No 11 (2015)

Objective. To make a systems analysis of the data available in the current literature on the effect of vitamin D on the efficiency of assisted reproductive technology (ART) programs and its role in the physiology of the female reproductive system. Subject and methods. The review includes the data of Russian and foreign articles found in the Pubmed database on this topic and published in the past lOyears. Results. The possible mechanisms of vitamin D involvement in embryo implantation processes and the impact of the concentration of this vitamin on the ovarian reserve marker anti-MUllerian hormone are described. The genetically caused vitamin D metabolic features are presented. Conclusion. There is a need for further investigations of the effect of vitamin D on an ovarian response to gonadotropin stimulation and on the outcomes of in vitro fertilization, the occurrence of clinical pregnancy and the birth of a healthy baby in the assisted reproductive technology programs.

Objective. To study current ideas on endometriosis. Subject and methods. Articles were sought using the key words: endometriosis, treatment, diagnosis, and pathogenesis in the PUBMED and Russian Science Citation Index databases. Sixty-five papers were selected after the search. Results. The only internationally recognized classification system of the American Society of Reproductive Medicine is widely used in the world. The following stage processes: attachment of endometrial cells to the mesothelial cells; penetration of endometrial cells into the mesothelium; angiogenesis in the endometrioid implants; proliferation of ectopic cells; and process involvement of inflammatory cells maintaining the development of implants are considered as the key components of the pathogenesis of endometriosis. Long-term diagnostic delay and lower quality of life have been found in women with endometriosis. The main techniques for diagnosing endometriosis were ultrasonography, magnetic resonance imaging, colonoscopy, and cystoscopy. Laboratory methods are of additional value. A combined approach involving surgical and medical treatments is a generally recognized tactic. The endometriosis recurrence rate after surgical treatment is 21-40%. Conclusion. In spite of numerous investigations and the considerable social value of the problem, there is no uniform system concept of a multidisciplinary approach to the organization and surgical treatment of patients with disseminated forms of endometriosis.

Objective. To define contraceptive methods preferred by young women, their expectations of chosen hormonal means to prevent an unwanted pregnancy, and a way to enhance their adherence. Subjects and methods. The results of a sociological survey of 1007young women, conducted in 2012, were analyzed. A structured interview, a method to retrieve information from a questionnaire containing open- questions, was applied; 402 Moscow students were anonymously interviewed. Results. The survey demonstrated the current characteristics of marriage, reproductive, and contraceptive behavior in 20-24-year-old women: a decline in the number of registered marriages (29.3%), stabilization of birth rates at a level of 90%o, a 26% reduction in abortion rates in the past 15 years; condom preferences (59%), coitus interruptus (26%), and combined oral contraceptives (COCs) (33%) with a low adherence to the latter. The main expectations of the women in choosing a hormonal contraceptive were its high efficacy, minimum side effects, convenience and easiness to use, and good menstrual cycle control. The above parameters were used to compare a number of COCs. The latter in a 24/4 regimen containing 20 fig of ethinylestradiol and 3 fig of drospirenone were noted to have advantages in reducing the incidence of adverse reactions and in having additional non-contraceptive benefits that were of importance for the young women to choose a contraceptive. Conclusion. Reliable contraceptives containing minimal hormones, which guarantee minimum side effects and high menstrual cycle control, may become an effective alternative for young women, by enhancing their adherence.

Objective. To compare clinical data and pathomorphological characteristics in patients with a uterine scar concurrent with placental presentation. Subjects and methods. The retrospective investigation enrolled 104 patients with a uterine scar, placental presentation, and a pathomorphologically verified diagnosis of placenta accreta. Results. Out of the 104 women, 51 (49%), 36 (34.7%), 15 (14.4%), and 2 (1.9%) had a scar after 1, 2, 3, and 4 cesarean sections, respectively. After fetal extraction for hemostasis, 45 (43.3%) patients underwent uterine artery embolization; temporary balloon occlusion of the common iliac arteries was carried out in 22 (21.2%), ligation of internal iliac arteries was done in 2 (1.9%). Sutures applied to the placental bed on the side of the uterine cavity were used in 35 (33.6%) patients with an insignificant extent of abnormal placental presentation. The thinning or absent of decidual tissue is a main pathomorphological sign of placental invasion. The wall of the uterus on its side has a scalloped surface, the shape of which is similar to that of placenta accreta. An incompetent uterine scar due to its dehiscence is represented by the fibrous tissue covered by the peritoneum adjoined by chorionic villi. A pronounced commissural process between the wall of uterus and the posterior wall of the bladder and the gestational rearrangement of the vessels of the latter imitate placenta percreta. Conclusion. Invasion of placenta previa into cicatrical tissue after cesarean section is different from that into uterine muscle. It is impossible to reveal the penetration of chorionic villi to the thickness of a uterine scar and the wall of the bladder.

Objective. To study the expression ofproliferation markers in the cells offibrous and glandular endometrial polyps (FGEP) to specify the pathogenetic aspects of endometrial hyperplastic processes in elderly and senile women. Subjects and methods. Examinations were made in 288elderly and senile women suspected of having endometrial pathology, as evidenced by ultrasound screening, who had undergone hysteroscopy, endometrial biopsy, followed by morphological verification. Immunohistochemical examination was performed in 9 postmenopausal patients with FGEP; a comparison group consisted of 10 reproductive-aged patients. Results. As compared with reproductive-aged women, the menopausal women showed a statistically significantly lower expression of estrogen and progesterone receptors in the nuclei of epithelial and stromal cells of FGEP. The expression of the apoptosis inhibitor Bcl-2 in the epithelial and stromal cells was more marked and that of the apoptosis inductor Bax antigen was, on the contrary, significantly suppressed. The expression of ACP450 was also pronounced manly in the epithelium of the glands. Conclusion. As compared to the reproductive-aged women, the menopausal women had basic molecular biological differences in FGEP, which suggests that the polyps are less related to the effect of estrogens and progesterone and that there is an increased risk for neoplastic transformation.

Objective. To enhance the efficiency of diagnosis and management tactics in patients with cervical intraepithelial neoplasia (CIN), by studying the markers of prediction, such as voltage-dependent anion channel 1 (VDAC1) in the outer external mitochondrial membrane and the protein hexokinase 2 (HK2). Subjects and methods. The investigation enrolled 32 women. According to the results of cytological examination, all the patients were divided into 4 groups: a control group, patients with atypical squamous cells of undetermined significance (ASCUS), low-grade squamous lesion (TSIT), or high-grade squamous lesion (HSIL). In all the patients, VDAC1 and HK2 protein expression levels were determined in the cervical epithelial scrapes using a western-blot analysis and chemiluminescent detection protocol. Results. Analysis of the findings revealed a relationship between VDAC1 protein expression levels, the enzyme HK2, and the degree of CIN. Conclusion. The examined proteins may be potential markers for predicting the progression of CIN and breast cancer at their early stages, which calls for further investigation.

Objective. To comparatively evaluate the efficiency of different treatment regimens for chronic endometritis (CE) in view of pathogen eradication, normalization of the endometrial morphological structure, and restoration of the reproductive potential. Subjects and method. The investigation enrolled 101 patients with CE and 31 apparently healthy women. According to the treatment received, the patients with CE were randomized into two groups: 1) empiric antibiotic (AB) therapy using antibiotic combinations in conjunction with antiaggregants and antihypoxants regardless of the presence of the pathogen (n = 54); 2) personified complex treatment including AB and/or nonsteroidal antiinflammatory drugs (NSAIDs) in combination with antiaggregants and antihypoxants was prescribed on the basis of a detailed assessment of the microbial landscape (n = 47). Before and after treatment, the patients included in the study underwent ultrasonography of the small pelvic organs, hysteroscopy, and diagnostic curettage or pipelle endometrial biopsy with further morphological examination, as well as real-time polymerase chain reaction study of the microflora in endometrial biopsy specimens. Statistical processing used Student’s t-testand Mann- Whilney U-test, X 2 test to compare discrete quantities, and McNemar’s test. P-values < 0.05 were considered statistically significant for all types of analysis. Results. Following empiric AB treatment (Group 1), abnormal uterine bleeding was noted in 30.3% of the cases; the infectious agents in the endometrium were detected in 21.2%; the endometrial morphological pattern became normalized in 60.6%; the conception rate was 30.3%; after selective therapy with regards to the presence or absence of a microbial agent (Group 2), these indicators were 6.1% (p = 0.009), 3% (p = 0.024), 90.9% (p = 0.003), and 63.6% (p = 0.007), respectively. Conclusion. It is necessary to study the endometrial microbial landscape compulsorily to choose adequate therapy for CE in each specific clinical case. If the infectious agents are present in the uterine cavity in CE, combination therapy should be used in conjunction with AB agents in view of the detected pathogen; the morphological efficiency is 68.4%; reproductive function is realized in 42.1%. If the infectious agents are absent in the endometrium to treat CE, it is expedient to incorporate NSAIDs into combination treatment; the morphological efficiency is 94.7%; the conception rate is 63.2%.

Objective. To investigate the efficacy of Isoprinosine in the combination therapy of cervical precancerous diseases in the presence of human papillomavirus (HPV) types 16 and 18 in combination with conization of the cervix uteri. Subjects and methods. Eighteen patients with morphologically verified high-grade squamous intraepithelial lesions and HPV 16/18 were examined. A control group consisted of 10 gynecologically and somatically healthy women whose mean age was 25.8+5.7years. Results. Post-treatment analysis of changes in T cell components indicated that Isoprinosine had a marked immunomodulatory effect. CD3, CD4, CD8, CD20, and IgG were responsible for a significant increase in the indicators versus the baseline values. The patients tolerated the used treatment without complications. Conclusion. The investigation conducted proves once again the need for combination treatment for cervical precancerous diseases. Timely adequate treatment will prevent malignant processes of the cervix uteri.

Objective. To estimate changes in the degree of postmenopausal urogenital disorders (UGD) during trioginal therapy. Subjects and methods. Sixty-nine postmenopausal patients (mean age 58.46+3.59 years) with UGD were examined and enrolled in the trial. The patients were treated with vaginal trioginal by the scheme: 2 capsules simultaneously once daily for 14 days, then 1 capsule daily for 7 days, thereafter the patients took 1 capsule twice weekly for 2 months. Changes in the degree of UGD were estimated using questionnaires and the data of instrumental and laboratory studies, including calculation of karyopyknotic index (KPI), at baseline and at every subsequent visits. The magnitude of psychoemotional, autonomic vascular, and urogenital symptoms and metabolic disturbances was estimated using the Kupperman index (KI). A quality of life questionnaire was separately applied in conjunction with the evaluation of dysuria (Scale S and Scale L). Results. The symptoms of urinary incontinence were observed to be reducedjust two weeks after therapy initiation. During the therapy, there was a 2.8-fold improvement in quality of life (L) and pronounced positive changes in KI. The mean KPI increased by more than twice. There were positive changes in pH level. During the therapy, all the patients had no signs of endometrial thickening, as evidenced by ultrasound study. All the investigation participants completed a trioginal treatment cycle in accordance with the study design without changing the therapy regimen. Conclusion. The good tolerability, no adverse events of, and satisfaction with the performed treatment permit trioginal to be recommended for use as a highly effective and safe drug to correct postmenopausal UGD.

The paper presents experience in following up and managing rhesus-negative pregnant women having a gestational complication as threatened miscarriage with vaginal bleeding (a potentially sensitizing event (PSE)). It notes the importance of preventive measures as a component of management tactics and the necessity of preventing the development of immunization in unsensitized patients. Objective. To assess the risk for rhesus immunization in rhesus-negative pregnant women with threatened miscarriage when preventing and not preventing PSE. Subjects and methods. The investigation included 56 rhesus-negative pregnant women aged 27-35years without antibody titers with the above-mentioned gestational complication. A study group consisted of 29pregnant women with threatened miscarriage accompanied by vaginal bleeding, who underwent prenatal ad hoc prevention of rhesus immunization with human immunoglobulin anti-rhesus Rho(D). A comparison group comprised 27 pregnant women with threatened miscarriage accompanied by vaginal bleeding, who had not prenatal ad hoc prevention of rhesus immunization because of their refusal. Results. The immunized pregnant women who had not received a prophylactic immunoglobulin dose for gestational complications were 7.4% (n=2); and those who had not used this dose for gestational complications and refused prenatal prophylaxis at 28-30 weeks’ gestation were 11.1%. Conclusion. Ad hoc prevention of Rh immunization in this cohort of patients in conjunction with decreed antenatal and postnatal prophylaxis prevents the development of maternal immunization to Rh-1) antigen.

Background. Prosthetic heart valve thrombosis during pregnancy is a rare, but very serious complication and poses a threat to maternal and fetal life and the time and method of its treatment remain controversial. Description. The paper presents a case of successful pregnancy prolongation with a favorable outcome in a patient with critical aortic prosthetic thrombosis and further operations: delivery, aortic valve reprosthetic replacement, and dual chamber pacemaker implantation. Conclusion. In case of pregnancy prolongation, only a comprehensive approach to managing these patients may offer the prospect for a favorable outcome for a pregnant women and a fetus.