The migration speed of nucleolar precursor bodies in pronuclei affects in vitro fertilization-derived human embryo ploidy status and live birth.

Purpose: To study the relationship between clinical outcomes after assisted reproduction and the migration speed of nucleolus precursor bodies (NPBs) in male and female pronuclei (mPN; fPN). Methods: NPB migration speed, embryo ploidy status, and live birth (LB) were retrospectively analyzed in IVF-derived zygotes. The central coordinates of the mPN, fPN, and NPBs were noted at multiple timepoints. The migration distance of NPBs between two sequential images was measured to calculate NPB migration speed. Results: The NPB migration speeds in mPN and fPN were significantly faster in euploid zygotes than in aneuploid zygotes. In multivariate logistic analysis, NPB migration speed in mPN and the female age were associated with euploidy. The NPB migration speeds in mPN and fPN were also significantly faster in zygotes that led to LB than in zygotes that led to no pregnancy. In a receiver operating characteristic curve analysis of LB by NPB migration speed in mPN, the cut-off value was 3.74 µm/h (AUC: 0.825, 95%CI: 0.688-0.963). When the zygotes were categorized by this cut-off value, there were significantly more LBs in zygotes with migration speed ≥ the cut-off (78.9% vs. 21.1%). Conclusions: Zygotes with quickly migrating NPBs demonstrated the developmental potential to become a baby.

[Interstitial Lung Disease after OK-432 Pleurodesis for Malignant Pleural Effusion in Breast Cancer-A Case Report].

The patient was a 42-year-old woman. After 4 courses of capecitabine therapy for right chest wall recurrence of breast cancer, ER(+, 10-15%), PgR(-), HER2(-), she underwent pleurodesis using OK-432 for increased right pleural effusion. On the 12th day after pleurodesis diffuse infiltrative shadows in the right lung, and frosted shadows in both lungs, were observed, and she was diagnosed with drug-induced lung injury. About 3 weeks after administration of prednisolone 1 mg/ kg a tendency for improvement in lung injury was observed, but the patient died of breast cancer progression. Drug- induced lung injury by pleurodesis carries the risk of delaying resumption of chemotherapy. We report this case with a review of the literature.

Outcome of in vitro fertilization cycles with automatic time-lapse instrumentation combined with the early embryo viability assessment score.

AIM: To evaluate whether embryo selection using the early embryo viability assessment (EEVA) score increases the ongoing pregnancy rate of in vitro fertilization and intracytoplasmic sperm injection patients. METHODS: One hundred eighty-one patients whose serum anti mullerian hormone (AMH) level was greater than 0.5 ng/µL were enrolled in the study. All patients received oocyte retrieval repeatedly from June 2017 to January 2019. Transferred embryos were selected using the EEVA score and Veeck's criteria. We investigated the blastocyst rate according to the EEVA score and Veeck's criteria and also evaluated the clinical outcome following embryo transfer of the blastocysts. RESULTS: Blastocyst development rate (48.7%) and high-quality blastocyst (42.4%) of Veeck 1 was statistically higher than others. The blastocyst rate (71.4%) and high-quality blastocyst rate (60.0%) for EEVA 1 was the highest, and a correlation between the EEVA score and the blastocyst rate was also identified in cases younger than 40 years. Blastocyst rate of EEVA 1 + 2 (69.8% 208/298) was statistically higher than that of Veeck 1 + 2 (40.1% 317/791) (p < 0.05) and high-quality blastocyst rate of EEVA 1 + 2 (50.0% 104/208) was also higher than that of Veeck 1 + 2 (36.6% 117/320) (p < 0.05). However, there was a significant correlation between EEVA and the pregnancy rate and pregnancy rate of EEVA 1 + 2 showed no statistical difference compared with Veeck 1 + 2. CONCLUSIONS: Although it remains to be answered whether a computer can substitute Veeck's classification, the EEVA score could be a viable alternative to predict the blastocyst rate and to select those high-potential embryos that improve the pregnancy rate.

Migration speed of nucleolus precursor bodies in human male pronuclei: a novel parameter for predicting live birth.

PURPOSE: To study the relationship between the migration speed of nucleolus precursor bodies (NPBs) in male and female pronuclei (mPN; fPN) and human embryo development during assisted reproduction. METHODS: The migration speed of 263 NPBs from 47 zygotes was quantitated, and embryonic development was observed until the blastocyst stage. The central coordinates of mPN, fPN, and NPBs were noted at multiple timepoints. Then, the distance traveled by the NPBs between two sequential images was measured, and migration speed was calculated. Additionally, we investigated the relationship between NPB migration speed and ploidy status (N = 33) or live birth/ongoing pregnancy (LB/OP) (N = 60) after assisted reproduction. RESULTS: The NPB migration speed in both mPN and fPN was significantly faster in the zygotes that developed into blastocysts (N = 25) than that in the zygotes that arrested (N = 22). The timing of blastulation was negatively correlated with NPB migration speed in the mPN. Faster NPB migration was significantly correlated with LB/OP. In multivariate logistic analysis, NPB migration speed in the mPN was the only morphokinetic parameter associated with LB/OP. In a receiver-operating characteristic curve analysis of LB/OP by the NPB migration speed in the mPN, the cut-off value was 4.56 µm/h. When this cut-off value was applied to blastocysts with preimplantation genetic testing for aneuploidy, 100% of the blastocysts faster than or equal to the cut-off value were euploid. CONCLUSION: The NPBs migrated faster in zygotes having the potential to develop into a blastocyst, and eventually into a baby. This predictor could be an attractive marker for non-invasive embryo selection.

Usefulness of the APTT waveform for the diagnosis of DIC and prediction of the outcome or bleeding risk.

BACKGROUND: The usefulness of the activated partial thromboplastin time (APTT) waveform has been reported in hemophilia, acquired hemophilia and monitoring for anticoagulants. MATERIAL AND METHODS: The APTT waveform was examined in patients suspected of having disseminated intravascular coagulation (DIC) to analyze its usefulness for the diagnosis of DIC or the prediction of the outcome or bleeding risk. RESULTS: DIC with fibrinogen < 2 g/L was frequently associated with infectious diseases (43.3%). The heights of the first derivative peak (1stDP) and second DP (2ndDP) were extremely low in DIC, especially DIC with hypofibrinogenemia, but high in infectious patients without DIC. The peak time and width of the 1stDP and 2ndDP were prolonged in patients with DIC. The heights of the 1stDP and 2ndDP were markedly low in patients with a poor outcome or those with hemoglobin < 8.0 g/dl. DISCUSSION AND CONCLUSION: As bleeding type DIC was observed in infectious DIC, DIC without hypofibrinogenemia might switch to DIC with hypofibrinogenemia by the progression of DIC. The height of the 1stDP and 2ndDP is useful for the diagnosis of DIC and prediction of the bleeding risk or outcome.

Failure of complete hatching of ICSI-derived human blastocyst by cell herniation via small slit and insufficient expansion despite ongoing cell proliferation.

PURPOSE: To assess the effect of intracytoplasmic sperm injection (ICSI) on embryo hatching and visualise the effects of zona thinning (ZT) on the embryo using time-lapse monitoring. METHODS: In vitro fertilisation (IVF) (n = 178) and ICSI (n = 110)-derived cryopreserved blastocysts were donated by patients who previously had a baby. This study investigated the impacts of IVF, ICSI, laser-assisted hatching by ZT and formation of ICSI penetration trace on zona pellucida of IVF-derived blastocyst on blastcyst diameter, the estimated number of trophectoderm (TE) cells and completed hatching rate. RESULTS: The completed hatching rate and diameters of the completely hatched blastocysts at hatching commencement and at the maximum expansion were significantly greater in the IVF than in ICSI groups. The completed hatching rate significantly increased with ZT in both groups. The maximum diameters of the completely hatched blastocysts were significantly smaller in the ZT than in non-ZT groups. The estimated TE cell numbers increased from hatching commencement to their maximum expansion points. The incompletely hatched ICSI-derived blastocysts intermittently herniated cells via small slits until degeneration. The completed hatching rate significantly decreased by the formation of ICSI penetration trace on zona pellucida of IVF-derived blastocyst. CONCLUSION: ICSI-derived blastocysts intermittently release proliferating cells and extracted TE cells and/or inner cell masses via a small slit; thus, blastocyst expansion is not sufficiently increased, leading to a reduced complete hatching rate. Therefore, the ICSI penetration trace potentially has negative effects on blastocyst expansion process in vitro and is a risk factor for the failure of completed hatching.

Association of follicular fluid volume with membrane stretchability of human metaphase II oocytes following the gonadotropin-releasing hormone agonist protocol during intracytoplasmic sperm injection.

PURPOSE: The authors previously revealed the association of the follicular fluid (FF) volume with oolemma stretchability following the gonadotropin-releasing hormone (GnRH) antagonist protocol during intracytoplasmic sperm injection (ICSI). However, the impact of the GnRH agonist protocol on oolemma stretchability remains unclear. METHODS: Data that were obtained from 74 ICSI cycles were reviewed retrospectively. Controlled ovarian stimulation was performed in accordance with the short GnRH agonist protocol. Each follicle was individually aspirated and assigned to one of six groups, according to the FF volume. The oolemma stretchability during ICSI was evaluated by using a mechanical stimulus for oolemma penetration; that is, oolemma penetration with or without aspiration (high vs low stretchability, respectively). RESULTS: The incidence of low oolemma stretchability was significantly higher in the <1.0 mL group than that in the ≥1.0 mL group. The normal fertilization rate was significantly lower in the <1.0 mL group than that in the 2.0-<3.0 mL group. The rate of blastocyst development was lower in the <1.0 mL group than that in the 3.0-<4.0 mL group. CONCLUSION: The FF volume potentially was associated with metaphase II oolemma stretchability, fertilization, and blastocyst development.

[A Case of Poorly Differentiated Carcinoma of Unknown Primary Site with Risk of Choriocarcinoma Syndrome Effectively Treated with Reduced Bleomycin,Cisplatin ,Etoposide Combination Regimen(BEP Regimen)].

A 64-year-old man visited his physician complaining of bilateral gynecomastia and left shoulder pain. Chest X-ray showed multiple bilateral masses in the lung, and he was referred to our hospital. Radiographical findings, elevation of serum total hCG, and histological findings of the cervical lymph node revealed multiple pulmonary, nodal, and brain metastases of poorly differentiated carcinoma of an unknown primary site with choriocarcinoma components. He was administered a regimen of reduced bleomycin, cisplatin, etoposide combination(reduced BEP regimen)to reduce the risk of acute respiratory failure with intra-alveolar hemorrhage related to post-chemotherapy early tumor necrosis. After chemotherapy, the tumor marker hCG levels were almost restored to normal levels, and radiography showed he had achieved a clinical partial response.

Lower FOXO3 mRNA expression in granulosa cells is involved in unexplained infertility.

AIM: The aim of this study was to investigate whether FOXO1 and FOXO3 mRNA expression in granulosa cells is the cause of unexplained infertility. METHODS: Thirty-one patients aged <40 years (13 with unexplained infertility and 18 with male partner infertility as a control group) whose serum anti-Müllerian hormone level was >0.5 ng/µL were enrolled in the study. All patients underwent oocyte retrieval under a short protocol from June 2012 to October 2013. Real-time PCR was carried out using mRNA extracted from granulosa cells retrieved from mature follicles. We compared FOXO1 and FOXO3 mRNA expression ratios in granulosa cells between the unexplained infertility group and the male infertility group. The relation between FOXO1 and FOXO3 mRNA expression ratios in granulosa cells and assisted reproduction technology clinical outcome was also examined. RESULTS: FOXO3 mRNA expression ratio was significantly lower in the unexplained infertility group than in the male infertility group. Moreover, FOXO3 mRNA expression ratio showed a positive correlation with both the number of retrieved oocytes and serum anti-Müllerian hormone level. A positive correlation was also identified between FOXO1 mRNA expression and total dose of hMG. As well, the number of retrieved oocytes in the unexplained infertility group was statistically lower than that in the male infertility group. CONCLUSION: A lower FOXO3 mRNA expression in granulosa cells leads to poor oocyte development in patients with unexplained infertility undergoing controlled ovarian stimulation for in vitro fertilization-embryo transfer.

Analyzing the risk factors for a diminished oocyte retrieval rate under controlled ovarian stimulation.

Aim: To investigate which risk factors contribute to a lower oocyte retrieval ratio in women who are receiving controlled ovarian hyperstimulation. Methods: The authors retrospectively analyzed 329 in vitro fertilization (IVF) cycles under controlled ovarian hyperstimulation by using a gonadotropin-releasing hormone antagonist or agonist at Osaka Medical College, Japan. The patients were classified into five groups: advanced age, male infertility, severe endometriosis, tubal infertility, and unexplained infertility. The primary outcomes were the patients' age, oocyte retrieval ratio, serum basal follicle-stimulating hormone, total dose of gonadotropin, and the clinical outcome. A secondary outcome was the stepwise multivariate logistic regression analysis to assess the factors associated with the failure of oocyte retrieval. Results: The oocyte retrieval ratio declined significantly with the patient's age. The ratio of endometriosis in unsuccessful cases was significantly higher than that in successful cycles. Advanced age and endometriosis were the factors that were significantly associated with a lowered oocyte retrieval rate. Conclusion: Advanced age and endometriosis are high-risk factors that contribute to oocyte retrieval failure in infertile patients who are receiving IVF treatment.

Development of variable-magnification X-ray Bragg optics.

A novel X-ray Bragg optics is proposed for variable-magnification of an X-ray beam. This X-ray Bragg optics is composed of two magnifiers in a crossed arrangement, and the magnification factor, M, is controlled through the azimuth angle of each magnifier. The basic properties of the X-ray optics such as the magnification factor, image transformation matrix and intrinsic acceptance angle are described based on the dynamical theory of X-ray diffraction. The feasibility of the variable-magnification X-ray Bragg optics was verified at the vertical-wiggler beamline BL-14B of the Photon Factory. For X-ray Bragg magnifiers, Si(220) crystals with an asymmetric angle of 14° were used. The magnification factor was calculated to be tunable between 0.1 and 10.0 at a wavelength of 0.112 nm. At various magnification factors (M ≥ 1.0), X-ray images of a nylon mesh were observed with an air-cooled X-ray CCD camera. Image deformation caused by the optics could be corrected by using a 2 × 2 transformation matrix and bilinear interpolation method. Not only absorption-contrast but also edge-contrast due to Fresnel diffraction was observed in the magnified images.

The effect of moderate to severe endometriosis on expression of growth differentiation factor-9 mRNA in human granulosa cells under controlled ovarian hyperstimulation.

Purpose: To investigate the effect of moderate to severe endometriosis on mRNA expression of growth differentiation factor-9 (GDF-9) in the granulosa cells of mature follicles. Methods: Follicular fluid (FF) was obtained from 13 patients with moderate to severe endometriosis and 11 without endometriosis, as a control group, and GDF-9 protein levels in both were assayed by western blotting. mRNA expression by GDF-9 and LH receptor (LHR) in granulosa cells obtained from all patients in the study were investigated by StepOne Real-Time PCR. Results: Although GDF-9 in FF from patients with endometriosis was no different from that of controls, GDF-9 mRNA expression in granulosa cells of patients with endometriosis was statistically significantly lower than for the control group. The number of oocytes and high-quality embryos was positively correlated with GDF-9 mRNA expression in controls but not in patients with endometriosis Moreover, a negative correlation was identified between GDF-9 mRNA expression and serum estrogen and progesterone levels in the control group, whereas no correlation was observed for the endometriosis group. Conclusions: Moderate to severe endometriosis can significantly reduce GDF-9 mRNA expression in the granulosa cells of patients with the disease compared with those without, thus causing poor oocyte maturation and lower embryo quality.

[Hypercoagulable State in Cancer].

It has been estimated that cancer patients have a 4- to 7-fold increased risk of VTE compared with the general population. The prothrombotic state variably results from tumor- and patient-specific factors. The pathophysiology of cancer-associated thrombosis is not entirely understood. The hypercoagulable state in cancer involves several complex interdependent mechanisms, including interaction among cancer cells, host cells, and the coagulation system. Key roles in pathophysiology are played by TF, inflammatory cytokines, and platelets. Many risk factors for cancer-associated thrombosis have been identified, including patient-, cancer-, and treatment-related factors. Several biomarkers have been identified as potentially predictive of VTE in multivariate analyses. Elevations of leukocyte and platelet counts and low hemoglobin levels are all predictive of chemotherapy- associated VTE. The levels of FRMs are significantly higher in patients with than in those without malignant diseases. A recently developed risk score referred to as the Khorana Risk Score can accurately stratify cancer patients into low, intermediate, and high risk for developing VTE. Observed rates of VTE in the development and validation cohorts were 0.8 and 0.3% in the low-risk category, 1.8 and 2% in the intermedi- ate-risk category, and 7.1 and 6.7% in the high-risk category, respectively. This model has now been validated in several other studies, including the prospective Vienna CATS study, which expanded the study and improved prediction by including biomarkers.

[Progress in diagnosis and treatment for disseminated intravascular coagulation].

As the development of a hypercoagulable state in the setting of disseminated intravascular coagulation (DIC) induces localized infection, therapy for DIC should be evaluated according to the findings of examinations for both severe sepsis and DIC. DIC is classified into the following types: "bleeding type," "organ failure type," "asymptomatic type," and "complication type." The "bleeding type" and "organ failure type" are considered to reflect the "plasmin inhibitor (PI) deficiency type" and "antithrombin (AT) deficiency type," respectively. In order to improve the diagnosis of DIC, in particular limitations in global coagulation tests, the Japanese Society of Thrombosis and Hemostasis recently proposed tentative diagnostic criteria for DIC using hemostatic molecular markers and AT. The recommendations for treatment of DIC, especially the use of AT concentrates, recombinant activated protein C and thrombomodulin, vary among several guidelines for the management of DIC. These agents inhibit the effects of key proteases in activating coagulation and consequently exert an anti-inflammatory effect on DIC. Hence, it is necessary to extensively evaluate these agents in well-conducted clinical trials.

Natural history of thrombotic thrombocytopenic purpura and hemolytic uremic syndrome.

The differential diagnosis of thrombotic microangiopathy (TMA) has become clearer following the establishment of the relationships between (1) diarrhea-associated hemolytic uremic syndrome (HUS) and Shiga toxin-producing Escherichia coli-HUS (STEC-HUS), (2) a markedly reduced ADAMTS-13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) level and typical thrombotic thrombocytopenic purpura (TTP), and (3) abnormalities in the complement regulatory system and atypical HUS (aHUS). These TMAs include typical TTP, other forms of TMA, STEC-HUS, and aHUS. The pathological mechanisms of TMA still overlap among several forms of TMA. With respect to the management of TMA, the use of plasma exchange (PE) for typical TTP, additional steroid therapy for TMA and rituximab for typical TTP with a high titer of the inhibitor of ADAMTS-13, as well as eculizumab for aHUS, have also been established. Although several issues remain in the pathophysiology and management of TMA, new findings will hopefully resolve these problems in the near future.

Compared with cystectomy, is ovarian vaporization of endometriotic cysts truly more effective in maintaining ovarian reserve?

STUDY OBJECTIVE: To evaluate how endometriotic cystectomy and vaporization affect ovarian reserve after conservative surgery. DESIGN: Prospective study (Canadian Task Force classification II-1). SETTING: Hokusetsu General Hospital. PATIENTS: Ninety-nine women who underwent conservative surgery to treat endometriotic cysts from June 2011 to July 2013. INTERVENTIONS: Vaporization with bipolar current was performed in nulligravid women, and cystectomy in those who had a child. In women with endometriotic cysts, bilateral cystectomy was performed in 28, bilateral vaporization in 15, unilateral cystectomy in 40, and unilateral vaporization in 16. In all patients, preoperative and postoperative serum anti-müllerian hormone (AMH) and follicle-stimulating hormone (FSH) concentrations at the early proliferative phase were assayed, and the change in concentrations was evaluated for each operation. MEASUREMENT AND MAIN RESULTS: In the bilateral cystectomy group, the mean (SD) postoperative FSH concentration (19.3 [21.8] IU/mL) was statistically higher than the preoperative concentration (9.0 [6.2] IU/mL) (p < .01). AMH significantly declined after all operations to treat endometriotic cysts, and the rate of decline in the AMH concentration was >50% compared with preoperative concentrations. CONCLUSION: Whether endometriotic cysts are unilateral or bilateral, both cystectomy and vaporization using bipolar current can lower ovarian reserve. Therefore, it is necessary to develop more effective surgical procedures to prevent ovarian damage.

Associations between the pre-pregnancy body mass index and gestational weight gain with pregnancy outcomes in Japanese women.

AIM: To examine the associations between the pre-pregnancy body mass index (BMI) and gestational weight gain (GWG) with pregnancy outcomes in Japanese women. METHODS: The medical records of 1883 Japanese women who delivered singleton infants from January 2010 to January 2013 at Osaka-Minami Medical Center were retrospectively reviewed. We use the BMI classification which the World Health Organization defined for Asian populations and the GWG classified based on the current 2009 Institute of Medicine (IOM) recommendations. The odds ratio (OR) of each of the groups for the different pregnancy outcomes were compared to the recommended group using a logistic regression analysis adjusted by age, gestational weeks, parity, weight gain, mode of delivery, pregnancy induced hypertension (PIH) and gestational diabetes mellitus. RESULTS: Women who were obese (BMI, ≥25 kg/m(2) ) and overweight (BMI, 23-24.9 kg/m(2) ) had a higher rate of developing PIH (adjusted OR, 6.68 and 3.21 [95% confidence interval [CI], 3.31-13.3 and 1.29-7.24]). In contrast, GWG exhibited a correlation with the weight of the infant. The inadequate GWG group had a higher rate of small-for-gestational age (SGA) infants (adjusted OR, 1.72 [95% CI, 1.22-2.46]). The rate of emergency cesarean section was not significantly different between the groups. CONCLUSION: A pre-pregnancy BMI less than 23 kg/m(2) is desirable to prevent Japanese women from developing PIH. GWG within the IOM recommendations also reduced the risk of PIH and SGA.

Analyzing the possible involvement of anti-Müllerian hormone and anti-Müllerian hormone receptor II single nucleotide polymorphism in infertility.

PURPOSE: We performed TaqMan genotyping assays of anti-Mullerian hormone (AMH) and anti-Mullerian hormone receptor type II (AMHRII) single nucleotide polymorphisms (SNPs) in order to investigate how their frequency and distribution affect infertility treatment outcome. METHODS: Eighty Japanese women (advanced age: n = 51, endometriosis: n = 18, male infertility as a control: n = 11) who undertook ART were included in the study, and all couples underwent a full infertility investigation protocol. In order to investigate the natural distribution of SNPs, a naturally pregnant group of 28 subjects was recruited from among women who conceived naturally and subsequently delivered in our department. Genomic DNA was extracted from peripheral blood and genotyping was conducted by TaqMan genotyping assay. The relationship of AMH and AMHRII SNPs and treatment outcome in infertile women. Comparison of allele and genotype frequencies of infertile patients with naturally pregnant women. RESULTS: AMHRII -482 A>G homozygote mutation was complicated with ISV 5-6 C>T homozygote mutation and showed a significantly lower oocyte retrieval rate compared with a wild type. Two of 3 cases of AMHRII -482 A>G homozygote mutation were poor responders, and the distribution and frequency of each allele of naturally pregnant women showed no statistical difference compared with infertile women. CONCLUSIONS: This study revealed the possible involvement of AMHRII -482 A>G polymorphism on the malfunction of follicular development in Japanese women.

[Diagnosis of thrombosis by hemostatic markers].

Hemostatic markers are measured when diagnosing cases presenting with either thrombosis or thrombophilia. Decreased antithrombin (AT), protein C and protein S levels, and positive anti-phospholipid antibody findings together suggest a risk for venous thromboembolism (VTE). Increased thrombin AT complex (TAT) and soluble fibrin (SF) levels indicate a hypercoagulable state, and the addition of elevated fibrinogen and fibrin degradation products (FDP) as well as D-dimer suggests the presence of VTE. D-dimer is frequently measured in VTE cases, but this marker is affected by fibrinolysis and requires standardization. The prothrombin time, FDP and fibrinogen are all used in the diagnosis of disseminated intravascular coagulation. Markedly reduced ADAMTS13 level is a useful sign for the diagnosis of thrombotic thrombocytopenic purpura.

Comparison of the perinatal outcomes after laparoscopic myomectomy versus abdominal myomectomy.

BACKGROUND/AIMS: To compare the perinatal outcomes after laparoscopic myomectomy (LM) versus abdominal myomectomy (AM). METHODS: The medical records of 105 Japanese females who delivered after myomectomy from 2004 to 2012 at Osaka Medical College were reviewed retrospectively. RESULTS: Of the 105 females who delivered after myomectomy, 48 had undergone LM and 57 had undergone AM. There were no significant differences in the perinatal outcomes including the rates of emergency cesarean sections, preterm deliveries, placental abnormalities, pregnancy-induced hypertension, low Apgar score, non-reassuring fetal heart rate patterns, and intrauterine fetal death. No significant difference was observed in the incidence of post-partum hemorrhage. There was no uterine rupture in either group. 15 (31%) of the females who had LM were candidates for transvaginal delivery, and 14 delivered vaginally (93% success rate). In contrast, 20 (35%) of the females who had AM were candidates for transvaginal delivery, and 19 delivered vaginally (95% success rate). CONCLUSION: There were no significant differences in the perinatal outcomes between the females who had LM and AM. Moreover, both groups had a high rate of successful transvaginal delivery after selecting the appropriate candidates.