strategies involve mainly surgical interventions, including myomectomy by hysteroscopy, laparotomy, or laparoscopy, and nonsurgical approaches, such as uterine artery embolization and focused ultrasound performed under radiologic or echographic guidance. The risks and benefits of each option should be discussed with patients, and several factors need to be considered, including the skills of surgeons and availability of different resources in various centers. Concerning the efficacy of oral gonadotropin-releasing hormone antagonists (i.e., elagolix, relugolix, and linzagolix), they were shown to have a rapid impact on heavy menstrual bleeding (HMB) in >70% of women. When used without add-back therapy, these drugs cause a significant reduction in fibroid volume, namely, approximately 50% from baseline to week 24. Further studies are required to determine the best protocol and optimal dosage if a reduction in myoma volume is the main goal, as in case of myoma-related infertility.
Topics: Humans; Female; Leiomyoma; Uterine Neoplasms; Infertility, Female; Treatment Outcome; Fertility; Risk Factors; Uterine Artery Embolization; Uterine Myomectomy
PubMed: 38453041
DOI: 10.1016/j.fertnstert.2024.02.049 -
Maturitas Jun 2024Abnormal uterine bleeding is a frequent symptom in the perimenopause. Causes are numerous, ranging from physiological reactions due to decreasing/unstable ovarian... (Review)
Review
Abnormal uterine bleeding is a frequent symptom in the perimenopause. Causes are numerous, ranging from physiological reactions due to decreasing/unstable ovarian function to premalignant and malignant conditions. Benign findings such as endometrial polyps and myomas increase with age, leading to more abnormal uterine bleeding in the perimenopause. Cervical and vaginal causes of abnormal uterine bleeding should be excluded by speculum examination. Sexually transmitted diseases or pregnancy should be ruled out. Measurement of haemoglobin and iron levels, human chorion gonadotropin and thyroid hormones are relevant in selected cases. Transvaginal ultrasound is an ideal first step for the evaluation of perimenopausal abnormal uterine bleeding. Saline or gel contrast sonohysterography improves the diagnostic accuracy. Based on the ultrasound findings, invasive procedures such as endometrial biopsy or hysteroscopy can be planned. Once premalignant and malignant causes are excluded, the necessity for treatment can be evaluated in collaboration with the patient. Heavy menstrual bleeding causing anaemia will need immediate treatment. In less severe cases and in intermenstrual bleeding, expectant management can be considered. Hormonal treatment, such as oral progestogens, combined oral contraceptives or insertion of the levonorgestrel intrauterine system, may be a possibility if anovulatory bleeding is interfering with quality of life. The amount of bleeding can be reduced both by antifibrinolytic and non-steroidal anti-inflammatory drugs, progestogens and the levonorgestrel intrauterine system. Focal intrauterine lesions such as endometrial polyps or submucous myomas may require operative hysteroscopic procedures. Endometrial ablation or endometrial resection are good choices in selected cases, but some women will need a hysterectomy to treat their abnormal uterine bleeding in perimenopause.
Topics: Humans; Female; Perimenopause; Uterine Hemorrhage
PubMed: 38412750
DOI: 10.1016/j.maturitas.2024.107944 -
Journal of Clinical Medicine Jul 2023The latest classification from the Fédération Internationale de Gynécologie et d'Obstétrique (FIGO) has reclassified type 3 myomas, changing their classification... (Review)
Review
The latest classification from the Fédération Internationale de Gynécologie et d'Obstétrique (FIGO) has reclassified type 3 myomas, changing their classification from intramural to submucosal. While hysteroscopic myomectomy is considered the gold standard treatment for patients experiencing symptoms from submucosal myomas, there are currently no specific guidelines available for managing type 3 myomas, and the optimal surgical approach remains uncertain. The search for suitable articles published in English was carried out using the following databases (PROSPERO ID CRD42023418602): MEDLINE, EMBASE, Global Health, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register), Health Technology Assessment Database, Web of Science and search register. Only original studies reporting data on hysteroscopic myomectomy of type 3 myoma were considered eligible. The main outcomes investigated were the effectiveness and feasibility of hysteroscopic myomectomy and reproductive outcomes after surgical treatment. Two hundred and sixty-one studies were screened and nineteen of these were read for eligibility. Three studies encompassing 56 patients in total were included. Among the overall population studied, three patients needed an additional procedure to completely remove the myoma and five cases of post-surgical synechiae were recorded. No complications were reported. Of 42 patients wishing for pregnancy, the cumulative live birth rates before and after the hysteroscopic myomectomy were 14.3% and 42.9%, respectively. Hysteroscopic myomectomy appears to be a safe and feasible approach. Nevertheless, data reported in the literature are extremely scarce and based on studies with few patients enrolled. New evidence is needed to assess the safety and effectiveness of hysteroscopic treatment for FIGO type 3 myomas.
PubMed: 37568356
DOI: 10.3390/jcm12154953 -
Cureus Dec 2023Uterine leiomyomas are the most common benign tumors of the female genital track, causing various symptoms and problems, including a possible impact on fertility. The... (Review)
Review
Uterine leiomyomas are the most common benign tumors of the female genital track, causing various symptoms and problems, including a possible impact on fertility. The relationship between fibroids and infertility has long been a debate among gynecologists. Management of fibroids in women with otherwise unexplained infertility worldwide lacks standardized, evidence-based guidelines. Therefore, a review of guidelines from the Royal Australian and New Zealand College of Obstetricians and Gynecologists, the American College of Obstetricians and Gynecologists, the Society of Obstetricians and Gynecologists of Canada, the Collège National des Gynécologues et Obstétriciens Français, and the American Society of Reproductive Medicine was conducted. There is agreement among all guidelines that the effect of fibroids on fertility is related to their position in the uterus and the alteration of the endometrial cavity. However, whether surgical intervention (laparotomy, laparoscopy, or hysteroscopy) is required varies among committees. More specifically, for submucous myomas, all guidelines agree that surgical intervention is needed. On the other hand, regarding intramural myomas, there is no consensus on what the approach may be. Novel treatments such as uterine artery embolization (UAE) and magnetic resonance-guided focused ultrasound surgery (MRgFUS) should only be used in clinical trial settings. Nevertheless, all guidelines agree that medical management of fibroids further delays efforts to conceive and has no role as a stand-alone treatment of fibroids; though, the use of GnRH analogues preoperatively can be useful to improve anemia and/or reduce fibroid volume. There is a need for updated international protocols to be introduced, in order to help clinicians dealing with fibroids and infertility to better suggest the optimal treatment.
PubMed: 38259363
DOI: 10.7759/cureus.50992 -
Heart, Lung & Circulation May 2024Cardiac tumours can occur in association with genetic syndromes. Rhabdomyomas have been reported in association with tuberous sclerosis, myxomas with Carney's complex,... (Review)
Review
Cardiac tumours can occur in association with genetic syndromes. Rhabdomyomas have been reported in association with tuberous sclerosis, myxomas with Carney's complex, cardiac fibromas with Gorlin syndrome, and paragangliomas with multiple endocrine neoplasm syndrome. The presentation and prognosis of cardiac tumours associated with genetic syndromes differ compared with sporadic cases. Knowledge about the associated syndromes' genetic features and extracardiac manifestations is essential for the diagnosis, prognosis, and management of cardiac neoplasms. Moreover, identifying genetic mutations in benign and malignant cardiac tumours is needed to personalise management and improve treatment outcomes. Thus, this review discusses the genetic abnormalities associated with cardiac tumours, the current genetic screening recommendations, and the effect of those genetic mutations on the outcomes.
Topics: Humans; Heart Neoplasms; Mutation; Genetic Testing; Rhabdomyoma
PubMed: 38161083
DOI: 10.1016/j.hlc.2023.11.005 -
Fertility and Sterility Oct 2023To review important diagnostic considerations for accurate identification of a prolapsing submucosal myoma and to highlight surgical techniques for minimally invasive... (Review)
Review
OBJECTIVE
To review important diagnostic considerations for accurate identification of a prolapsing submucosal myoma and to highlight surgical techniques for minimally invasive and uterine-sparing combined vaginal and hysteroscopic myomectomy. Submucosal myomas can present with various symptoms, including vaginal bleeding, pelvic pain, and abnormal discharge, and can also contribute to infertility. This type of myoma has the potential to prolapse through the cervical canal, and prompt identification and management are essential to avoid serious sequelae, including hemorrhage, infection, and sepsis.
DESIGN
A case report. Patient consent was received to publish. This publication received an exemption from institutional review board approval from the institution as this was a case report. The investigators have no conflicts of interest.
SETTING
Academic medical center.
PATIENTS
We present a 33-year-old G5P2032 patient with pelvic pain and vaginal bleeding. Her clinical course involved multiple encounters with inaccurate diagnoses, leading to worsening symptoms. She was found ultimately to have a large, prolapsing submucosal myoma. The patient included in this video gave consent for publication of the video and posting of the video online, including on social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, Scopus, and others), and other applicable sites.
INTERVENTION(S)
Given the severity of her symptoms and her desire for uterine preservation for future fertility, the patient was counseled on the need for surgical intervention and elected to proceed with a combined vaginal and hysteroscopic myomectomy.
MAIN OUTCOME MEASURE(S)
Preoperative considerations discussed in this video include common mimics of this condition, the importance of a thorough pelvic examination and preoperative imaging, as well as recommendations for surgical management.
RESULT(S)
We reviewed the following surgical techniques: (1) adequate exposure; (2) clamping of the myoma stalk; (3) morcellation "cone" technique; (4) use of intracervical vasopressin; (5) hysteroscopic evaluation; and (6) insertion of an intrauterine balloon.
CONCLUSION(S)
Prolapsing submucosal myomas can present as common gynecologic complaints but can lead to serious sequelae when timely diagnosis and treatment are not performed. Appropriate evaluation, accurate diagnosis, preoperative imaging, and knowledge of surgical techniques are critical for optimizing patient outcomes and avoiding complications in patients with a prolapsed myoma.
Topics: Humans; Female; Adult; Pregnancy; Leiomyoma; Uterine Neoplasms; Uterine Myomectomy; Myoma; Uterine Hemorrhage; Pelvic Pain; Hysteroscopy
PubMed: 37487820
DOI: 10.1016/j.fertnstert.2023.07.009 -
Medicina Clinica Oct 2023
Topics: Humans; Female; Leiomyoma; Uterine Neoplasms; Myoma
PubMed: 37923514
DOI: 10.1016/j.medcli.2023.06.036 -
Prenatal Diagnosis Jan 2024The mammalian/mechanistic target of rapamycin (mTOR) is a protein kinase that plays a crucial role in regulating cellular growth, metabolism, and survival. Although... (Review)
Review
The mammalian/mechanistic target of rapamycin (mTOR) is a protein kinase that plays a crucial role in regulating cellular growth, metabolism, and survival. Although there is no absolute contraindication for the use of mTOR inhibitors during pregnancy, the specific fetal effects remain unknown. Available data from the past 2 decades have examined the use of mTOR inhibitors during pregnancy in patients with solid organ transplantation, showing no clear link to fetal complications or structural abnormalities. Recently, a handful of case reports and series have described transplacental therapy of mTOR inhibitors to control symptomatic and complicated pathologies in the fetus. The effect of these agents includes a significant reduction in lesion size in the fetus and a reduced need for mechanical ventilation in neonates. In this context, we delve into the potential of mTOR inhibitors as in-utero therapy for fetal abnormalities, with a primary focus on lymphatic malformation (LM) and cardiac rhabdomyoma (CR). While preliminary reports underscore the efficacy of mTOR inhibitors for the treatment of fetal CR and fetal brain lesions associated with tuberous sclerosis complex, chylothorax, and LMs, additional investigation and clinical trials are essential to comprehensively assess the safety and efficacy of these medications.
Topics: Pregnancy; Infant, Newborn; Female; Humans; Sirolimus; MTOR Inhibitors; TOR Serine-Threonine Kinases; Tuberous Sclerosis; Fetus; Rhabdomyoma
PubMed: 38177082
DOI: 10.1002/pd.6492