Classical surgical management of endometriotic ovarian cysts using the laparoscopic stripping technique has been recently questioned because of the surgical-related injury to the ovarian reserve. ...Accordingly, available guidelines suggest that endometriomas with a mean diameter below 4 cm should not be systematically removed before IVF procedures. However, conservative management may have some potential drawbacks and risks. The presence of the endometrioma may theoretically interfere with ovarian responsiveness to hyperstimulation and oocyte competence, the retrieval of the oocytes may be more difficult and risky, the disease may progress during the procedure, pregnancy outcome may be affected and there is the risk of missing occult malignancies with cancer development later in life. In the present review, we aimed at assessing whether these risks do exist and, if so, at estimating their clinical relevance.
We searched PubMed for articles published in the English language between January 1990 and August 2014 that reported on endometriomas and assisted reproductive techniques. Special care was given to studies reporting data purporting to distinguish the effects of ovarian endometriomas per sé from those consequent to surgery for endometriosis or from endometriosis in general.
Based on the evidence reviewed in the present study, it can be concluded that conservative management may actually expose women to four of the following theoretical risks, i.e. infection of the endometriomas, follicular fluid contamination with the endometrioma content, higher risk of pregnancy complications and cancer development later in life. The first three conditions do not justify surgery because these events are uncommon and the number of women needed to be treated would be exceedingly high and would not justify the costs and risks of the intervention. Albeit also very rare, the possibility of developing ovarian cancer later in life is more troublesome because it is a life-threatening condition. However, this alarmism is supported by only one cohort study and this risk can be effectively prevented by postponing surgery until after the IVF programme is concluded or when women have definitely satisfied their reproductive wishes.
The available evidence on the risks of conservative management does not support systematic surgery before IVF in women with small ovarian endometriomas.
The high rate of disease recurrence after surgery is critical and frustrating for women with endometriosis. Adjuvant treatments using a 3- to 6-months course of hormone therapy after surgery have ...been extensively investigated during the last 2 decades; however, results have been unsatisfactory, primarily because the benefits of hormone therapy rapidly vanish once treatment is discontinued. The protective effect is limited to the period of use. Accordingly, it is recognized that suppressive hormone therapy after surgery markedly prevents recurrent episodes only if given over the long term. The emerging view is that estroprogestins do not ameliorate the effects of surgery but demonstrate tertiary prevention of the disease. They prevent ovulation and reduce retrograde menstrual flow, two crucial events in the pathogenesis of endometriosis. The available literature strongly supports the benefits of prolonged administration of estroprogestins after surgery in preventing recurrence of endometriomas and dysmenorrhea. In contrast, data on dyspareunia and nonmenstrual pelvic pain remain scanty and unconvincing, and there is no information about recurrence of other forms of endometriosis such as peritoneal implants and adhesions. Overall, estroprogestin therapy after surgery to treat endometriosis should be recommended in women who do not seek to become pregnant. Further evidence is warranted to better delineate the beneficial effects of this emerging but convincing strategy.
What are the frequency, characteristics and consequences of technical diffiiculties encountered by physicians when carrying out oocyte retrieval in women with ovarian endometriomas?
We prospectively ...recruited women undergoing IVF and compared technical difficulties between women with (n = 56) and without (n = 227) endometriomas.
In exposed women, the cyst had to be transfixed in eight cases (14%, 95% CI 7 to 25%) and accidental contamination of the follicular fluid with the endometrioma content was recorded in nine women (16%, 95% CI 8 to 27%). Moreover, follicular aspiration was more frequently incomplete (OR 3.6, 95% CI 1.4 to 9.6). In contrast, the retrievals were not deemed to be more technically difficult by the physicians and the rate of oocytes retrieved per developed follicle did not differ. No pelvic infections or cyst ruptures were recorded (0%, 95% CI 0 to 5%).
Oocyte retrieval in women with ovarian endometriomas is more problematic but the magnitude of these increased difficulties is modest.
The first organocatalytic, stereoselective and direct aldol reaction of activated thioesters with aldehydes has been accomplished. The trichlorosilyl ketene thioacetal generated in situ by adding a ...tertiary amine to a trifluoroethyl thioester in the presence of tetrachlorosilane is activated by catalytic amounts of an enantiomerically pure biheteroaromatic phosphine oxide to react with different aldehydes, coordinated to as well as activated by the chiral cationic hypervalent silicon species. Starting from a variety of readily available thioesters, this Lewis acid‐mediated Lewis base‐catalyzed transformation allows the direct synthesis of syn‐β‐hydroxy thioesters in up to 95% ee.
The use of immobilized metal‐free catalysts offers the unique possibility to develop sustainable processes in flow mode. The challenging intermolecular organocatalyzed enantioselective alkylation of ...aldehydes was performed for the first time under continuous flow conditions. By using a packed‐bed reactor filled with readily available supported enantiopure imidazolidinone, different aldehydes were treated with three distinct cationic electrophiles. In the organocatalyzed α‐alkylation of aldehydes with 1,3‐benzodithiolylium tetrafluoroborate, excellent enantioselectivities, in some cases even better than those obtained in the flask process (up to 95 % ee at 25 °C), and high productivity (more than 3800 h−1) were obtained, which thus shows that a catalytic reactor may continuously produce enantiomerically enriched compounds. Treatment of the alkylated products with Raney‐nickel furnished enantiomerically enriched α‐methyl derivatives, key intermediates for active pharmaceutical ingredients and natural products.
Flowing enantioselectivity: The organocatalyzed α‐alkylation of aldehydes with 1,3‐benzodithiolylium tetrafluoroborate is performed under continuous flow conditions; excellent enantioselectivities (up to 95 % ee) and high productivity (>3800 h−1) are obtained. Thus, a metal‐free catalytic reactor can continuously produce enantiomerically enriched compounds.
The management of endometriosis-related infertility remains debated. However, in recent years, the role of in vitro fertilization (IVF) has progressively grown. Reasons to explain this change include ...(1) the improvement of the effectiveness and safety of IVF, (2) the raised awareness of the modest effectiveness of surgery, (3) the inherent risks of surgery including in particular the damage to the ovarian reserve when ovarian endometriomas have to be removed, (4) the ineffectiveness of intrauterine insemination and the possible risks of endometriosis progression associated with the use of this technique. However, IVF is not able to overcome all the potential detrimental effects of endometriosis and can actually fail. Future efforts should aim at improving the effectiveness and safety of both surgery and IVF. Fertility preservation techniques may play a role in the future, but data are currently too scanty to support its recommendation.
Objectives: To model trajectories of visuospatial reasoning measured using Kohs Block Design test under realistic missing data assumptions and evaluate their association with hazard of death. ...Methods: A joint longitudinal-survival model was used to estimate trajectories of visuospatial reasoning under a missing not at random assumption of participants from the Origins of Variance in the Old–Old: Octogenarian Twins study. Sensitivity analyses to missing data assumptions were conducted. Results: Visuospatial reasoning declined at constant rate. Baseline age, dementia status, education, and history of stroke were associated with visuospatial reasoning performance, but only dementia was associated with its rate of decline. Importantly, our results demonstrated an association between poorer visuospatial reasoning and increased hazard of death. Baseline age and sex were associated with risk of death. Discussion: We confirmed an association between visuospatial reasoning and death under plausible missing data assumptions.
A highly stereoselective direct aldol condensation of ketones to aromatic aldehydes was realized; the trichlorosilyl enolether generated in situ in the presence of tetrachlorosilane is activated by ...catalytic amounts of an enantiomerically pure biheteroaromatic phosphine oxide to react with aldehydes, coordinated as well as activated by the chiral cationic hypervalent silicon species. This Lewis acid-mediated Lewis base-catalyzed transformation allowed, starting from two carbonyl compounds, to directly synthesize β-hydroxy ketones generally with high
anti stereoselectivity and up to 93% ee for the
anti isomer.
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Objective To evaluate the accuracy of antral follicular count (AFC) in predicting ovarian responsiveness in ovaries with endometriomas or with a past history of surgical excision of endometriomas. ...Design Retrospective review. Setting Academic hospital. Patient(s) Eighty-three women for a total of 166 gonads. Intervention(s) None. Main Outcome Measure(s) Total number of developing follicles. Result(s) The ovaries were characterized as four groups: 1 unoperated gonads without endometriomas (n = 42, control group), 2 unoperated gonads with endometriomas (n = 46), 3 operated gonads without endometriomas (n = 55), and 4 operated gonads with endometriomas (n = 23). The analyses subsequently considered all ovaries with endometriomas (groups 2 + 4, n = 69) and all operated ovaries (groups 3 + 4, n = 78). The capacity of AFC to predict low response (≤2 follicles) or hyperresponsiveness (≥7 follicles) was evaluated using receiver operating characteristic curves. We used a linear regression model to calculate the adjusted B coefficients. The adjusted B coefficients in unaffected ovaries, in all ovaries with endometriomas, and in all operated ovaries were 0.55 (95% confidence interval CI, 0.07–1.03), 0.76 (95% CI, 0.54–0.98), and 0.51 (95% CI, 0.26–0.76), respectively. The area under the curve (AUC) for the prediction of low response was 0.83 (95% CI, 0.68–0.99), 0.83 (95% CI, 0.73–0.93), and 0.74 (95% CI, 0.63–0.85), respectively. The AUC for the prediction of hyperresponse was 0.84 (95% CI, 0.70–0.97), 0.74 (95% CI, 0.63–0.85), and 0.77 (0.60–0.94), respectively. Conclusion(s) The accuracy of AFC for predicting ovarian response is similar in unaffected ovaries, ovaries with endometriomas and ovaries with a history of surgery for endometriomas.
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