Value of vaginal cervical position in estimating uterine anatomy.

The anatomy of the uterus is defined with the angles of the vagina, cervix and uterine corpus. Hereunder there are angles of version and flexion. The cervical position observed during the vaginal speculum examination, may give information about the uterine anatomy. In this study, we investigated the place of the cervical position in the estimation of the uterine anatomy observed during the cervical examination. We enrolled 240 patients in our study, who applied to our routine gynecology outpatient clinic with various complaints. We divided these patients into two groups according to the cervical position (anterior cervical position and posterior cervical position) observed during the speculum examination. We recorded the uterine anatomy also with the transvaginal ultrasonography. During the speculum examination, we determined that 90% of the cases with posterior fornix position were anteverted and 10% retroverted; 64.2% of the cases with anterior fornix position were anteverted and 35.8% retroverted. According to these findings, cervical position observed during the speculum examination might be useful in the estimation of the uterine anatomy regarding the angles of the version. However, the ultrasonographic examination is essential for a definitive determination of the uterine anatomy. Clin. Anat. 30:404-408, 2017. © 2017 The Authors. Clinical Anatomy published by Wiley Periodicals, Inc. on behalf of American Association of Clinical Anatomists.

Polycystic Ovary Syndrome and Increased Soluble Tumor Necrosis Factor Like Weak Inducer of Apoptosis Levels Are Independent Predictors of Dyslipidemia in Youth.

BACKGROUND/AIMS: Dyslipidemia is common in women with polycystic ovary syndrome (PCOS) irrespective of age. Our aim was to investigate soluble tumor necrosis factor like weak inducer of apoptosis (sTWEAK), a cardiovascular risk marker in PCOS, and to determine if it is associated with dyslipidemia in youth. METHODS: A prospective-observational study was carried out including 35 PCOS patients and 35 healthy controls. Serum sTWEAK levels were measured using commercially available kits. Multiple logistic regression analysis was then performed to verify the statistically significant differences in the possible predictors of dyslipidemia. RESULTS: Serum sTWEAK levels and the percentage of women with dyslipidemia were significantly higher in the PCOS group (p = 0.024 and p < 0.001, respectively). Participants were further divided into 2 subgroups based on the presence of dyslipidemia. The percentage of women with PCOS was significantly higher in the dyslipidemic group when compared with controls; 70.7 vs. 20.7%, respectively (p < 0.001). Multiple logistic regression analysis revealed that both the presence of PCOS (OR 7.924, 95% CI 2.117-29.657, p = 0.002) and increased levels of sTWEAK (>693 pg/ml; OR 3.810, 95% CI 1.075-13.501, p = 0.038) were independently associated with dyslipidemia. CONCLUSIONS: Increased levels of both sTWEAK and PCOS were found to be independently associated with dyslipidemia in youth.

Are serum gamma-glutamyl transferase, high-sensitivity C-reactive protein, and ischaemia-modified albumin useful in diagnosing PCOS?

We assessed the serum levels of gamma-glutamyl transferase (GGT), high-sensitivity C-reactive protein (hsCRP) and ischaemia-modified albumin (IMA) in patients with polycystic ovary syndrome (PCOS). Fifty-three patients with PCOS were included in our study along with 40 women with no PCOS as the control group. The patients were divided according to their body mass index (BMI). GGT levels were significantly higher in the women with PCOS than the women in the control group (p < 0.05). They were also significantly higher in the PCOS women who were normoweight and overweight than the normoweight and overweight women in the control group (p < 0.001). There was no significant difference in the circulating levels of hsCRP and IMA between the women with PCOS and the controls or between the normoweight and overweight subgroups. GGT may be associated with the diagnosis of PCOS when the threshold is set at >15.5 U/L. With the application of this threshold, raised GGT levels had 83% sensitivity (95% CI 0.70-0.90) and 67.5% specificity (95% CI 0.52-0.79), for the diagnosis of PCOS. In our study, GGT levels were elevated in the PCOS patients independent of BMI and could thus be an important marker of PCOS.

Success rates of single-dose methotrexate and additional dose requirements among women with first and previous ectopic pregnancies.

OBJECTIVE: To compare the success of the single-dose methotrexate regimen and the requirement for a second or third dose of methotrexate between women with their first ectopic pregnancy (EP) and those with previous EP. METHODS: In a retrospective cohort study, data were analyzed from women treated for EP by single-dose methotrexate at a Turkish tertiary referral center between January 2010 and December 2013. Data were compared between women with at least one previous EP and those with their first EP. RESULTS: The success rate of the protocol in the first and previous EP groups was similar: 93.0% (320/344) and 87.3% (48/55), respectively. History of previous EP was not a predictor of treatment failure. However, the requirement for additional methotrexate doses was significantly higher in the previous EP group (16/48 [33.4%]) than in the first EP group (55/320 [17.2%]; P=0.03). Multivariate analysis showed that history of tubal surgery (P=0.006) and initial levels of the ß-subunit of human chorionic gonadotropin (P=0.001) were significant predictors of treatment failure. CONCLUSION: Although the single-dose regimen had similar success rates in the previous EP and first EP groups, additional doses of methotrexate were more frequently required in the previous EP group.

Comparison of the Perioperative Outcomes of a Vessel Sealing Instrument-Assisted Technique with a Conventional Technique in Abdominal Myomectomy.

INTRODUCTION: In gynaecologic practice, LigaSure Precise(TM) is generally used in endoscopic and open surgeries, such as hysterectomy, adnexectomy, and cancer surgery. However, there is no case report or main research article where LigaSure Precise(TM) has been used for myomectomy. We want to compare a technique using a vessel sealing instrument with a conventional technique in abdominal myomectomy. MATERIALS AND METHODS: Fifty-five women who underwent abdominal myomectomy were divided two groups: (1) a vessel sealing instrument-assisted technique (24 patients); and (2) a conventional technique (31 patients) between January 2011 and December 2014 at the Department of Gynaecology and Obstetrics, Gulhane Military Medical Academy, Ankara, Turkey. The data for the operation times, the occurrence of perioperative complications, the hospitalization times, and changes in haemaglobin and haematocrit levels for the two techniques were collected and compared. RESULTS: The mean operation time was 48 minutes for the vessel sealing instrument-assisted technique and 54 minutes for the conventional technique. No statistically significant differences were determined for haemoglobin and haematocrit changes, hospital stay and perioperative complications. CONCLUSION: We did not find any difference in the occurrence of complications, changes in haemoglobin or haematocrit levels, or hospital stay. The vessel sealing instrument-assisted technique is feasible and effective in reducing operation times.

Using narrow-band imaging with conventional hysteroscopy increases the detection of chronic endometritis in abnormal uterine bleeding and postmenopausal bleeding.

AIM: A preliminary study was designed to evaluate whether a narrow-band imaging (NBI) endoscopic light source could detect chronic endometritis that was not identifiable with a white light hysteroscope. MATERIAL AND METHODS: A total of 86 patients with endometrial pathology (71 abnormal uterine bleeding and 15 postmenopausal bleeding) were examined by NBI endoscopy and white light hysteroscopy between February 2010 and February 2011. The surgeon initially observed the uterine cavity using white light hysteroscopy and made a diagnostic impression, which was recorded. Subsequently, after pressing a button on the telescope, NBI was used to reevaluate the endometrial mucosa. RESULTS: The median age of the patients was 40 years (range: 30-60 years). Endometritis was diagnosed histologically. Six cases of abnormal uterine bleeding (6/71, 8.4%, 95% confidence interval [CI] 0.03-0.17) and one case of postmenopausal bleeding (1/15, 6%, 95%CI 0.01-0.29) were only diagnosed with chronic endometritis by NBI (7/86, 8.1%, 95%CI 0.04-0.15). CONCLUSION: Capillary patterns of the endometrium can be observed by NBI and this method can be used to assess chronic endometritis.

A modified technique to reduce spillage and the operative time in laparoscopic dermoid cyst excision.

INTRODUCTION: To determine whether controlled drilling, cyst excision, and removal in a bag can reduce the operative time and intraperitoneal spillage in dermoid cysts. MATERIALS AND METHODS: Laparoscopic dermoid cyst excision was performed in 45 women using a different technique: controlled drilling of dermoid cysts in a bag, excision of these cysts, and their removal in the same bag. RESULTS: The median age of the patients was 29.5 years (range, 18-42 years), the median size of the cysts was 55 mm (range, 30-100 mm), the median operative time was 40 minutes (range, 25-60 minutes), the median level of cancer antigen 19-9 was 28.5 U/mL (range, 1.2-127 U/mL), the median parity was 1 (range, 0-3), and the median hospitalization time was 1 day (range, 1-2 days). Twenty-five cysts were in the right ovary, and 20 were in the left ovary. In all cases, the dermoid cysts were ruptured with the controlled drilling. There was no intraperitoneal spillage of the cyst contents in the abdomen. No complication occurred intraoperatively or postoperatively. There was no recurrence 3 months after the operation. CONCLUSIONS: Controlled drilling, excision, and removal of a dermoid cyst inside the same bag seems to be a feasible method to prevent intraperitoneal spillage and to reduce the operative time.

Prenatal diagnosis of the acute meconium peritonitis secondary to ileum volvulus perforation: a case report.

This is an unusual case in comparison to other sonographically described prenatal cases due to very early diagnosis and surgical intervention following prompt delivery. A 40-year-old pregnant, ultrasonography showed presence of cystic structure in the fetal abdomen that was consistent with intestinal dilatation. At 32 weeks' of gestation, repeat ultrasound showed collapse of the bowel dilatation along with the presence of hyperechogenic fluid in the fetal abdominal cavity. Cesarean section was performed. The clinical utility of this report is the recognition that meconium peritonitis (MP) may be diagnosed in the acute phase with typical ultrasound features, and should be considered in the differential diagnoses of cases presented with reduced fetal movements. Although it appears that morbidity and mortality in MP cases depend upon gestational age, this case report may help to manage similar cases for defining the appropriate delivery time and treatment modality after prenatal identification of the problem.

Comparison of efficacy of bromocriptine and cabergoline to GnRH agonist in a rat endometriosis model.

OBJECTIVE: To determine the effect of dopamine agonists in a surgically induced endometriosis model on rats. STUDY DESIGN: In this prospective randomized experimental study, surgical induction of endometriosis was performed by autotransplantation technique on 52 adult female Wistar-Albino rats. Endometriosis formation was confirmed by a second-look laparotomy (n:48) 1 month later. Four study groups were randomly generated according to their treatment regimens: group 1 (leuprolide acetate, n = 12), group 2 (bromocriptine, n = 12), group 3 (cabergoline, n = 12) and group 4 (control, n = 12). Endometriotic implants were excised for histopathological examination after treatment at the setting of laparotomy. The mean surface areas and histopathological glandular tissue (GT) and stromal tissue (ST) scores of endometriotic implants were studied and compared among groups. RESULTS: After 30 days of treatment, the mean surface area of the endometriotic implants of leuprolide acetate, bromocriptine and cabergoline groups was significantly decreased. The regression of endometriotic foci size in comparison to control was highest in group 1, followed by group 2, then group 3. In the histopathological evaluation both the ST and GT scores of group 1, 2 and 3 were significantly decreased in comparison to controls without a statistically significant difference between the groups. CONCLUSION: Dopamine agonists are as effective as GnRH agonists in the regression of experimental endometriotic implants in rats. Further trials are needed to elucidate the pathways affected by dopamine agonists.

Long Term Patient Satisfaction of Burch Colposuspension with or Without Concomitant Total Abdominal Hysterectomy.

INTRODUCTION: Urinary incontinence negatively affects the quality of life. Various methods are used in the treatment of stress incontinence. Burch colposuspension (BC) is the classical treatment of urinary incontinence. AIM: To compare the long-term satisfaction in patients receiving BC with or without concomitant total abdominal hysterectomy. MATERIALS AND METHODS: One hundred and twenty patients with stress incontinence underwent burch colposuspension with or without concomitant total abdominal hysterectomy. Ninety-three (77.5%) patients were interviewed by telephone. Of these, 91(75, 8%) patients agreed to participate in the study. The patients were divided into two groups according to the type of the surgical procedure. Group 1(N=48, 52.7%) had received burch colposuspension with concomitant total abdominal hysterectomy. Group 2 (N=43, 47.3%) had received burch colposuspension without concomitant total abdominal hysterectomy. RESULTS: In Group 1, 41 patients (85%) were satisfied with the surgery and did not complain of urinary incontinence (p<0.05). In Group 2, 37 (86%) patients were satisfied with the surgery (p<0.05). CONCLUSION: There were no difference in patient satisfaction between hysterectomy and BC and only BC to treat incontinence.

The relationship between the VEGF/sVEGFR-1 ratio and threatened abortion.

PURPOSE: The aim of this study was to evaluate the levels of vascular endothelial growth factor (VEGF), soluble VEGF receptor-1 (sVEGFR-1) and placenta growth factor (PlGF) and VEGF/SVEGFR-1 ratio in pregnant women with threatened abortion (TA) compared to uncomplicated pregnancies at the same gestational week. METHODS: Thirty-three pregnant women with TA and thirty-three pregnant women with uncomplicated pregnancies were included in this case-control study. The level of VEGF, sVEGFR-1, and PIGF was analyzed by enzyme-linked immunosorbent assay (ELISA). The primary purpose of this study was to compare the VEGF, sVEGFR- 1, and PlGF levels and VEGF/sVEGFR-1 ratios in pregnant women with TA and pregnant women with uncomplicated pregnancies. The secondary purpose of this study was to evaluate the correlation between serum levels of these markers and gestational age. RESULTS: The serum levels of the sVEGFR-1 [0.60 (0.21-1.68) vs. 0.24 (0.09-0.57) ng/ml], VEGF [39.10 (6.57-163.56) vs. 5.24 (0.84-15.08) ng/ml] and VEGF/SVEGFR-1 ratio [68.64 (6.45-550.48) vs 24.12 (2.63-72.63)] were significantly elevated in women with TA (respectively, p: 0.001, p: 0.001, p: 0.001). However, PlGF did not elevate in women with TA [20.80 (3.13-93.11) vs 20.16 (1.22-49.91) ng/ml] (p: 0.473). CONCLUSION: These findings support the hypothesis that increased levels of the VEGF and sVEGFR-1 and VEGF/SVEGFR-1 ratio may be associated with the pathogenesis of TA.

Random-start controlled ovarian hyperstimulation with letrozole for fertility preservation in cancer patients: case series and review of literature.

The aim of this case series was to describe our experience with random-start controlled ovarian hyperstimulation (RS-COH) with the use of letrozole for fertility preservation. GnRH antagonist and letrozole cycles were started in three patients with a diagnosis of cancer and had a limited time window for fertility preservation for COH before initiating cancer therapy. Cycles were started in the late follicular or luteal phase, and the duration of COH ranged between 7-8 days. A total of 4-14 oocytes were retrieved, the peak E2 levels were 252-354 pg/ml and the saved time for start of the cancer treatment were 16-26 days for each patient. In conclusion, RS-COH with letrozole cycle is a reasonable option for fertility preservation in cancer patients for whom the treatment window may be narrow. Also, the use of a letrozole for COH may decrease the potential risk of ovarian hyperstimulation syndrome.

Effect of a low dose of gonadotropin releasing hormone antagonist on in vitro fertilization outcomes.

PURPOSE: This study aims to determine whether a low dose of the gonadotropin releasing hormone antagonist, cetrorelix, prevents a premature luteinizing hormone (LH) surge and affects in vitro fertilization (IVF) outcomes compared to the standard dose of 0.25 mg/day. METHODS: In this study, 45 IVF/intracytoplasmic sperm injection patients were stimulated with recombinant follicle stimulation hormone from day 2 of the cycle. Cetrorelix was injected daily from day 6 of gonadotropin administration. Twenty-two patients received cetrorelix at a dose of 0.25 mg/day, whereas 23 participants received half dose. RESULTS: The mean consumption of gonadotropins was significantly higher in patients receiving 0.25 mg/day of cetrorelix (2,213 vs. 1,350 U; p = 0.046). The clinical pregnancy rates were similar in both groups (31.8 vs. 47.8 %; p = 0.273). Premature LH surge was detected in 9.1 % of the patients receiving cetrorelix 0.25 mg/day and in 13 % of the patients receiving cetrorelix 0.125 mg/day (p > 0.05). The difference between two groups was not statistically significant (p > 0.05). CONCLUSIONS: Our results suggest that there is no difference between a cetrorelix dose of 0.125 or 0.25 mg/day in preventing premature LH rise during ovarian stimulation for IVF.

Ovarian reserve testing before and after laparoscopic tubal bipolar electrodesiccation and transection.

OBJECTIVE: To find out whether tubal sterilization leads to loss of ovarian reserve, we assessed the hormonal and ultrasonographic parameters of ovarian reserve in women who underwent laparoscopic tubal sterilization by bipolar electrodesiccation and transection. STUDY DESIGN: In this preliminary study, laparoscopic tubal sterilization was performed on 49 healthy women who had voluntarily requested elective surgical sterilization. Among the current ovarian reserve indicators, in the early proliferative phases, preoperative (baseline) and postoperative (third month) serum follicle-stimulating hormone (FSH), estradiol (E2), and anti-Mullerian hormone (AMH) levels, ovarian volume, and antral follicle counts (AFCs) were determined. Analysis of these hormonal and ultrasonographic parameters of ovarian reserve preoperatively and postoperatively was the main outcome measure. RESULTS: Preoperative and third-month postoperative FSH, LH, E2, and AMH levels did not reveal statistically significant differences (p=0.101, p=0.180, p=0.254, and p=0.079; respectively). The ultrasonographic indicators of ovarian reserve did not change in terms of total ovarian volume and total AFC (p=0.793 and p=0.098, respectively). CONCLUSIONS: Short-term follow-up study results revealed a slight but non-significant change in the current ovarian reserve markers, especially in the AMH levels.

Asymmetrical dimethylarginine levels on the implantation success of in vitro fertilization and embryo transfer.

The aim of this study was to evaluate the level of asymmetrical dimethylarginine (ADMA) levels before gonadotrophine treatment and on the day of oocytes retrieval in order to determine whether ADMA can be used as a predictive marker for implantation success in in vitro fertilization (IVF) cycles. Forty-four unexplained infertile patients were included in the study. Controlled ovarian hyperstimulation was performed using the recombinant follicle-stimulating hormone (FSH) with the standard long protocol for all patients. ADMA and E2 were measured at the beginning of the ovulation induction and on oocyte retrieval day. The primary outcome was the difference in ADMA levels in implantation positive and implantation negative women. At the beginning of the ovulation induction, the mean ADMA levels were 1553 µmol/L and 1.464 µmol/L in the implantation positive and negative groups, respectively. There was no statistically significant difference between groups (p: 0.90). On the day of oocyte retrieval, the mean ADMA levels were 1173 µmol/L and 1170 µmol/L in the implantation positive and negative groups, respectively. There was no statistically significant difference between groups (p: 0.97). In conclusion, ADMA levels before gonadotrophine treatment and the day of oocytes retrieval cannot be used as a predictive marker for implantation success in IVF cycles.

Assessment of the predictive value of serum progesterone levels on early pregnancy prognosis in spontaneous twin gestations: a prospective study.

OBJECTIVES: The aim of this study was to assess the predictive value of serum progesterone levels in early pregnancy prognosis in spontaneous dichorionic-diamniotic twin gestations. STUDY DESIGN: This study was carried out among 38 spontaneous dichorionic-diamniotic twin gestations between January 2003 and June 2005 in the Department of Obstetrics and Gynaecology at the Gulhane Military Medical Academy. Serum progesterone levels were measured at 7 and 10 weeks' gestation and pregnancies were followed until 14 gestational weeks by ultrasound examination. RESULTS: We found that a progesterone level of 58 nmol/l in the 7th gestational week and of 51 ng/ml at 10 gestational weeks has a predictive value for viable intrauterine twin pregnancies with 83% sensitivity and 69% specificity and 83% sensitivity and 84% specificity, respectively. CONCLUSION: Progesterone levels in the early gestational weeks may be a biochemical marker for the prediction of a twin pregnancy outcome and may reduce the number of ultrasound examinations.

Outcome of in vitro fertilization and ovarian response after endometrioma stripping at laparoscopy and laparotomy.

OBJECTIVE: To add further data on in vitro fertilization (IVF) outcome and ovarian response after endometrioma stripping via either laparoscopy or laparotomy. STUDY DESIGN: IVF outcome and ovarian response parameters in patients who had undergone unilateral endometrioma stripping at laparoscopy (n=28) or laparotomy (n=10) before IVF were retrospectively compared. RESULTS: Fertilization rates, number of embryos transferred and pregnancy rates did not differ between the groups. Significantly more recombinant FSH was used to induce folliculogenesis, and fewer metaphase II oocytes were retrieved in the laparotomy group. The laparotomy-postcystectomy ovaries were significantly smaller and malpositioned. In both stripping groups, significantly smaller operated-on ovaries with lower numbers of antral and mature follicles were observed as compared to intact ovaries. CONCLUSION: A higher amount of FSH is needed to achieve an acceptable IVF outcome after unilateral endometrioma surgery. Indications for surgical treatment of patients having larger and bilateral cysts with an expectation for future fertility should be cautiously reviewed

Isolated torsion of fallopian tube in a premenarcheal 12-year-old girl.

Isolated torsion of fallopian tubes should be considered even at premenarcheal ages in cases of acute pelvic pain, and prompt surgery can preserve the tube and thus fertility. It is an uncommon emergency event and a difficult condition to evaluate clinically. This report focuses on a 12-year-old premenarcheal girl who presented with acute pelvic pain of 2 days. Pelvic ultrasound showed an adnexal mass on the left side. Laparoscopy was performed and an isolated tubal torsion was discovered. The tube was necrotic and salpingectomy was performed. The appendix appeared to be hyperemic and erectile. Appendectomy was also performed to rule out appendicitis. It's our recommendation that in the differential diagnosis of acute lower abdominal pain of girls, isolated torsion of the fallopian tubes should be considered. Also, preservation of the tube and fertility should be possible with prompt surgical intervention.