Granda Ospedale Maggiore Policlinico Research Articles

Comparison of facial features in foetuses and newborns following natural delivery with cephalic presentation: a pilot study.

Malocclusions are usually diagnosed around 3-4 years of age according to specific criteria. The purpose of this protocol is to validate a method to understand how the type of delivery can influence the development of malocclusions. This pilot study, conducted at the Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico of Milan, evaluated the relationship between the type of delivery, foetal presentation, and the presence of malocclusions in children. The sample included 5 healthy term newborns, all born to healthy mothers with uncomplicated pregnancies by vaginal delivery or C-section. Measurements were taken at the 37th week of gestation (T0) and on the second day of life (T1), including head circumference, lower facial angle, frontonasal angle, labial fissure length, and interpupillary distance. The results suggest that further research is necessary to better understand the influence of delivery mode and fetal presentation on the development of malocclusions. This study represents an important first step, highlighting the need for larger samples and more in-depth investigation methods to obtain more conclusive results.

Current Management of Warm Autoimmune Haemolytic Anaemia and Recent Advancements in Research: Interview with a Key Opinion Leader

Warm autoimmune haemolytic anaemia (wAIHA) is a rare, life-threatening disorder caused by autoantibodies that lead to the premature destruction of erythrocytes (haemolysis). There is currently no licensed targeted therapy for wAIHA. Until recently, there has been little research attention on autoimmune haemolytic anaemias (AIHA), with few developments in the field over the past 20 years. The last 3 years have seen a surge in research interest in wAIHA, with the development of potential new therapies for this rare disorder. For this article, the EMJ conducted an interview in June 2024 with key opinion leader, Bruno Fattizzo, from the University of Milan, and Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy, to raise awareness of wAIHA, and explore recent advancements in research on this disease. Fattizzo, who has a wealth of experience and expertise in the clinical management of wAIHA, provided valuable insights into topics such as the clinical and quality of life (QoL) impact of wAIHA on the patient; current management of wAIHA, including steroids, rituximab, immunosuppressants, splenectomy, anticoagulant prophylaxis, and recombinant erythropoietin; and remaining unmet needs in the disease area. Also discussed were potential future therapies for this autoimmune disorder, including tyrosine kinase inhibitors, neonatal fragment crystallisable receptor (FcRn) inhibitors, and B cell activating factor receptor (BAFF-R) antagonists, and the challenges involved in managing patients with wAIHA. Finally, Fattizzo described the patient experience of living with wAIHA, proposed how best to raise awareness of wAIHA among healthcare professionals, the scientific community, patients, and the public, and outlined what the future of the management of patients with wAIHA might look like.

Clinical significance of atypical glandular cells on cytology: 10 years' experience of a colposcopic referral center.

'Atypical glandular cells' (AGC) is an uncommon cytological result of cervical Pap smears which includes a wide of histopathological diagnoses, from benign to premalignant and malignant cervical disorders, endometrial cancer and, occasionally, other genital malignancies. This study aims to provide a comprehensive overview of AGC, assessing risk factors and clinical and histological features in affected patients. A retrospective analysis was conducted on a cohort of 239 women diagnosed with AGC between 2012 and 2022 at the 'Regional Referral Center for Prevention, Diagnosis and Treatment of HPV-related Genital Disorders', Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy. Following AGC detection, patients underwent colposcopy with endocervical sampling and endometrial assessment via pelvic ultrasound. Selective cases also received endometrial biopsies. Among a total of 190 women who underwent both colposcopy and endometrial assessment, 116 (61%) had negative clinical and histopathological findings. The remainder displayed various abnormalities: 36 women (18.9%) were found to have endometrial or cervical polyps, 23 (12.1%) were diagnosed with preinvasive cervical neoplasia, and 21 (10.9%) with invasive cervical or endometrial disease. Menopause, multiparity, and older age were all significantly associated with endometrial cancer, but none of the abovementioned variables were significantly associated with cervical neoplasia. Our data confirm that AGC may reveal the presence of a wide range of histopathological conditions. Patients diagnosed with AGC should undergo a careful evaluation including both colposcopy with endocervical sampling and an endometrial assessment.

P-613 Natural cycles monitoring for frozen embryo transfers: is it beneficial to start immediately after ovarian stimulation?

Abstract Study question Are there more advantages in performing frozen embryo transfer (FET) immediately after ovarian stimulation or in delaying it by at least one menstruation? Summary answer In natural cycles, timing of frozen embryo transfer does not affect clinical pregnancy rates, but immediate transfer is associated with higher rates of cycle cancellation. What is known already In order to achieve a reduced time to pregnancy and avoid additional stress for the couple, some Centers initiate FETs immediately, i.e. on the first menstrual cycle after ovarian stimulation. However, the detrimental effect of hormonal stimulation on ovarian function and endometrial receptivity may persist in the following cycle and immediate FETs may increase the possibility of cycle cancellation and reduce pregnancy rate. Available evidence on this subject, mainly focused on endometrial preparation with hormonal replacement therapy (HRT), showed contrasting results. Moreover, studies on FETs performed on natural cycles are lacking. Study design, size, duration This is a retrospective study conducted at the Infertility Unit of the Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico in Milan, Italy. A large amount of single FETs, performed between 2014 and 2021, was considered and was then divided in two groups according to their timing (immediate or delayed). The primary outcome was to assess the clinical pregnancy rate (CPR); secondary outcomes were live birth rate (LBR) and the cycle cancellation rate. Participants/materials, setting, methods True natural cycles (T-NC) and modified cycles with the use of triggered ovulation (M-NC) protocols for endometrial preparation were pursued in women with regular menses; otherwise, HRT was used. Immediate FET was defined when performed on the first menstruation following ovarian stimulation (i.e. withdrawal bleeding occurring after ovarian stimulation or after a failed fresh embryo transfer). Delayed FETs included those performed after at least two menstruations. Only the first transfer after ovarian stimulation was considered. Main results and the role of chance A total of 5,765 FET cycles were included in the study. FET cycles were achieved through T-NC in 4,477 cases (78% of all FETs), of which 364 were immediate and 4,113 were delayed. M-NC cycles accounted for 1% of the total amount of FETs and HRT protocols were pursued in 11% of cases. The analysis showed no impact of FET timing on CPR both in the whole cohort and in the subgroups based on different endometrial preparation protocols. Focusing on T-NC cycles, the CPR in the immediate group was comparable to that of the postponed group (29 vs. 32% respectively, OR 0.90 [95% CI 0.71 - 1.14]). On the other hand, LBR in T-NC cycles was significantly lower in the immediate group than in the delayed group (20% vs. 25% respectively, OR 0.74 [95% CI 0.56 - 0.96]). Consequently, immediate FETs resulted to be associated with a significantly higher rate of pregnancy loss (31% vs. 21% respectively, p = 0.03). Furthermore, cycle cancellation occurred more frequently in the immediate T-NC group, compared with the delayed group (18% vs. 12% respectively, p = 0.003). Similar results were observed in HRT cycles (15% in immediate FETs vs. 7% in delayed FETs, p = 0.08). Limitations, reasons for caution The retrospective nature of this study involves a risk of selection bias. Moreover, the reason for cycle cancellation was not always available; thus, these data were not included in the analysis. Lastly, these outcomes are only applicable to a similar cohort, that is Centers following a non-elective freeze-all policy. Wider implications of the findings This is the largest investigation on T-NC FETs and is among the very few studies providing separate results on different endometrial preparation protocols. Evidence from this study is in line with some previous retrospective analyses and in contrast with others. Thus, randomized controlled trials are needed to confirm these results. Trial registration number not applicable

P-275 Advanced hemostasis assessment in endometriosis: strengthening confidence in the safety of hormonal treatments

Abstract Study question Are women with endometriosis in a state of systemic imbalance between pro- and anti-coagulants? Summary answer Women with endometriosis do not seem to exhibit a coagulation imbalance, at least at a systemic level. What is known already A state of platelet hyperactivation potentially leading to a hypercoagulation status has been described in women with endometriosis. This phenomenon could induce an altered local environment, promoting platelet-mediated paracrine changes in endometrial tissue and also increasing cardiovascular risk, which could be worsened by the use of estrogen dependent hormonal treatments. However, despite a slight difference in some coagulation parameters has been observed between women affected and controls, their levels remain, generally, within the normal reference range. Study design, size, duration This prospective case-control study including 101 women seeking infertility consultation at the Infertility Unit of Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano between January and July 2023 aimed to assess hemostasis function beyond traditional coagulation parameters. Participants/materials, setting, methods Blood of women with endometriosis (n = 51) or tubal or male factor infertility (controls; n = 50) was obtained before any ART treatment, and a complete panel of coagulation tests were performed, including basic parameters (aPTT, PT, FVIII, FII, PC, AT, FIV-C, DD, vWF, ADMT) as well as more sophisticated ones, such as Thrombin Generation Assay and Thromboelastometry, providing data on endogenous thrombin potential (ETP), clot formation time (CFT) and maximal clot firmness (MCF). Main results and the role of chance There were no significant differences between cases and controls in terms of age (37 [34-39] vs 36 [33-39]; p = 0.53, respectively) and smoking habits (14% vs 28%; p = 0.14, respectively). Women affected had a lower BMI compared to controls (22.7 [20.9-24.9] vs 21.4 [19.6-23.8]; p = 0.03), as it is usually expected. Results from TGA were expressed as ETP ratio (with-/without- thrombomodulin), and high ones were indicative of thrombomodulin resistance, taken as indexes of procoagulant imbalance; however, it was not different between women with and without the disease (0.75 [0.65-0.82] vs 0.75 [0.66-0.82]; p = 0.82, respectively). Other markers of procoagulant imbalance evaluated by thromboelastometry were also similar between cases and controls, including CFT (66 sec [58-78] vs 65 sec [59-79]; p = 0.69, respectively) and MCF (65 mm [62-68] vs 66mm [63-68]; p = 0.95, respectively). Considering the vWF/ADAMTS13 ratio, recently proposed to be altered in endometriosis, no difference was seen between affected and no-affected women (0.95 [0.76-1.14] vs 0.91 [0.68-1.15]; p = 0.41, respectively). Finally, all the basic coagulation parameters were also similar between groups. Limitations, reasons for caution Our sample size does not allow us to perform sub-analyses regarding the type of endometriosis, although we cannot exclude differences according to the various manifestations of the disease. Also, not having a systemic haemostasis imbalance does not exclude the possibility of local coagulation imbalances. Wider implications of the findings An altered systemic haemostasis could be worsened by the use of hormonal treatments. Our result indicating that there is no coagulation imbalance at a systemic level reassures about the absence of further contraindications to hormonal drugs as a treatment for endometriosis. Trial registration number not applicable

P-006 Fertility outcomes in men diagnosed with oncohematological diseases who stored their semen for fertility preservation

Abstract Study question What is the prevalence of conceptions among patients who underwent semen cryopreservation before receiving treatment for oncohematological disease? Summary answer Natural live birth rate after oncohematological treatments is around 38%(95%CI:31-45%), but can rise to 61%(95%CI:54-67%) with the use of frozen semen during ART cycles. What is known already Due to advancements in cancer treatments, there is a growing population of male adult cancer survivors. These individuals are at risk of experiencing treatment-induced infertility, and it is generally advised for them to preserve their semen before starting therapies. However, the details regarding the long-term utilization and effectiveness of frozen sperm samples in this particular population remain unclear. Study design, size, duration The study included males with oncohematological disease who stored semen (1987-2018) at Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico’s Assisted Reproductive Technology Unit in Milan. Data, gathered from records or proactive inquiry, assessed natural and ART conceptions post-treatment. The study also examined semen analysis, parenthood attempts, and the usage rates of stored spermatozoa as primary outcomes. Participants/materials, setting, methods The study is limited to men who meet the following eligibility criteria: i) semen cryopreserved for fertility preservation between 1987 and 2018; ii) diagnosis of oncohematological disease; iii) survival of at least 5 years from cryopreservation. Main results and the role of chance A total of 424 patients who underwent semen cryopreservation for oncohematological diseases were included in the study. The median [IQR] age at the time of sperm banking was 27 [23-33]. The most common indication was lymphoma (86%), and 102 subjects (24%) underwent hematopoietic stem cell transplantation. The median sperm concentration at the time of storage was 54 [20-98] million/ml. Among the participants, 242 (57%) men underwent post-treatment sperm analysis, revealing azoospermia in 87 of them (36%, 95%CI: 30-42%). Of the remaining, only 93 (38%) exhibited normal semen parameters. A total of 188 out of the 424 men included (44%) expressed a desire for childbearing and seventy-one achieved a natural live birth (38%, 95%CI: 31-45%). Eighty-nine individuals used their cryopreserved sperm samples, constituting 21% (95%CI: 17-25%) of the entire cohort. Among these 89 men, 45 experienced at least one live birth (51%, 95%CI: 40-61%). Notably, thirty-three men, despite actively seeking pregnancy, did not utilize their frozen semen. In summary, out of the 188 men interested in fatherhood, a total of 114 achieved a live birth (61%, 95%CI: 54-67%). Limitations, reasons for caution Our study is constrained by the lack of detailed information on the illness status, comorbidities, and specific cancer therapies administered. Furthermore, the data concern a single-center population, potentially limiting the generalizability of the results. Wider implications of the findings Oncohematological disease often require systemic therapies or even hematopoietic stem cell transplantation resulting in a very high percentage of infertile patients These findings support the need to prioritize sperm preservation before therapies in these patients, even in cases who are not candidates for stem cell transplantation in the first instance Trial registration number NA

UNRAVELING GENDER DISPARITIES AND PROGNOSTIC INSIGHTS IN MODERATE AORTIC STENOSIS: A RETROSPECTIVE STUDY

Abstract Aortic stenosis (AS) is the most prevalent valvular heart disease in developed countries, associated with reduced survival if severe AS remains untreated. Recent reports note unfavorable outcomes in moderate AS (mAS) patients, challenging optimal intervention timing. Variations in pathophysiology linked to sex differences, involving sex hormones, activation of the renin–angiotensin–aldosterone system, and dysregulation in collagen synthesis, have been observed. Yet, limited data exists on sex–specific differences in mAS outcomes. This single–center, retrospective study included 150 patients (median age 79±13 years, female sex 48%) diagnosed with mAS who underwent comprehensive echocardiography in IRCCS Fondazione Ca’ Granda Ospedale Maggiore Policlinico of Milan from July 2022 to October 2023. Clinical data, encompassing demographics details and therapy, were obtained via record reviews and phone interviews. Death verification relied on the ‘Sistema Informativo Socio–Sanitario Regione Lombardia’ database. Echocardiographic records were digitally stored and post–processed by four independent investigators using Medimatic ComPACS workstation. Men were significantly younger than women (75±10 vs 79±9.7 years, p= 0.016). They exhibited lower left ventricular (LV) ejection fraction, larger LV end–systolic volume and stroke volume compared to women (54±7 vs 59±10%; p=0.028. 55±36 vs 31±13 ml; p<0.001. 83±18 vs 75±18 ml; p=0.030). Men had significantly smaller aortic valve (AV) area index to body surface area (BSA) (0.6±0.09 vs 0.7±0.1 cmq/mq; p<0.001) and lower doppler velocity index (0.32±0.07 vs 0.38±0.11; p<0.001) than women. Coronary artery disease and smoking were more frequent in men (53.3 vs 46.7%; p=0,002. 52.6 vs 47.4%; p<0.001). In survival analysis, 15% of women and 30.8% of men experienced events, with male gender independently associated with the composite outcome (all–cause mortality and AV replacement) over a mean follow–up time of 200 ± 133 days, showing a median survival of 244±16 vs 255±15 days for females (p–value=0.025). In multivariable analysis including relevant clinical variables (hemoglobin and AV index to BSA), male sex remained independently associated with the composite outcome (hazard ratio 2,01; CI 1.0–4.17; p=0.05). Women diagnosed with mAS exhibited a lower incidence of AV replacement and all–cause mortality. These findings may suggest the existence of different clinical and echocardiographic phenotypes among patients with AS.

Paediatric cutaneous lymphomas including rare subtypes: A 40-year experience at a tertiary referral centre.

Primary cutaneous lymphomas are neoplasms of the immune system with a distinct tropism for the skin and an absence of extracutaneous manifestations at the time of diagnosis. Studies focusing on cutaneous lymphomas in children and adolescents remain scarce and often do not encompass the rare subtypes. To address this knowledge gap by describing the clinical, histological and molecular characteristics of a large group of paediatric patients affected by primary cutaneous lymphoma. We also provided the Paediatric Primary Cutaneous Lymphoma Atlas that illustrates the clinicopathological spectrum of observed presentations, in the hope of supporting other physicians in the diagnostic process. Retrospective chart review of paediatric patients diagnosed with primary cutaneous lymphomas between 1980 and 2022 at the Paediatric Dermatology Unit of Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan. A total of 101 patients (58 males, 43 females) met the inclusion criteria. The most common subtypes were lymphomatoid papulosis (n = 48) and mycosis fungoides (n = 31). These were followed by primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorders (n = 7), primary cutaneous anaplastic large-cell lymphomas (n = 5), primary cutaneous marginal zone B-cell lymphomas (n = 3), primary cutaneous follicle centre lymphomas (n = 2), subcutaneous panniculitis-like T-cell lymphomas (n = 2), primary cutaneous peripheral T-cell lymphoma not otherwise specified (n = 1), primary cutaneous precursor B-lymphoblastic lymphoma (n = 1) and Sézary syndrome (n = 1). Clinical follow-up data covering a median of 70.8 months (range 1-324) were available for 74 patients, of whom three died due to cutaneous lymphoma. Our findings shed light on the peculiar aspects and long-term outcomes of paediatric cutaneous lymphomas, particularly emphasizing their distinctive features in comparison to their adult counterparts and exploring the less common subtypes. Further larger-scale studies are warranted to better characterize these entities and to achieve a more rapid and accurate diagnosis.

Recurrence in acromegaly: two tertiary centers experience and review of the literature

BackgroundRecurrence of acromegaly after successful surgery is a rare event, but no clear data are reported in the literature about its recurrence rates. This study aimed to evaluate the recurrence rate in a series of acromegalic patients treated by transsphenoidal surgery (TSS) with a long follow-up.MethodsWe retrospectively analyzed data from 283 acromegalic patients who underwent TSS at two pituitary units in Milan (Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico and IRCCS Humanitas Research Hospital). The diagnosis and recurrence of acromegaly were defined by both elevated IGF-1 levels and a lack of GH suppression based on appropriate criteria for the assay used at the time of diagnosis.ResultsAfter surgery, 143 patients (50%) were defined as not cured, 132 (47%) as cured and 8 (3%) as partially cured because of normalization of only one parameter, either IGF1 or GH. In the cured group, at the last follow-up (median time 86.8 months after surgery), only 1 patient (0.7%) showed full recurrence (IGF-1 + 5.61 SDS, GH nadir 1.27 µg/l), while 4 patients (3%) showed only increased IGF1. In the partially cured group at the last follow-up, 2/8 (25%) patients showed active acromegaly (IGF-1 SDS + 2.75 and + 3.62; GH nadir 0.6 and 0.5 µg/l, respectively).ConclusionsIn the literature, recurrence rates range widely, from 0 to 18%. In our series, recurrence occurred in 3.7% of patients, and in fewer than 1%, recurrence occurred with elevation of both IGF-1 and the GH nadir. More frequently (25%), recurrence came in the form of incomplete normalization of either IGF-1 or GH after surgery.

The role of immune suppression in COVID-19 hospitalization: clinical and epidemiological trends over three years of SARS-CoV-2 epidemic.

Specific immune suppression types have been associated with a greater risk of severe COVID-19 disease and death. We analyzed data from patients >17 years that were hospitalized for COVID-19 at the "Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico" in Milan (Lombardy, Northern Italy). The study included 1727 SARS-CoV-2-positive patients (1,131 males, median age of 65 years) hospitalized between February 2020 and November 2022. Of these, 321 (18.6%, CI: 16.8-20.4%) had at least one condition defining immune suppression. Immune suppressed subjects were more likely to have other co-morbidities (80.4% vs. 69.8%, p < 0.001) and be vaccinated (37% vs. 12.7%, p < 0.001). We evaluated the contribution of immune suppression to hospitalization during the various stages of the epidemic and investigated whether immune suppression contributed to severe outcomes and death, also considering the vaccination status of the patients. The proportion of immune suppressed patients among all hospitalizations (initially stable at <20%) started to increase around December 2021, and remained high (30-50%). This change coincided with an increase in the proportions of older patients and patients with co-morbidities and with a decrease in the proportion of patients with severe outcomes. Vaccinated patients showed a lower proportion of severe outcomes; among non-vaccinated patients, severe outcomes were more common in immune suppressed individuals. Immune suppression was a significant predictor of severe outcomes, after adjusting for age, sex, co-morbidities, period of hospitalization, and vaccination status (OR: 1.64; 95% CI: 1.23-2.19), while vaccination was a protective factor (OR: 0.31; 95% IC: 0.20-0.47). However, after November 2021, differences in disease outcomes between vaccinated and non-vaccinated groups (for both immune suppressed and immune competent subjects) disappeared. Since December 2021, the spread of the less virulent Omicron variant and an overall higher level of induced and/or natural immunity likely contributed to the observed shift in hospitalized patient characteristics. Nonetheless, vaccination against SARS-CoV-2, likely in combination with naturally acquired immunity, effectively reduced severe outcomes in both immune competent (73.9% vs. 48.2%, p < 0.001) and immune suppressed (66.4% vs. 35.2%, p < 0.001) patients, confirming previous observations about the value of the vaccine in preventing serious disease.

External validation of a clinical prediction tool for the use of manual therapy for patients with temporomandibular disorders: a protocol for a prospective observational study

IntroductionClinical guidelines recommend conservative treatment for the management of temporomandibular disorders (TMD), and manual therapy directed to temporomandibular structures is commonly applied to reduce pain and improve function. In a...

Diabetes and orthostatic hypotension: are all patients created equal?

aDepartment of Medicine and Surgery, University of Milano-Bicocca bDepartment of Cardio-Thoracic-Vascular Diseases, Foundation IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy cDepartment of Cardiology, University Hospital ‘Dr Dragisa Misovic-Dedinje’, Belgrade, Serbia Correspondence to Professor Cesare Cuspidi, University of Milano-Bicocca Meda, Milan, 20821, Italy. E-mail: [email protected]

P-353 possible correlation between the second-to-four digit ratio (2d:4d) and endometriosis: a case-control study

Abstract Study question This study investigates a possible association between the second-to-four digit ratio and endometriosis. Summary answer There is an association between a higher 2D:4D ratio and the presence of endometriosis. What is known already Endometriosis is characterised by the presence of endometrium epithelium and/or stroma outside the uterus. Recent findings suggest that endocrine disruptors during intrauterine life could determine the onset of the disease.The ratio between the length of the index finger (2D) and the ring finger (4D) is a sexually dimorphic feature. Moreover, it has been proposed as a marker of prenatal hormonal exposure since high level of androgens results in a lower 2D:4D ratio, whereas a prenatal oestrogenic environment results in a higher one. Therefore, a longer 2D:4D ratio could be considered as a silent sign of the disease. Study design, size, duration This study was conducted at the Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico. Participants were recruited from July 2021 to October 2022. Cases included women with a past surgical diagnosis of endometriosis or with a current nonsurgical diagnosis of the disease. Women attending the outpatient clinics for periodic visits, contraception, severe male infertility, and cervical cancer screening programme and without a previous clinical or surgical diagnosis of endometriosis were enrolled as the control group. Participants/materials, setting, methods Women with endometriosis were divided into two groups: deep infiltrating endometriosis (DIE) and ovarian endometrioma (OMA) depending on the lesion localization. Among controls, endometriosis was excluded based on gynaecological history, pelvic transvaginal ultrasound, gynaecological bimanual examination and vaginal inspection.The digit lengths were measured on the right hand's ventral surface because previous studies suggested that the right hand is more sensitive to androgens. In addition, other clinical details were collected on standardised forms. Main results and the role of chance A total of 424 participants (endometriosis n = 212; controls n = 212) were recruited for this study. The group of cases included 114 women with ovarian endometriomas and 98 patients with deep infiltrating endometriosis.Although the median age in the endometriosis group was 37 years, significantly higher than controls (p &amp;lt; 0.01), other variables (such as BMI, ethnicity, smoking habit, age at menarche, parity, previous miscarriages and previous IVF) did not differ between the study groups.The right hand 2D:4D digit ratio resulted significantly higher in women with endometriosis compared to controls with 2D:4D ratio of 1.00 [0.97 - 1.03] and 0.99 [0.96 - 1.02] respectively (p = 0.002).The significant association remained when exclusively focussing on women with ovarian endometriomas (p = 0.002). In contrast, the association was no more significant when the analysis was restricted to women with deep infiltrating forms (p = 0.07).These findings support the potential role of intrauterine exposure of estrogen in the pathogenesis of the disease. A low ratio of testosterone-to-estradiol during fetal life may play a crucial role in endometriosis onset and progression. Limitations, reasons for caution The selection of controls may represent a source of bias since endometriosis was ruled out based on gynaecological and ultrasonography examination. Therefore, it could not be excluded having inadvertently included some cases among controls. Wider implications of the findings In conclusion, there is an association between a higher 2D:4D ratio and the presence of endometriosis. Our results support the hypothesis claiming potential influences of intrauterine hormonal and endocrine disruptors exposure during fetal life on the onset of the disease. Trial registration number not applicable

P-226 Conventional IVF rather than ICSI when only on oocyte is retrieved: time to overcome irrational fears

Abstract Study question Is the use of conventional-IVF (c-IVF) a viable option in single oocyte retrieved cycles? Summary answer The use of c-IVF on single oocyte seems to be a successful strategy in terms of laboratory performance indicators outlined in the Vienna Consensus. What is known already Intracytoplasmic Sperm Injection (ICSI) has greatly improved the chances of reproductive success in cases of male factor infertility, but it is often used without strong evidence, such as in cases of low numbers of retrieved oocytes, assuming it will avoid unexpected total fertilization failure (TFF). On these bases, several ART centers irrationally opt for ICSI when few oocytes are retrieved. This approach is due to the fear of facing TFF the following day. This situation is boosted when only one oocyte is available. Available studies on c-IVF in these circumstances are generally reassuring, but evidence is limited and inconclusive. Study design, size, duration This is a monocentric retrospective observational study performed at the Infertility Unit of the Fondazione Ca' Granda Ospedale Maggiore Policlinico between 2014 and 2021. The primary outcome of the study is normal fertilization rate, which is expected to be ≥ 60% according to the Vienna Consensus. The study sample (about 300 cycles) was calculated to obtain a 95% CI within the range of ± 5%. A binomial distribution model was used to determine the 95%CI of proportions. Participants/materials, setting, methods Only women who had recovered one oocyte at the oocyte retrieval were included in the study. Collected data included age of both partners, previous pregnancies, female BMI, antral follicle count, total motile sperm count. A multivariate analysis was performed to identify predictive factors for fertilization. Based on the policy of our Center, c-IVF was performed only in case of normal sperm variables according to WHO 2010 manual and in the absence of history of TFF. Main results and the role of chance Out of 700 cycles with single oocyte retrievals, 304 were treated with c-IVF, which resulted in normal fertilization (2PN) in 209 cases, corresponding to a fertilization rate of 69% (95%CI: 63-74%). In 13 cycles, oocytes were shown to be immature (germinal vesicle or metaphase I) at the time of fertilization check. In these cases, fertilization could not occur. If we exclude them, the fertilization rate raised to 72% (209/291) (95%CI: 66-77%). This fertilization rate was within the Vienna Consensus KPI for competency range and was no more than 5% lower compared to the benchmark value. Clinical pregnancy and live birth rates per cycle were 14% and 11%, respectively. Finally, we compared baseline characteristics of cycles with normal fertilization to those with failed fertilization. Both univariate and multivariate analyses failed to identify predictive factors of fertilization. Limitations, reasons for caution The retrospective nature and the absence of a control group do not allow us to draw robust and definitive conclusions. However, the large sample sized allowed us a precise estimation of the fertilization rate. Wider implications of the findings Fear about TFF is not a valid reason to opt for ICSI in women retrieving only one oocyte. The use of ICSI increases costs without providing benefits. We also failed di identify predictive factors of fertilization, hampering the possibility to select a subgroup of women who may benefit from ICSI. Trial registration number Not applicable

P-247 Total Fertilization Failure after conventional IVF: it is not the end of the story

Abstract Study question Could Rescue IntraCytoplasmatic Sperm Injection (R-ICSI) coupled with frozen transfers be an effective treatment for Total Fertilization Failure (TFF) after conventional InVitro Fertilization (c-IVF) cycles? Summary answer Applying R-ICSI after TFF of c-IVF, a blastulation rate of 28% could be obtained, allowing the cycle rescue in a consistent proportion of couples. What is known already Conventional IVF is to date the most indicated technique in infertile couples in the absence of male factor. However, the incidence of TFF following c-IVF, in presence of normozoospermic samples, ranges from 5 to 20%. TFF leaves experts with limited alternatives, which include cancelling the cycle with subsequent indication to proceed with ICSI in the next cycle or attempting R-ICSI in the current cycle. R-ICSI coupled with frozen embryo transfer may overcome most of the technical and biological issues associated with fresh transfer after R-ICSI, possibly representing an efficient procedure for couples experiencing TFF following c-IVF. Study design, size, duration Our retrospective study included 33 couples who underwent assisted reproduction techniques (ART) at the Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico of Milan from October 2021 to December 2022 and that experienced TFF after c-IVF, regardless the number of oocytes retrieved. Overall, TFF was reported in 7% of c-IVF cycles (33/439). An indication for male factor infertility was an exclusion criterium. World Health Organization (WHO) reference values for human semen characteristics have been adopted. Participants/materials, setting, methods Fertilization failure was considered in terms of absence of the two pronuclei and the second polar body. Out of 158 unfertilized oocytes, 128 MII oocytes were microinjected after c-IVF in the same cycle. R-ICSI consists of performing ICSI 22-24 hours after insemination with an unsuccessful c-IVF, using the same semen sample maintained at room temperature overnight. Fertilized oocytes after R-ICSI were cultured to the blastocyst stage according to our standard protocol. Main results and the role of chance The fertilization rate was 42% (95%CI: 34-51%). Fertilization failure was still observed in 9 patients (27%, 95%CI: 13-46%) after R-ICSI, with a median value of 2 [2-5] oocytes available for insemination. In the 24 patients who obtained at least one zygote, the blastulation rate was 28% (95%CI: 16-42%). A total of 15 blastocysts were cryopreserved in 10 patients on day 5 or 6 after R-ICSI. Of these 10 patients, 6 have undergone frozen/thawed single embryo transfer, and the success rate (ongoing pregnancy) was 50% (95%CI: 12-88%). Limitations, reasons for caution One of the limitations is the small sample size, since this is an emergency procedure. However, the study is still ongoing. Women were not subjected to inclusion criteria, thus fertilization failure could be attributed to several factors different from semen quality. Wider implications of the findings This study turns out to be important in light of the interesting implantation rate obtained. With the advantage of reducing both costs and psychological burden of the couple, the technique can be proposed as a rescue strategy in cases of TFF allowing to confidently increase the number of c-IVF procedure. Trial registration number not applicable

P-344 Prevalence and maternal risk factors for neonatal uterine bleeding (NUB): a possible origin of endometriosis?

Abstract Study question What is the prevalence and the cause of neonatal uterine bleeding, also known as “genital crisis”? Is it associated with maternal lifestyle and obstetric history? Summary answer The prevalence of NUB has been estimated as 29% and it seems to be correlated to some aspects of the maternal lifestyle What is known already NUB is considered a physiological phenomenon characterized by a menstrual-like bleeding occurring during the first days of life in female newborns, with an estimated incidence of 3-5%. It seems to be related to the reduction of steroid hormones in the baby after the separation from the maternal placenta, although, actually, some theories hypothesize NUB as a consequence of the exposure to molecular disruptors during intrauterine life. However, data regarding NUB still remain uncertain. Interestingly, recent theories assume a correlation between NUB and endometriosis onset, considering it as a consequence of the retrograde menstruation of stem cells during the genital crisis Study design, size, duration This is a prospective cohort study performed in a population of 105 mothers-to-be who delivered their babies at Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico of Milan between March 2022 and December 2022. Inclusion criteria were: gestation of a single female fetus, age between 18 and 42, being in healthy condition and undergoing a low-risk pregnancy. Women with endometriosis had also been included Participants/materials, setting, methods At the time of recruitment few days before delivery, patients were asked to fill a questionnaire regarding general clinical characteristics (BMI, smoking habits, diet). After two weeks from delivery, a follow up was performed asking them information about pregnancy outcomes (time to pregnancy, complications and type of delivery), a possible vaginal bleeding for the baby and its duration, the type of lactation (breastfeeding, formula or both) and clinical neonatal information. Main results and the role of chance NUB frequency was unexpectedly high. Twenty-nine percent of the babies experienced NUB with a duration of 3 days and insurgence 2 days post-partum. Among the variables analyzed, genital crisis resulted higher in newborns from women with significantly higher BMI compared to women with a lower BMI (BMI 23 vs 21.5 respectively, p&amp;lt;0.05). Smoking during pregnancy was associated with a higher incidence of newborns with NUB (20% vs 4% in controls; p &amp;lt; 0.05). According to the type of lactation, in newborns with genital crisis, 43% of them received maternal breastfeeding while the same type of feeding has been reported in 69% of controls (p&amp;lt;0.05). Lastly, soy consumption by the mothers was observed only in 41% of cases of genital crisis while among mothers whose newborns did not experience NUB, 58% declared presence of soy in their diet (p&amp;lt;0.05). Limitations, reasons for caution The population size is relatively small. Also, as prospective cohort study, loss of individuals at follow up and recall bias may occur Wider implications of the findings Collecting more information on the hormonal determinants of NUB could be useful for future studies on intrauterine life and reproductive disorders. If a link between NUB and endometriosis is confirmed, NUB might lead to the understanding of the onset of this pathological condition Trial registration number not applicable

P-435 HPV and infertility in couples requiring Assisted Reproduction Techniques (ART).

Abstract Study question How frequent is Human Papilloma Virus (HPV) infection in both partners of infertile couples referring to our ART center and whats its impact? Summary answer Only 6% of infertile couples are positive for HPV and infection has no impact on embryologic parameters. What is known already There is limited and conflicting evidence about the relationship between HPV infection in male partners and infertility. Notably, most of the previous studies did not assess the presence of the infection in both partners in the context of ART. Furthermore, even if considered, the influence of the infection of the female partner may be underestimated because only data on adverse pregnancy outcomes were evaluated. Elucidating the HPV-positive status of the two individuals belonging to the couple could open up new scenarios. Study design, size, duration This prospective cohort study was performed on 81 couples. The analysis was conducted on semen samples of male patients and on cervical samples of female partners who underwent assisted reproduction techniques (ART) treatment at the infertility unit of Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico of Milan from February 2022 to November 2022. Participants/materials, setting, methods The female partecipants were recruited before the beginning of the controlled ovarian stimulation (COS) while male participants were recruited on the day of the female ovum pick-up (OPU). The technique used to assess the presence of the HPV virus was the Real Time PCR (RT-PCR). Personal characteristics, lifestyle habits and sexual habits were investigated as possible favoring elements for the insurgence of HPV infection. Main results and the role of chance Among 81 couples recruited, 12 men and 22 women tested positive for high- and low risk HPV viruses. This streins corrisponds to a prevalence of about 15% (95% CI: 9-24%) for males and 27% (95% CI: 19-38%) for females. Among these positive couples, only 5 cases (6%, 95% CI: 3-14%) simultaneously tested positive for both partners: in two pairs they were positive for the same viral strains, in two other pairs there was no concordance between the viral strains found, and in one pair there was only a partial concordance. McNemar's test (a dichotomous evaluation test for data paired aimed at assessing possible associations) was not significant. No differences in embryo developmental failure, “top-quality” embryo formation and “top-quality” blastocyst formation were found between the two groups (positive vs negative couples). Limitations, reasons for caution A possible limitation of the study is the small sample size. Additionally we mainly focused on the impact of infection by HPV on embryological variables, without considering developmental pregnancies and live birth rate. Wider implications of the findings The very low concordance observed suggests that infection follows intricate pathways, far beyond the trivial view of a ping-pong effect between partners of the couple. These results suggest that HPV infection probably develops independently in the two individuals of the couple, as if there is not a mutual influence. Trial registration number NOT APPLICABLE

Low ovarian reserve and risk of miscarriage in pregnancies derived from assisted reproductive technology.

Do low levels of anti-Müllerian hormone (AMH) or antral follicle count (AFC) properly predict miscarriage in young women conceiving with ART? Low ovarian reserve, as indicated by AMH or AFC, is not associated with miscarriage in young women conceiving with ART. Presently, the impact of low ovarian reserve on the risk of miscarriage remains controversial. Some studies have reported an association between serum AMH levels and AFC and miscarriage, but others have failed to confirm these findings. The main limitation that undermines the reliability and consistency of the results is the confounding effect of female age. Indeed, after 35 years of age, on the one hand, the risk of miscarriage starts increasing because of impaired oocyte quality while, on the other, the physiological decline in AMH and AFC levels continues, thus hampering the possibility to properly explore the real effects of reduced ovarian reserve. Indeed, the two processes, i.e. the gradual loss of resting primordial follicles and the loss of oocyte quality, progress in parallel. In other words, the older the woman becomes, the higher is the risk of miscarriage, but one cannot distinguish between the effects of biological aging on oocyte quality and those mediated by a lower ovarian reserve. The present retrospective monocentric cohort study was carried out at Fondazione IRCSS Ca Granda Ospedale Maggiore Policlinico, Milan. All women referred to the ART Unit between 2014 and 2021 and who underwent either conventional IVF (c-IVF), ICSI, or IUI were reviewed. Only women younger than 35 were eligible because, up to this age, the risk of miscarriage is steady and not strictly related to age. Women younger than 35 who achieved a singleton clinical pregnancy with c-IVF, ICSI, or IUI were selected. Women with patent causes of recurrent miscarriage were excluded, as well as those undergoing pregnancy termination for fetal or medical causes. Women who did and did not have a pregnancy loss before 20 weeks' gestation were compared. Detailed information was obtained from charts of the consulting patients. ART procedures were performed according to the standardized policy of our Unit. All women underwent serum AMH measurement and a transvaginal assessment of AFC prior to initiation of treatment. AMH levels were measured by a commercially available ELISA assay. To assess AFC, all identifiable antral follicles 2-10 mm in diameter at ultrasound were recorded. The primary outcome was the risk of miscarriage for women with serum AMH levels below 5 pmol/l. There were 538 women were included, of whom 92 (17%) had a miscarriage. The areas under the ROC curves for prediction of miscarriage based on AMH levels and AFC were 0.51 (95% CI: 0.45-0.58) and 0.52 (95% CI: 0.45-0.59), respectively. The odds ratio (OR) of miscarriage for women with serum AMH levels below 5.0 pmol/l was 1.10 (95% CI: 0.51-2.36); the adjusted OR was 1.12 (95% CI: 0.51-2.45). Analyses were repeated considering other thresholds for AMH (2.9, 3.6 and 7.9 pmol/l) and for AFC (thresholds of 7 and 10). No associations emerged. The retrospective design of the study hampered the collection of more precise but potentially relevant clinical information of the couples. We did not exclude women suffering from PCOS, a condition possibly associated with miscarriage. Moreover, the baseline characteristics of women who did and did not have a miscarriage differed in some characteristics. Thus, we adjusted the OR using a multivariate analysis, but we cannot fully exclude residual confounding effects. Finally, our results cannot be inferred to women older than 35. The mechanisms causing premature exhaustion of ovarian reserve may be different in younger and older women and this may lead to a different impact on the risk of miscarriage. Women embarking on ART with low ovarian reserve should be informed of their likely poor response to ovarian stimulation but can be reassured that, if conception occurs, their risk of miscarriage is not increased. This study was partially funded by Italian Ministry of Health-Current research IRCCS. E.S. reports grants from Ferring and honoraria for lectures from Merck-Serono and Gedeon-Richter. All the other authors do not have any competing interest to declare. N/A.

P87 GENETIC CARDIOMYOPATHIES: THE FIRST YEAR OF THE FONDAZIONE IRCCS CÀ GRANDA OSPEDALE MAGGIORE POLICLINICO OF MILAN DEDICATED CLINICAL SERVICE

Abstract Objectives Cardiac genetic counselling and testing for inherited cardiomyopathies have become essential aspects of cardiovascular care. A genetic diagnosis in a family can offer an invaluable tool for cascade genetic testing of at–risk relatives. A careful clinical and individualized approach to genetic cardiomyopathies is now needed to guarantee the best care possible. We report the results of our first–year genetic cardiomyopathies single–centre experience. Methods From September 2021, 69 genetic tests have been carried out at Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico of Milan by the staff of a new specific clinical service dedicated to genetic cardiomyopathies. Results The present study collects the data of 69 patients who underwent genetic testing and clinical follow up at our centre in suspicion of underlying genetic etiology of disease. Next generation sequencing was adopted to conduct genetic testing either by a customized panel of 54 specific genes for cardiomyopathies or by a clinical exome (180 genes). Time required for reporting and patient communication were 8 and 12 weeks, respectively. Female sex was 36%, mean age was of 53.2 ± 21.3 years. The main indications for genetic testing were dilated cardiomyopathy (DCM) and hypertrophic cardiomyopathy (HCM). Figure 1. 41% of DCM and 50% of HCM patients tested positive for a pathogenic or likely pathogenetic mutation. Cascade genetic tests conducted on at–risk relatives were 21 (30%). Among these subjects, 38% resulted positive at genetic screening and 57% were in turn positive at phenotypic screening. The genes hit by pathogenic or likely pathogenetic mutations are illustrated in Figure 2. Conclusion The first year of a specific clinical service dedicated to genetic cardiomyopathies made it possible to identify a substantial number of patients and at–risk relatives affected by pathogenic or likely pathogenetic genetic mutations.

Mitigating the economic burden of GnRH agonist therapy for progestogen-resistant endometriosis: why not?

Is it possible to reduce the cost of GnRH agonist treatment for endometriosis by using non-standard dosing regimens? An extended-interval dosing regimen of a 3.75 mg depot formulation of triptorelin injected every 6 weeks instead of every 4 weeks reduces the cost by one-third without compromising the effect on pain relief. Cost constitutes a limit to prolonged GnRH agonists use. Alternative modalities to reduce the economic burden of GnRH agonist treatment have been anecdotally attempted. A systematic review was conducted to evaluate and compare the effect of three alternative modalities for GnRH use in women with endometriosis, i.e. intermittent oestrogen deprivation therapy, reduced drug dosage, and extended-interval dosing regimens of depot formulations. A PubMed and Embase search was initially conducted in October 2022 and updated in January 2023 using the following search strings: (endometriosis OR adenomyosis) AND (GnRH-agonists OR gonadotropin-releasing hormone agonists OR triptorelin OR leuprorelin OR goserelin OR buserelin OR nafarelin). Full-length articles published in English in peer-reviewed journals since 1 January 1980, and reporting original data on GnRH agonist treatment of pain symptoms associated with endometriosis were selected. Information was extracted on study design, GnRH-agonist used, dosage, total duration of therapy, side effects, treatment adherence, and pelvic pain relief. Reviews, commentaries, conference proceedings, case reports, and letters to the editor were excluded. Of the 1664 records screened, 14 studies regarding clinical outcomes associated with the 3 considered alternative modalities for GnRH agonist use were eventually included (intermittent oestrogen deprivation therapy, n = 2; low-dose or 'draw-back' therapy, n = 8; extended-interval dosing regimen, n = 4). Six studies were randomized controlled trials (RCTs) (double blind, n = 2) and eight adopted a prospective cohort design (non-comparative, n = 6; comparative, n = 2). A total of 776 women with endometriosis were recruited in the above studies (intermittent oestrogen deprivation therapy, n = 77; low-dose or 'draw-back' therapy, n = 528; extended-interval dosing regimen, n = 171). Robust data demonstrating cost saving without detrimental clinical consequences were available for the extended-interval dosing regimen only. In particular, the 3.75 mg triptorelin depot preparation inhibits ovarian function for a longer period compared with the 3.75 mg leuprorelin depot preparation, allowing injections every 6 instead of 4 weeks. Based on the cost indicated by the Italian Medicine Agency for the 3.75 mg triptorelin depot preparation, this would translate in a yearly saving of €744.60 (€2230.15-€1485.55; -33.4%). The quality of the evidence reported in the selected articles was not formally evaluated and a quantitative synthesis could not be performed. Some studies were old and the tested therapeutic approaches were apparently obsolete. Only cost containment associated with GnRH analogue use, and not cost-effectiveness, has been addressed. Consuming less resources without negatively impacting on health outcomes carries ethical and practical implications for individuals and the community, as this approach may result in overall increased healthcare access. This study was supported by the Italian Ministry of Health (Ricerca Corrente 2023, IRCCS Ca' Granda Ospedale Maggiore Policlinico Milano). E.S. discloses payments from Ferring for research grants and honoraria from Merck-Serono for lectures. All other authors declare they have no conflict of interest. N/A.