Uterine Vein Research Articles

Akt Activation and Inhibition of Cytochrome C Release: Mechanistic Insights into Leptin-promoted Survival of Type II Alveolar Epithelial Cells.

Fetal growth restriction (FGR) increases the risk of perinatal death, partly due to defects in lung development. Leptin, a polypeptide hormone, is involved in fetal lung development. We previously demonstrated that treatment with exogenous leptin during gestation significantly promotes fetal lung maturity in the rat model of FGR. In this study, to delineate the molecular pathways through which leptin may enhance fetal lung development, we investigated the impact of leptin treatment on the survival of type II alveolar epithelial cells (AECs), essential leptin-responsive cells involved in lung development, in a rat model of FGR. The rat model of FGR was induced in pregnant Sprague-Dawley rats by partial uterine artery and vein ligation. In vivo and in vitro analyses of fetal lung tissues and freshly-isolated cultured AECs, respectively, showed that leptin protects type II AECs from hypoxia-induced apoptosis. Further molecular studies revealed the role of Akt activation in the leptin-mediated promotion of survival of type II AECs. The data also showed that the anti-apoptotic effects of leptin are dependent on phosphoinositol 3-kinase (PI3K) activation, and involve the down-regulation of caspases 3 and 9, upregulation of pro-survival proteins Bcl-2, and p-Bad, and inhibition of the release of cytochrome c from mitochondria. Taken together, our data suggested that leptin enhances the maturity of fetal lungs by mediating the regulation of caspase-3 and -9 during hypoxia-induced apoptosis of type II AECs and provide support for the potential of leptin as a therapeutic agent for promoting lung development in FGR.

A surgical technique using the ovarian vein in non-human primate models of potential living-donor surgery of uterus transplantation.

Living donor surgery in organ transplantation should be performed in a minimally invasive manner under conditions that are as safe as possible. The objective of this study is to examine whether the procedure for using the ovarian vein makes donor surgery less invasive in a cynomolgus monkey model of potential living-donor surgery of uterus transplantation. Twenty-two female cynomolgus monkeys aged 6-9 years and with body weights of 3.55 ± 1.28 kg were used in the study. Vessels and tissues surrounding the uterus were dissected while preserving the uterine artery/vein. The deep uterine vein was used as a venous pedicle in four monkeys (Group 1), and the ovarian vein was used instead of the deep uterine vein in 18 monkeys (Group 2). With the uterine artery/vein and deep uterine vein (Group 1) or ovarian vein (Group 2) connected to the uterus, the vaginal canal was cut. The vessels were then clamped to produce a donor surgery model. Surgical time, intraoperative organ and vascular injury were examined in each animal. The average surgical time from laparotomy to clamping of vessels was 230 ± 112 min in all 22 cynomolgus monkeys, and significantly longer in Group 1 (n = 4) than in Group 2 (n = 18) (393 ± 71 vs. 194 ± 84 min, p < 0.05). Surgical time in Group 2 showed a tendency to decrease in animals treated later in the study, with a significantly longer time in the first 10 monkeys compared with the last 8 (253 ± 65 vs. 120 ± 26 min, p < 0.05). All monkeys had no complications, including no injuries to other organs and no unanticipated vascular injury. The procedure using the ovarian vein was less invasive than that using the deep uterine vein in mimicking living-donor surgery in a cynomolgus monkey model of uterus transplantation.

Maternal metabolizable protein restriction during late gestation on uterine and umbilical blood flows and maternal and fetal amino acid concentrations near term in sheep

To examine the effects of maternal metabolizable protein (MP) restriction during late gestation on uterine and umbilical blood flows, conceptus size, and amino acid concentrations in the uterine and umbilical vessels, 11 ewes with singleton pregnancies were assigned to one of three isocaloric diets formulated to provide 60% of MP (MP60), 80% of MP (MP80), or 100% of MP (MP100) requirements from days 100 to 130 of gestation. On day 130 of gestation, intraoperative uterine and umbilical blood flows were obtained as well as serum samples from the uterine artery, uterine vein, umbilical artery, and umbilical vein. Ewes on the MP60 diet had lighter (P=0.04) and smaller (P≤0.05) fetuses, but increased (P=0.02) uterine blood flow relative to fetal weight compared with MP100 ewes, with MP80 being intermediate. Umbilical blood flow was similar (P=0.70) across treatments. Glutamine, glycine, isoleucine, leucine, ornithine, serine, and valine concentrations were impacted (P≤0.02) by maternal treatment. While uterine flux of total serum nitrites was greater (P=0.03) in MP60 and MP80 ewes compared with MP100 ewes, fetal flux did not differ. Decreased maternal protein intake resulted in less (P<0.01) maternal cytochrome P450 1A enzyme activity. There were minimal impacts of maternal diet on steroid concentrations. Maternal dietary protein may alter fetal growth by impacting placental vasculature function and nutrient absorptive capabilities.

The Swedish uterus transplantation project: the story behind the Swedish uterus transplantation project.

The Swedish uterus transplantation project: the story behind the Swedish uterus transplantation project.

Ruptured traumatic ovarian artery pseudoaneurysm in a pregnant patient.

A woman at 36 weeks' gestation was involved in a motor vehicle crash. She required emergency delivery of a healthy infant by cesarean section. She received anticoagulation, despite a splenic injury, for a possible inferior vena cava clot. She re-presented with new retroperitoneal hemorrhage around the juxtarenal aorta. A computed tomography scan suggested a vague contrast blush anterior to the aorta. Arteriography disclosed a right ovarian artery pseudoaneurysm, which was treated with microcoil embolization. The patient has subsequently recovered fully. In major trauma in pregnant patients, ovarian artery pathology needs to be considered in the differential diagnosis of post-traumatic hemorrhage.

Step-by-step Type C Laparoscopic Radical Hysterectomy With Nerve-sparing Approach.

To show the laparoscopic technique to perform type C radical hysterectomy with a nerve-sparing approach and pelvic lymphadenectomy. Educational video with step-by-step explanation of the technique using videos and pictures to highlight the anatomic landmark that guides the procedure. The goal of this procedure is to enlarge the resection of the paracervix at the junction with internal iliac vascular system, leaving the neural part of the structure under the deep uterine vein untouched. Type C consists in the resection of the uterosacral ligament at the rectum level and the vesicouterine ligament at the bladder level. The ureter is mobilized completely, and 15 to 20 mm of the vagina from the tumor or cervix is resected. Performing such an enlarged hysterectomy, the preservation of the nerve supply to the bladder is crucial, leading to the creation of the subclasses. Type C1 conserves a nerve-sparing approach remaining above the deep uterine vein, whereas in type C2 a resection beyond this landmark including the neural part of the paracervix is performed. Total laparoscopic type C1 radical hysterectomy with pelvic lymphadenectomy. This video shows the feasibility of type C radical hysterectomy through a minimally invasive approach. The possibility to perform this type of procedure laparoscopically matches with the more conservative approach to cervical cancer, bringing all the advantages of this technique into this field of gynecologic surgery.

Placental glucose transfer: a human in vivo study.

ObjectivesThe placental transfer of nutrients is influenced by maternal metabolic state, placenta function and fetal demands. Human in vivo studies of this interplay are scarce and challenging. We aimed to establish a method to study placental nutrient transfer in humans. Focusing on glucose, we tested a hypothesis that maternal glucose concentrations and uteroplacental arterio-venous difference (reflecting maternal supply) determines the fetal venous-arterial glucose difference (reflecting fetal consumption).MethodsCross-sectional in vivo study of 40 healthy women with uncomplicated term pregnancies undergoing planned caesarean section. Glucose and insulin were measured in plasma from maternal and fetal sides of the placenta, at the incoming (radial artery and umbilical vein) and outgoing vessels (uterine vein and umbilical artery).ResultsThere were significant mean (SD) uteroplacental arterio-venous 0.29 (0.23) mmol/L and fetal venous-arterial 0.38 (0.31) mmol/L glucose differences. The transplacental maternal-fetal glucose gradient was 1.22 (0.42) mmol/L. The maternal arterial glucose concentration was correlated to the fetal venous glucose concentration (r = 0.86, p<0.001), but not to the fetal venous-arterial glucose difference. The uteroplacental arterio-venous glucose difference was neither correlated to the level of glucose in the umbilical vein, nor fetal venous-arterial glucose difference. The maternal-fetal gradient was correlated to fetal venous-arterial glucose difference (r = 0.8, p<0.001) and the glucose concentration in the umbilical artery (r = −0.45, p = 0.004). Glucose and insulin concentrations were correlated in the mother (r = 0.52, p = 0.001), but not significantly in the fetus. We found no significant correlation between maternal and fetal insulin values.ConclusionsWe did not find a relation between indicators of maternal glucose supply and the fetal venous-arterial glucose difference. Our findings indicate that the maternal-fetal glucose gradient is significantly influenced by the fetal venous-arterial difference and not merely dependent on maternal glucose concentration or the arterio-venous difference on the maternal side of the placenta.

Ultrasonic shears and bipolar vessel-sealing system for three-port laparoscopic ovariohysterectomy in dogs

In the current experimental study, two different instruments were compared for prophylactic hemostasis during a 3-port technique of laparoscopic ovariohysterectomy (OVH) in bitches. Moreover, the need for port enlargement for specimen retrieval using 5mm or 10mm trocartes, technical difficulties and complications were assessed. Ultrasonic energy and a vascular sealing system were tested. Duration of surgery, patient weight and diameter of the uterine arteries and veins were compared among the groups. Fifteen dogs randomly divided into three groups (GI, GII, GIII) were submitted to ovariohysterectomy with hemostasis from the use of ultrasonic scalpel or vascular sealing equipment. In GI and GII the LigaSure(tm)impedance-controlled bipolar vessel-sealing device was used, differing in the size of trocartes used between groups, and in GIII Autosonix(tm) was used. Patients' weight, duration of surgery, technical difficulties and complications were compared among the groups. Statistical analysis showed no difference between the data analyzed among the groups. In conclusion, both methods of hemostasis were effective for 3-port total laparoscopic ovariohysterectomy in bitches. However, 5mm trocartes were not adequate for retrieval of the uterus and ovaries without need for enlargement of the port incision.

Hemoperitoneum Caused by Spontaneous Uterine Varicose Vein Rupture in the Third Trimester of Pregnancy-A Case Report

Spontaneous rupture of uterine varicose veins is a rare and poorly understood complication during pregnancy. Its clinical presentation is misleading and non-specific. Due to the high maternal and fetal mortality, the diagnosis of a hemoperitoneum must be done quickly. We report a case of spontaneous rupture of uterine varicose veins revealed by an abundant hemoperitoneum that occurred in a 35 year-old pregnant patient at 32 weeks of gestation. A laparotomy enabled the diagnosis and the treatment of this complication in addition to the extraction through a cesarean section of a healthy newborn.

Implantation and Establishment of Pregnancy in Ruminants.

The establishment of pregnancy in ruminants occurs during the peri-implantation period and involves the suppression of the endometrial luteolytic mechanism to maintain progesterone production by the corpus luteum (CL). Reciprocal interactions between the elongating conceptus (embryo/fetus and associated extraembryonic membranes) and endometrium culminate in implantation. Antiluteolytic effects of the conceptus are due to the production of interferon tau (IFNT) by the trophoblast that has a paracrine effect to inhibit the upregulation of oxytocin receptors in the endometrial epithelia, thereby disrupting uterine release of luteolytic prostaglandin F2 alpha (PGF) pulses. Additionally, IFNT is released into the uterine vein and has endocrine actions to induce ISGs in peripheral tissues. For example, IFNT may induce luteal resistance to PGF, thereby ensuring survival of the CL and maintenance of pregnancy. Survival of the blastocyst and elongation of the conceptus requires embryotrophic factors from the epithelia of the uterus, and those embryotrophic factors are regulated by ovarian progesterone as well as conceptus-derived factors including IFNT and prostaglandins. This review provides new concepts on mechanisms of the establishment of pregnancy and implantation in ruminants with emphasis on conceptus-maternal signaling associated with elongation of the blastocyst and endometrial responses to the presence of a conceptus.

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Objectives Gap junctions (GJ) are intercellular channels that contribute to the robust vasodilation found in pregnancy in several vascular beds. GJs allow for the coordination of endothelial cell responses by directing cell-cell communication via facilitated diffusion of signaling molecules (e.g. cAMP, cGMP). The phosphorylation of GJ protein Cx43 at serine (Ser) residues regulates both open (Ser365) and closed gating (Ser368), thus allowing the passage of signaling molecules between cells. Although the phosphorylation events of cAMP are well studied, little is known about cGMPs role on gap junction intracellular communication (GJIC) and function. Hypothesis: The inhibition of cAMP and cGMP-mediated pathways will modulate the phosphorylation and expression of Cx43 at their respective phosphorylation sites and thus increase or reduce GJIC in pregnant ovine uterine artery endothelial cells (P-UAECs) and human umbilical vein endothelial cells (HUVECs). Methods P-UAECs were pretreated with the respective cAMP and cGMP nucleotide cyclase inhibitors SQ22536 and ODQ (0.1–100 μ M) followed by treatment with 100 μ M of ATP or Forskolin, or 1 μ M–1 mM 8-Bromo-cAMP or 8-Bromo-cGMP and analyzed using ELISA, western analysis, or scrape-loading/dye transfer technique. Results ELISA revealed that the inhibitors SQ22536 and ODQ specifically and completely abrogated (P 0.01) cAMP and cGMP productions, respectively. Western analysis showed that SQ22536, decreased (P 0.05) the ATP, Forskolin, and cAMP-induced phosphorylation at Ser365 in P-UAECs and HUVECs, while GJIC function was reduced. ODQ decreased (P 0.05) ATP and cGMP-induced elevation at Ser365 in P-UAECs and HUVECs. In contrast, ODQ alone had no effect on GJIC. Conclusions cAMP via adenylyl clycase and cGMP via guanylyl cyclase differentially regulate Cx43 phosphorylation and expression, which is important in regulating GJIC. Although both cyclic nucleotides may serve as important regulation mechanisms in controlling vascular tone, cAMP may play the most important functional role in GJICs. These findings also suggest an expanded role of cGMP signaling on GJ function. Disclosures B. Ampey: None. I. Bird: None. R. Magness: None.

Pulmonary Embolism and Uterine Venous Plexus Thrombosis in the Postpartum Period

Pregnancy is associated with an increased risk of venous thromboembolism, which includes pulmonary embolism (PE) and deep vein thrombosis. The incidence of venous thromboembolism is estimated at 0.76 to 1.72 per 1,000 pregnancies, which is four times higher than that in non-pregnant women [1]. The incidence of PE in the postpartum period is much higher than during pregnancy [2]. There are few reports on uterine vein thrombosis, consisting mostly of cases involving thrombi in external and internal iliac veins [3]. Uterine venous plexus thrombosis (UVPT) is a rare diagnosis. Sudden death linked to pulmonary thromboembolism (PTE) in the presence of UVPT without deep vein thrombosis in the lower extremities is even more uncommon. We report a case of sudden, unexpected death due to acute PTE associated with UVPT in a postpartum woman.

Anatomical basis of female pelvic cavity for nerve sparing radical hysterectomy.

The separation and sparing of the vesical branch of the inferior hypogastric plexus (IHP), to preserve the pelvic autonomic nerve, is critical and difficult in nerve sparing radical hysterectomy. Pelvic local anatomy was performed to provide the necessary anatomical information. Precise pelvic anatomy was performed in 15 adult corpses, and immunohistochemical analysis was carried out on the parametrial tissues of three fresh cadavers to analyze the nerve fiber type and content of the vesical branch of the IHP. The deep uterine vein is located in the upper region of the cardinal ligament (CL), with three to six multiple branches and anatomical variation, including one or two cervical branches, and two to four vesical branches. Three branches were found to be most common (63.3 %). The major distribution of the vesical branch of the IHP is dorsomedial to the middle and inferior vesical veins, with less ventral and lateral distribution. There are more sympathetic fibers than parasympathetic fibers in the vesical branch. There is a region rare of vasculature and nerve between the vaginal lateral margin and the vesical branch. The deep uterine vein is suggested as an anatomical landmark during surgery, to process the CL and preserve the pelvic splanchnic nerves. The middle and inferior vesical veins can be used as the landmark to preserve the vesical branch of the IHP.

Recent advances in research on nitrergic nerve-mediated vasodilatation.

Cerebral vascular resistance and blood flow were widely considered to be regulated solely by tonic innervation of vasoconstrictor adrenergic nerves. However, pieces of evidence suggesting that parasympathetic nitrergic nerve activation elicits vasodilatation in dog and monkey cerebral arteries were found in 1990. Nitric oxide (NO) as a neurotransmitter liberated from parasympathetic postganglionic neurons decreases cerebral vascular tone and resistance and increases cerebral blood flow, which overcome vasoconstrictor responses to norepinephrine liberated from adrenergic nerves. Functional roles of nitrergic vasodilator nerves are found also in peripheral vasculature, including pulmonary, renal, mesenteric, hepatic, ocular, uterine, nasal, skeletal muscle, and cutaneous arteries and veins; however, adrenergic nerve-induced vasoconstriction is evidently greater than nitrergic vasodilatation in these vasculatures. In coronary arteries, neurogenic NO-mediated vasodilatation is not clearly noted; however, vasodilatation is induced by norepinephrine released from adrenergic nerves that activates β1-adrenoceptors. Impaired actions of NO liberated from the endothelium and nitrergic neurons are suggested to participate in cerebral hypoperfusion, leading to brain dysfunction, like that in Alzheimer's disease. Nitrergic neural dysfunction participates in impaired circulation in peripheral organs and tissues and also in systemic blood pressure increase. NO and vasodilator peptides, as sensory neuromediators, are involved in neurogenic vasodilatation in the skin. Functioning of nitrergic vasodilator nerves is evidenced not only in a variety of mammals, including humans and monkeys, but also in non-mammals. The present review article includes recent advances in research on the functional importance of nitrergic nerves concerning the control of cerebral blood flow, as well as other regions, and vascular resistance. Although information is still insufficient, the nitrergic nerve histology and function in vasculatures of non-mammals are also summarized.

Therapeutic potential of mesenchymal stem cell transplantation in a nitrofen-induced congenital diaphragmatic hernia rat model.

The aim of this study was to evaluate the efficacy of mesenchymal stem cells (MSCs) in a nitrofen-induced congenital diaphragmatic hernia (CDH) rat model. Pregnant rats were exposed to nitrofen on embryonic day 9.5 (E9.5). MSCs were isolated from the enhanced green fluorescent protein (eGFP) transgenic rat lungs. The MSCs were transplanted into the nitrofen-induced E12.5 rats via the uterine vein, and the E21 lung explants were harvested. The study animals were divided into three: the control group, the nitrofen-induced left CDH (CDH group), and the MSC-treated nitrofen-induced left CDH (MSC-treated CDH group). The specimens were morphologically analyzed using HE and immunohistochemical staining with proliferating cell nuclear antigen (PCNA), surfactant protein-C (SP-C), and α-smooth muscle actin. The alveolar and medial walls of the pulmonary arteries were significantly thinner in the MSC-treated CDH group than in the CDH group. The alveolar air space areas were larger, while PCNA and the SP-C positive cells were significantly higher in the MSC-treated CDH group, than in the CDH group. MSC engraftment was identified on immunohistochemical staining of the GFP in the MSC-treated CDH group. MSC transplantation potentially promotes alveolar and pulmonary artery development, thereby reducing the severity of pulmonary hypoplasia.

Laparoscopic Dissection and Anatomy of Sacral Nerve Roots and Pelvic Splanchnic Nerves

Study ObjectiveTo demonstrate the technique of laparoscopic dissection for identification of sacral nerve roots and pelvic splanchnic nerves. DesignCase report (Canadian Task Force classification III). SettingPrivate practice hospital in São Paulo, Brazil. PatientA 31-year-old woman with suspected iatrogenic and/or compression of sacral nerve roots. She reported debilitating pelvic, gluteal, and perineal unilateral left-sided pain (score 8 on a pain scale of 0–10), and had primary infertility with 1 previous failed attempt at in vitro fertilization. Surgical history included laparoscopic excision of endometriosis 10 months before the procedure and left oophoroplasty during adolescence because of a benign neoplasm. InterventionsStandard 4-puncture laparoscopy was performed. The peritoneum of the left pelvic sidewall was resected to preclude eventual residual endometriosis. This also enabled identification of uterine vessels including the deep uterine vein, which is the limit between the pars vascularis superiorly and the pars nervosa inferiorly in the uterine broad ligament. Surgery was using the laparoscopic neuro-navigation (LANN) technique, previously described by one of us (M. P.). For identification of the sacral roots, dissection was begun medial to the ureter and lateral to the uterosacral ligament. The Okabayashi pararectal space was entered as deep as possible via blunt dissection in avascular spaces. Hemostasis was performed using 5-mm bipolar forceps, and harmonic energy was not used. The hypogastric fascia was entered from medial to lateral, and the piriformis muscle was identified. The sacral nerve root S1 was identified lying over it. Dissection then proceeded caudally, and sacral roots S2 and S3 were sequentially identified. Small and delicate fibers forming the pelvic splanchnic nerves were isolated emerging from sacral roots S2 and S3. Other nerve fibers were identified caudally, probably representing pelvic splanchnic nerves emerging from S4. Measurements and Main ResultsThe surgical operative time was 70 minutes, and bleeding was minimal. No suspected compression or iatrogenic injury was identified. The patient was discharged on the day after the procedure. At 8-month follow-up, she had partial resolution of pain (score 5, pain scale 0–10), and another failed attempt at in vitro fertilization was attributed to unsatisfactory quality of the embryos. There were no symptoms or dysfunctions attributable to manipulation of the nerves. ConclusionLaparoscopy is a useful tool for identification of sacral roots and pelvic splanchnic nerves in suspected diseases. Its application in the field of neuropelveology can be expanded with proper knowledge and training.

Clinicopathologic features of intravenous leiomyomatosis with intracardiac extension

To investigate clinicopathological features, immunophenotype and differential diagnosis of intravenous leiomyomatosis with intracardiac extension. Clinical manifestations, morphologic features, and immunohistochemical staining were retrospectively analyzed in 19 cases of intravenous leiomyomatosis with intracardiac extension. The patients' age ranged from 33 to 59 years (mean 44 years). Clinical presentation included chest tightness, palpitation, dyspnea, edema of low extremity, abdominal distention or hypermenorrhea. However, a few patients were asymptomatic. Grossly, intravenous leiomyomatosis in most cases demonstrated coiled or nodular growth within the myometrium with worm-like involvement of the uterine vein in broad ligament or other pelvic veins with continued extension into the vena cava and the heart. The intravenous tumor surface was generally smooth and rubbery, with a greyish-white color. Microscopically, the tumors were composed of spindle cells with rare mitotic figures and the presence of abundant thick-walled vessels. Marked fibrosis, hyalinization, myxoid and edematous changes were common. The tumor cells were positive for SMA, ER, PR and desmin but negative for HMB45 and S-100. CD10 and CD34 were positive in 4 patients and negative in the remaining cases. Intravenous leiomyomatosis with intracardiac extension is a rare disease among women of child-bearing age, with specific morphologic manifestations and immunohistochemical profiles.

More of a good thing or less of a bad thing: gene copy number variation in polyploid cells of the placenta.

More of a good thing or less of a bad thing: gene copy number variation in polyploid cells of the placenta.

Embryo transfer cannot delineate between the maternal pregnancy environment and germ line effects in the transgenerational transmission of disease in rats

Adverse conditions in utero can have transgenerational effects, in the absence of a subsequent insult. We aimed to investigate the contribution of the maternal pregnancy environment vs. germ line effects in mediating alterations to cardiorenal and metabolic physiology in offspring from mothers born small. Uteroplacental insufficiency was induced by bilateral uterine artery and vein ligation (Restricted group) or sham surgery (Control group) in Wistar-Kyoto rats. Restricted and control female offspring (F1) were mated with either breeder males (embryo donor) or vasectomized males (embryo recipient). Embryo transfer was performed at embryonic day (E) 1, whereby second-generation (F2) embryos gestated (donor-in-recipient) in either a control (Cont-in-Cont, Rest-in-Cont) or restricted (Cont-in-Rest, Rest-in-Rest) mother. In male and female offspring, glomerular number and size were measured at postnatal day (PN) 35, and systolic blood pressure, glucose control, insulin sensitivity, and pancreatic β-cell mass were measured in separate sibling cohorts at 6 mo. Rest-in-Rest offspring were hypothesized to have similar characteristics (reduced growth, altered metabolic control, and hypertension) to non-embryo-transferred Rest, such that embryo transfer would not be a confounding experimental influence. However, embryo-transferred Rest-in-Rest offspring underwent accelerated growth during the peripubertal phase, followed by slowed growth between 2 and 3 mo of age compared with non-embryo-transferred Rest groups. Furthermore, renal function and insulin response to a glucose load were different to respective non-embryo-transferred groups. Our data demonstrate the long-term effects of in vitro embryo manipulation, which confounded the utility of this approach in delineating between the maternal pregnancy environment and germ line effects that drive transgenerational outcomes.

Posterior Deep Infiltrating Endometriotic Nodules: Operative Considerations according to Lesion Size, Location, and Geometry, during One’s Learning Curve

We conducted this prospective cohort study to standardize our laparoscopic technique of excision of posterior deep infiltrating endometriosis (DIE) nodules, according to their size, location, and geometry, including 36 patients who were grouped, according to principal pelvic expansion of the nodule, into groups with central (group 1) and lateral (group 2) lesions, and according to nodule size, into ≤2 cm (group A) and >2 cm (group B) lesions, respectively. In cases of group 1 the following operative steps were more frequently performed compared to those of group 2: suspension of the rectosigmoid, colpectomy, and placement of bowel wall reinforcement sutures. The opposite was true regarding suspension of the adnexa, systematic ureteric dissection, and removal of the diseased pelvic peritoneum. When grouping patients according to nodule size, almost all of the examined parameters were more frequently applied to patients of group B: adnexal suspension, suspension of the rectosigmoid, systematic ureteric dissection, division of uterine vein, colpectomy, and placement of bowel wall reinforcement sutures. Nodule size was the single most important determinant of duration of surgery. In conclusion, during the building-up of one's learning curve of laparoscopic excision of posterior DIE nodules, technique standardization is very important to avoid complications.