Anis Fadhlaoui

Objective: The aim of this study was to compare follicular liquid levels of IL6 and AMH in women with and without endometriosis and to evaluate their potential impact on ICSI outcomes. Materials and Methods: It is a prospective case-control study conducted on 25 women with proven endometriosis and 50 patients diagnosed with other causes of infertility. All these patients were candidates for ICSI cycles. Their follicular fluid was collected at the time of oocyte retrieval and used to evaluate IL-6 and AMH titers by electro-chemiluminescent immunoassay (Cobas e411-Roche). Results: The IL-6 levels in follicular fluid were higher in the endometriosis group than in the control group (152.3 vs. 19.9 pg/mL; p = 0.02). The median level for AMH was 2.2 ± 1.88 ng/mL with no statistical difference between the two groups (2.2 vs. 2.7 ng/mL, p = 0.41). No significant correlation between the follicular IL6 and AMH levels was observed. Conclusions: The oocyte quality seems to be preserved in patients with endometriosis with the adequate response to ovarian stimulation. High levels of follicular IL6 are in accordance with the inflammatory phenomenon of the disease; however, this increase has no impact on ICSI outcomes.

Diagnosis of adnexial torsion is difficult during pregancy (1). The time of decision and laparoscopy is that of the risk of necrosis of the adnexa and, therefore, of the ovarian prognosis. The loss of an ovary can compromise the following fertility. Even if concerns related to laparoscopy in pregnant patients include a limited surgical field, with a risk of uterine injury and negative fetal effects of CO₂ insufflation. Evidence base suggests that minimally invasive surgery can be safe and better than laparotomy for management of adnexal masses during late pregnancy with good postoperative and obstetric outcomes. If for most authors laparoscopy appears to become the best approach for ovarian torsion during pregnancy (2), nonetheless, the ideal surgical laparoscopic approach of adnexa in late pregnancy remains controversial. Since there is no technical gold standard to overcome surgical difficulties which could make laparoscopic procedures as real challenge in patients in second and third trimester (3); at least, in case of radical and non-conservative treatment, the risk for a first trimester of pregnancy is to remove the corpus luteum (1).

Minimally invasive surgery (MIS) can be considered as the greatest surgical innovation over the past thirty years. It revolutionized surgical practice with well-proven advantages over traditional open surgery: reduced surgical trauma and incision-related complications, such as surgical-site infections, postoperative pain and hernia, reduced hospital stay, and improved cosmetic outcome. Nonetheless, proficiency in MIS can be technically challenging as conventional laparoscopy is associated with several limitations as the two-dimensional (2D) monitor reduction in-depth perception, camera instability, limited range of motion and steep learning curves. The surgeon has a low force feedback which allows simple gestures, respect for tissues and more effective treatment of complications. Since 1980s several computer sciences and robotics projects have been set up to overcome the difficulties encountered with conventional laparoscopy, to augment the surgeon's skills, achieve accuracy and high precision during complex surgery and facilitate widespread of MIS. Surgical instruments are guided by haptic interfaces that replicate and filter hand movements. Robotically assisted technology offers advantages that include improved three- dimensional stereoscopic vision, wristed instruments that improve dexterity, and tremor canceling software that improves surgical precision.

Verrucous carcinoma of the vulva is a rare lesion (1). Affecting essentially postmenopausal women, this lesion is a distinct and particular entity in the vulva carcinoma classification and its scalability is uncertain and unpredictable. We present a case concerning a 48-year-old patient, without following after a condyloma acuminate of the vulva (large left lip). The origin of this case will be discussed in this article. The treatment decided was only surgical. A review of literature shows the scarcity of this lesion of the female genital tract.

Polycystic ovary syndrome (PCOS) is a frequent disorder, affecting approximately 5 to 10 % of infertile women. It can represent more than 80% of cases of infertility due to anovulation. The main goal of treatment is the induction of mono-ovulatory cycles. A pragmatic management of infertility in PCOS will allow most patients to conceive. Weight loss and clomiphene citrate (CC) are the first-line components of patients treatment before gonadotropins are used. However, during gonadotropin administration, there is a high risk of ovarian hyper-stimulation (OHSS) and multiple pregnancies. So, surgery with laparoscopic ovarian drilling (LOD) is often used before gonadotropins in order to obtain normal ovulatory cycles.

Objectives: The aim of this mini review is to determine the relationship between endometriosis and urinary tract symptoms and to investigate the consequences of surgical treatment of mild to severe endometriosis, especially deep lesions, on the vesico-sphincteral function (lower urinary tract function). Materials and Methods: We performed a literature review by searching the MEDLINE database for articles published between 2000 and 2014, limiting the searches to the words: urinary tract, vesico-sphincteral, dysfunction, endometriosis, symptoms and surgery. Results: The incidence of vesico-sphincteral symptoms in endometriosis varies from 3.4 up to 15.4%. The frequency of such symptoms seems to be under estimated because of a lack of specific questionnaire including urinary symptoms. Urodynamic evaluation could help to detect unsuspected abnormalities. It seems that endometriosis surgery (particularly deep infiltrating lesions) is a purveyor of de novo urinary dysfunction, with an incidence varying from 6.8 up to 17.5%. Nerve sparing Processes such as neuro-navigators or neuro-stimulators seem to be promising techniques to avoid postoperative urinary tract dysfunction. Conclusion: A precise anamnesis and the use of specific validated questionnaires (IPSS and BFLUTS) improve the screening of vesico-sphincteral symptoms in case of endometriosis. No recommendation can be found in the literature about the place of urodynamic evaluation. Most publications lack of proof and therefore do not allow making recommendations about optimal treatment of endometriotic lesions to avoid urinary tract disorders.

Trophoblastic tumors of placental site (PSTT) are rare. They represent a rare form of gestational trophoblastic disease. (GTD). They occur mainly in women who have a history of miscarriage, termination of pregnancy, or even a normal or pathological ongoing pregnancy. The clinical course is unpredictable. This malignancy has different characteristics from other gestational trophoblastic tumors. Following a clinical case that we encountered and treated, we conducted a literary research and review, focusing primarily on prognostic factors and treatment.

Endometriosis is defined as the presence of endometrial-like tissue (glands or stroma) outside the uterus, which induces a chronic inflammatory reaction. Although endometriosis impairs fertility, it does not usually completely prevent conception. The question of evidence based-medicine guidelines in endometriosis-associated infertility is week in many situations. Therefore, we will highlight in this issue where the challenges are.

The scientific progresses achieved, during the twenty-first century, in molecular biology, in cytogenetics, in the use of stem cells in the treatment of various pathologies by reprograming them (1), in medical imaging and in surgical instrumentation allow an avant-gardist management in the fields of assisted reproductive medicine, in oncology, in gynecological surgery, and even in obstetrics. Therefore, couples can benefit from a specific and personalized management. This management is supervised by multidisciplinary teams respecting laws of medical ethics and those of bio-ethics. Should we still use the term of “sterility” when such a therapeutic armada is at our disposal? Born in the 70s, the laparoscopic surgery, now offers a better topographic approach of lesions, an almost perfect macroscopic depiction of colors. Hence, surgeons can spare more healthy tissues such as vessels and nerves, and thus adapt a more conservative procedure while restoring normal anatomy that is essential for preserving fertility. Endometriosis is one of the most obvious examples (2, 3). These advancements were achieved owing to new 3D imaging technologies and to the use of CO₂ laser. The advent of new energies, i.e., RF, YAG laser, Argon laser, plasma energy, excimer, etc., opened new perspectives for surgical management of diseases. The miniaturization of instruments in hysteroscopy coupled with the development of hydrosonography allowed a better exploration of the uterine cavity, endometrial biopsies, and resection of intra-uterine lesions. Thus preventing invasive and radical treatments and reducing post-operative morbidity. However, the greatest advancements have been realized in cellular and molecular biology, in cytogenetics, and in proteomics. Indeed, the recent knowledge in the field of stem cells and their specific reprograming expand horizons to gene and cell therapy. A simple cell could be considered as a treatment by re-colonizing unhealthy tissues, thus preventing transplantation (1, 4, 5). The cryopreservation of ovarian tissue by vitrification before radiotherapy or chemotherapy in case of cancer gives a new hope to those couples touched by the disease. The in vitro culture of pathological cells, disease modeling, and collection of withdrawn tissues pre-operatively allows researchers to understand etiophysiopathogeny, and natural evolution of the disease as in endometriotic tissues (2). These procedures will avoid long, expensive, and ethically questionable studies on animal models, thus allowing pharmacotesting. Therefore, this will help defining new disease classification and propose therapeutic algorithms. Owing to progress in the field of infertility and assisted reproductive techniques (ART), i.e., intra cytoplasmic spermatozoid injection (ICSI) and vitrification of oocytes and embryos, increasing numbers of patients could be treated. In vitro endometrial culture leads to identification of reasons for treatment failure. Regarding pre-implantation genetic diagnosis (PGD), the progress in the knowledge of genetic mapping offers much hope to patients and couples suffering from family and hereditary diseases. A better knowledge of human papilloma viruses (HPV) and the conception of vaccination against those HPV contribute in the reduction of the prevalence of cervical cancer, since HPV is involved in the genesis of cervical dysplasia and thus in that of cervical cancer. A radical treatment of cervical dysplasia (surgical or laser CO₂ conization) prevents their transformation toward an invasive cervical cancer. The use of CO₂ laser coupled with colposcopy allowed “see-and-treat” management of cervical, vaginal, vulvar, and perineal lesions related to HPV in an ambulatory way with a minimal morbidity. Eradication of cervical cancer during this century is possible and conceivable, only if national programs of information of gynecologists, family practitioners, as well as a program of HPV vaccination are settled. In case of voiding dysfunction, stress urinary incontinence, overactive bladder, the innovations in the field of pressure sensors improved urodynamic measurements. A new clinical approach based on an itemized analysis of symptoms associated with progress of urodynamic tools allows a better therapeutic approach including both surgery and medical treatment. MRI, computerized mammography, 3D ultrasound, stereotactic, and ultrasound guided biopsies of breast lesions eased and fastened the diagnosis of breast cancer, with less morbidity. All these imaging techniques contributed to a better management of gynecological cancers and thus improved survival rates in these patients. Sentinel axillary lymph node biopsy with intra-operative frozen section allows to ovoid the systematically axillary lymph node resection. Protocols such as “ONCOTYPE,” based on cellular phenotyping, predict the need for chemotherapy. As an example, Her-2–Neu is used as a marker of poor prognosis and indicator for the use of HERCEPTIN neoadjuvant treatment. Radiotherapy becomes more focused on the tumor site, thus avoiding overdoses of irradiation and reducing side effects. Hormonal therapy is possible due to immunochemistry analysis of tumor-estrogen and -progesterone receptors, thus offering a longer period without recurrence. In case of mixed ovarian tumors, immunohistochemistry allows an accurate diagnosis. In the fields of contraception, a lot of progress has been achieved such as Levonorgestrel intra-uterine devices, progestogens of third and fourth generation allowing a decrease in ethinyl-estradiol dosage, progestogens implants, vaginal rings, and transdermal patches. So women have a very wide choice and contraception can be individually adapted. Gynecology is in constant progress allowing an ambulatory management with less morbidity thus reduced health costs, an earlier diagnosis with a better adapted and personalized treatment leading to higher survival rates. Obstetrics also knew considerable progresses. Since the twentieth century, prenatal diagnosis of congenital malformations and genetic diseases is made easier and earlier, a tribute of progresses in the fields of ultrasound, amniocentesis, and chorionic villi sampling (CVS), thus allowing an optimal management with less morbidity and less psychological disturbance in the respect of national legal frames. These great achievements could not be possible without progress in genetics and biology. Many markers are currently studied to screen earlier patients predisposed to develop preeclampsia during pregnancy or to predict premature rupture of membranes and labor, thus preventing wet lung syndrome. Progresses in neonatal resuscitation decreased perinatal morbidity and mortality. The detection of fetal DNA in the maternal blood with the hope of the complete genome fetal sequencing represents another breakthrough. Henceforth, in utero fetal surgery as a vesico-amniotic shunting (a twin–twin transfusion syndrome with Laser ablation of vessels), the treatment of fetal bladder obstructions, an aortic or pulmonary valvuloplasty (opening the aortic or pulmonary fetal heart valves to allow blood flow) (6), an atrial septostomy (opening the inter-atrial septum of the fetal heart to allow unrestricted blood flow between the atriums), the surgical treatment of a congenital diaphragmatic hernia by a Balloon tracheal occlusion and the treatment of spina bifida with a closure of the malformation entered clinical practice. Epidural anesthesia, the new standardized criteria of fetal heart rate analysis, the advent of the STAN, the analysis of scalp pH contributed to the improvement of perinatal prognosis. Techniques of embolization contributed to a less aggressive, but effective, treatment of post-partum hemorrhage, thus saving lives and sparing uteri. With such a therapeutic arsenal, there should be no more fatality. However questions arise, among them “should we go back to a more physiological or natural practice of obstetrics?” or “why the rate of cesarean sections increased, and all this technology is available?” Even though we cannot compromise progresses, the question is to be debated. In both gynecology and obstetrics, optimal training of the nurses, midwifes, and residents is essential. In these fields, specific simulators are ideal tools to start, maintain, and develop skills. Finally, internet and other media are obvious tools to enhance knowledge for patients, doctors, midwives, and nurses. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. 1. Bouquet de la Joliniere J, Feki A. “XXIst century odyssey of medicine” stems cells and their future. Front Physiol (2013) 4:250. doi:10.3389/fphys.2013.00162 CrossRef Full Text 2. Bouquet de la Joliniere J, Ayoubi JM, Lesec G, Validire P, Goguin A, Gianaroli L, et al. Identification of displaced endometrial glands and embryonic duct remnants in female fetal reproductive tract: possible pathogenic role in endometriotic and pelvic neoplastic processes. Front Physiol (2012). 3:444, 1.6. doi:10.3389/fphys.2012.00444 Pubmed Abstract | Pubmed Full Text | CrossRef Full Text 3. Ayoubi JM, Bouquet de la Joliniere J, Feki A, Pons JC. Laparoscopic tubal anastomosis: an assessment of the “one-stitch technique”. Reprod Syst Sex Disord (2013) 2:1. doi:10.4172/2161-038X.1000119 CrossRef Full Text 4. Hui P, Wang HL, Chu P, Yang B, Huang J, Baergen RN, et al. Absence of Y chromosome in human placental site trophoblastic tumor. Mod Pathol (2007) 20(10):1055–60. doi:10.1038/modpathol.3800941 Pubmed Abstract | Pubmed Full Text | CrossRef Full Text 5. Yang CM, Gong XL, Qiu J, Tang HX, Gong ZJ, Huang SZ, et al. Engraftment of genetically modified human amniotic fluid-derived progenitor cells to produce coagulation factor IX after in utero transplantation in mice. Cell Biol Int (2013) 37(5):420–9. doi:10.1002/cbin.10037 Pubmed Abstract | Pubmed Full Text | CrossRef Full Text 6. Perez-Negueruela C, Mayol J, Prada F, Caffarena-Calvar JM. Neonatal Ross-Konno operation and endocardial fibroelastosis resection after foetal percutaneous aortic valve balloon valvuloplasty: a complex approach to rescue the left heart. Eur J Cardiothorac Surg (2014). doi:10.1093/ejcts/ezu010 Pubmed Abstract | Pubmed Full Text | CrossRef Full Text Keywords: gynecology, obstetrics, reproductive techniques, assisted, laparoscopic surgery, genetics Citation: Bouquet de la Jolinière J, Fadhlaoui A, Dubuisson J-B and Feki A (2014) Gynecology and obstetrics has entered modern times: perspectives and challenges. Front. Surg. 1:19. doi: 10.3389/fsurg.2014.00019 Received: 11 April 2014; Accepted: 20 May 2014; Published online: 03 June 2014. Edited by: Reviewed by: Copyright: © 2014 Bouquet de la Jolinière, Fadhlaoui, Dubuisson and Feki. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. *Correspondence: anis.feki@h-fr.ch

Objective: In this article, we present two case reports. The first case was a malignant germ cell tumor of the right ovary in a 23 year old female and a case of a bilateral undifferentiated granulosa cell tumor in a 71 year old female. The aim of these reports is to illustrate the interest of the immuno-histochemical analysis to define the correct diagnosis, to better classify these ovarian tumours and improve their management. Methods: This study we report two cases. The first case concern a 23 years old woman (A) with a mixed germ cell tumour of the right ovary (dysgerminoma (75%), yolk sac tumour (20%), and a mature teratoma (5%), and the second case (B) a bilateral non differentiated and necrotic granulosa cell tumour of both ovaries concerning a 71 year old patient. The staging system used was according to both classifications, the one of International Federation of Gynaecology and Obstetrics (FIGO) 1987 for ovarian cancer, and the one of TNM code 2009. Results: The immunostaining establish the malignancy and the immunochemistry contribute to confirm effectively the right diagnosis (Table 2 and 3). Conclusion: An immuno-histochemical analysis is mandatory for the choice of chemotherapy to obtain the better response of the disease and improve the survival prognosis. The efficiency of the chemotherapy authorizes a conservative surgery including a unilateral salpingo-oophorectomy preserving fertility (A). Concerning the non-dysgerminoma tumour (B), and after a surgical staging and debulking, chemotherapy was recommended. The type of tumour and its histological feature conditioned the choice of treatment. The benefit of the immunohistological analysis in this case allowed the right adjuvant treatment. Key words: germ cell tumours, dysgerminoma, teratoma, yolk sac, ovarian cell tumour, and immunohistochemistry.