Is there a role for HIPEC in ovarian cancer?

Hyperthermic intraperitoneal chemotherapy (HIPEC) is promoted by some as a standard treatment for peritoneal carcinomatosis of epithelial ovarian cancer (EOC) and other tumor entities, despite lack of robust data supporting this. Publicly available evidence addressing the value of HIPEC in EOC is rather inconclusive, revealing contradictory and inconsistent results while some studies even report harm to the patients from a higher morbidity. On this ground, we cannot recommend the implementation and use of HIPEC outside of a randomized clinical trial setting.     

Is there a role for assisted reproductive technology in recurrent miscarriage?

Unexplained recurrent miscarriage (RM) is a significant health problem for which no effective treatment is available yet. In only 50% of couples with RM a cause can be found. In clinical practice, a frequently asked question is whether assisted reproductive technology (ART) is a treatment option. The scientific rationale and the chances of success for ART in couples with unexplained RM are still controversial. Presently, there is not enough evidence to justify IVF or intrauterine insemination (IUI) as a treatment option. Research on oocyte donation has been reported in one article. It is questionable whether couples with unexplained RM would undergo the potential risks and emotional aspects of ART. There is insufficient data on whether preimplantation genetic diagnosis improves the live birthrate in carriers of a structural chromosome rearrangement with a history of RM. No randomized controlled trials are available for preimplantation genetic screening (PGS) for unexplained RM. A recently published review concluded that the live birthrate for IVF/PGS and natural conception groups appears to be quite similar. Because evidence is lacking, we recommend refraining from ART in couples with recurrent miscarriage.     

Is there a role for kisspeptin in pathogenesis of polycystic ovary syndrome?

Aim: To investigate association of kisspeptin levels in infertile women with different ovarian reserve patterns.

Materials and methods: In this prospective cross-sectional study, 157 participants were recruited. The women were divided into three groups: (i) adequate ovarian reserve (AOR) (n?=?57), (ii) high ovarian reserve (PCOS) (n?=?60), (iii) diminished ovarian reserve (DOR) (n?=?40). Weight, height, waist circumference (WC), hip circumference (HC), body mass index (BMI), waist/hip ratio (WHR) were measured. The blood samples were analyzed for estradiol (E2), follicle-stimulating hormone (FSH), luteinizing hormone (LH), total testosterone (TT), 17-hydroxy progesterone (17OHP), dehydroepiandrosterone sulfate (DHEAS), antimullerian hormone (AMH), kisspeptin measurements.

Results: FSH concentration was higher and AMH concentration was lower in DOR group (p?p?p?=?.001, p?p?=?.003, respectively). The 17OHP level did not differ among the groups (p?=?.15). Women with PCOS possessed the highest kisspeptin level (p?=?.01). The kisspeptin level was negatively correlated with FSH level (r?=??0.18, p?=?.02) and positively correlated with TT and DHEAS levels (r?=?0.17, p?=?.02 and r?=?0.23, p?=?.003, respectively).

Conclusions: Women with PCOS had increased serum kisspeptin levels. Kisspeptin concentrations were negatively correlated with serum FSH and positively correlated with serum TT and DHEAS levels.     

Is there a role for pelvic lymph node debulking in advanced cervical cancer?

OBJECTIVES: The objectives of this study were to characterize the prognostic features of micropapillary serous ovarian carcinoma (MPSC), examine the clinical impact of surgical staging, and define the role of cytoreductive surgery for patients with advanced disease. METHODS: Fifty-one patients with MPSC were identified from hospital and tumor registry databases. Demographic, operative, pathologic, and follow-up data were abstracted retrospectively. Survival curves were generated using the Kaplan-Meier method, and statistical comparisons were performed using the log rank test, logistic regression analysis, and the Cox proportional hazards regression model. RESULTS: The median age at diagnosis was 45 years, and follow-up extended to a median of 43.0 months. Stage I/II disease was present in 25.5% of patients and no disease-related deaths were observed in this group. Stage III disease was discovered in 29.4% of patients with tumor clinically confined to the ovaries. Stage III/IV disease (74.5% of cases) was associated with median progression-free and overall survival times of 32.8 and 114.2 months, respectively. Menopausal status and the anatomic extent of disease were significantly associated with survival outcome. However, the strongest independent predictor of survival for patients with advanced disease was the amount of residual tumor. Median overall survival for patients with optimal cytoreduction (residual disease 1 cm residual tumor (P < 0.0002). CONCLUSIONS: MPSC carries a significant risk of extraovarian spread; however, adequately sampled Stage I/II disease is associated with a favorable prognosis. Optimal cytoreduction is associated with improved survival and should be the primary therapeutic objective for patients with advanced-stage MPSC.     

Is there a role for DHEA supplementation in women with diminished ovarian reserve?

Purpose

Poor ovarian reserve and poor ovarian response presents a challenge to IVF centers. Dehydroepiandrosterone (DHEA) supplementation is increasingly being used by many IVF centers around the world in poor responders despite the lack of convincing data. We therefore examined the rationale for the use of DHEA in poor responders, address the relevant studies, present new data, and address its potential mechanisms of action.

Methods

All published articles on the role of DHEA in infertile women from 1990 to April 2013 were reviewed.

Results

Several studies have suggested an improvement in pregnancy rates with the use of DHEA. Potential mechanisms include improved follicular steroidogenesis, increased IGF-1, acting as a pre-hormone for follicular testosterone, reducing aneuploidy, and increasing AMH and antral follicle count. While the role of DHEA is intriguing, evidence-based recommendations are lacking.

Conclusions

While nearly 25 % of IVF programs use DHEA currently, large randomized prospective trials are sorely needed. Until (and if) such trials are conducted, DHEA may be of benefit in suitable, well informed, and consented women with diminished ovarian reserve.     

Is there a role for hormone replacement therapy after breast cancer?

Breast cancer is the most common female malignancy in the UK, with an overall lifetime risk of 1 in 9. Despite the high incidence, breast cancer mortality is decreasing. Approximately 40,000 women were diagnosed with breast cancer in England and Wales in 2000 but the majority will have normal or near-normal life expectancy. One of the main contributory factors to this marked improvement in survival over the last 20 years in women of all ages has been the more widespread use of systemic therapy in early-stage disease. For women with hormone-sensitive cancer, this involves adjuvant endocrine therapy that reduces estrogen synthesis (i.e. ovarian suppression in premenopausal women or aromatase inhibitors in postmenopausal women) or estrogen activity (the anti-estrogen tamoxifen, irrespective of menopausal status). Many women experience health and quality-of-life problems related to estrogen deficiency as a result, the commonest being vasomotor symptoms and vaginal dryness. This article summarizes and interprets key recent papers on the use of hormone replacement therapy (HRT) and selective serotonin reuptake inhibitors in breast cancer survivors. HRT may be safe in women with receptor-negative disease or receptor-positive cancers in the presence of tamoxifen. However, there is a dearth of useful alternatives.     

Is there a place for tubal ligation in modern contraception?

About 30% of women with completed family planning choose tubal ligation as a method of contraception. Contraceptive safety of tubal ligation, with a Pearl index of 0.18, is comparable to those of OC or modern intrauterine devices (IUD). Pregnancies that occur after tubal ligation are often ectopic, especially in young women. There is currently no evidence that tubal ligation causes menstrual abnormalities. The risk of breast cancer, cancer of the endometrium or cervix is not elevated after tubal ligation, whereas the risk of ovarian cancer is even reduced. The risk of post-sterilization regret is higher when the operation was performed in women with children aged younger than 30 years. Tubal ligation is recommendable for women over 35 years of age with completed family planning, especially if contraindications for the use of OC or IUD exist. In general, vasectomy should always be discussed as a possible alternative.     

Is there a place for immunomodulation in assisted reproduction techniques?

We briefly review the history of the concepts of the materno foetal relationship, and the (various) rationales which have been used to justify lymphocyte alloimmunisation (LA) as a treatment for recurrent spontaneous abortion of putative immune origins. The effectiveness of the treatment is at best dubious and limited to a small number of women for which there is no real positive selection rationale, at worst it is not efficient. The rationales themselves are rather "evolutive". The present one is to use the Th1:Th2 paradigm and, thus, to propose to "dampen NK activity" in abortion prone women and this concept has been extended by some to implantation failure. We briefly review why the Th1:Th2 paradigms is no longer fully valid, describe briefly why it is inappropriate for implantation, and conclude that alloimmunisation should no longer be proposed for RSA, hence, more for implantation failure. We, however, do not reject immunotherapy, but we believe that molecular and cellular defects specific approaches should be used, tailored for the specific pathway whose disruption cause the clinical symptom.     

Is there a future for Fallopian tube insemination in women?

In unselected patients, the pregnancy rate after intrauterine insemination (i.u.i.) seldom goes beyond 10-15% per cycle. An insufficient number of spermatozoa at the fertilization site has been hypothesized for a long time to explain the low efficacy of this technique. Thus, the introduction of a larger number of male gametes into the female tubes has been thought of to give better results since the late eighties. First, a direct tubal catheterisation has been proposed for injection of spermatozoa, either by laparoscopy or transvaginally under ultrasound guidance or by tactile sensation. However, these procedures have been abandoned because of some severe traumatic and infectious complications. Alternatively, a spermatozoa suspension of several millilitres can be injected under pressure into the uterine cavity while sealing the cervical os, by various systems. This technique called Fallopian sperm perfusion (FSP) has yielded some interesting results, particularly in unexplained infertility. Nevertheless, the superiority of FSP over i.u.i. still remains controversial. This review describes the current knowledge about intratubal insemination and its potential role in the management of human infertility.     

Is there a role for colposcopy in the follow-up of treated low grade squamous intraepithelial lesions?

Is routine colposcopy justified in the follow up of treated low grade squamous intraepithelial lesions (LGSIL) of the cervix? This retrospective study analysed the notes of women treated at a public hospital colposcopy clinic over a 5-year period. Two hundred and fifty women fulfilled the inclusion criteria of whom 11 had persistent disease. Of these, only one case of LGSIL was detected by colposcopy in the absence of abnormal cytology. In the present study, routine colposcopy offered minimal additional benefit over cytology.