Anti-Müllerian hormone as a predictor of pregnancy in women under 35 years with unexplained infertility undergoing ICSI: a retrospective study.

BACKGROUND: Anti-Müllerian hormone (AMH) is a well-established marker for the determination of ovarian reserve. However, its role in the prediction of pregnancy is still under debate. In this retrospective study, we aimed to evaluate the relationship of serum AMH levels with pregnancy rates in patients with unexplained infertility undergoing ICSI. Moreover, we compared the predictive value of AMH with that of antral follicle count (AFC). METHODS: Records of 76 patients under 35 years of age with AMH levels between 1 and 3.5 ng/mL were examined retrospectively. Participants were divided into groups based on their AMH level and age. RESULTS: AMH levels in women under 30 years were found significantly higher than those in women over 30 years (P=0.033). Fifty-seven of 76 patients (75%) were pregnant. Age did not have a significant effect on the pregnancy rates in the selected study group (P=0.252). On the other hand, despite the poor predictive accuracy, serum AMH was shown to have a predictive value with a cut-off point of 1.95 ng/mL. Logistic regression tests demonstrated a higher pregnancy rate (3.396 fold) with an AMH level 1.95 or above. There was no significant relationship between AFC and pregnancy. CONCLUSIONS: AMH might have a role in the prediction of pregnancy after ICSI in patients under 35 years with unexplained infertility.

The effects of different therapeutic modalities on cardiovascular risk factors in women with polycystic ovary syndrome: A randomized controlled study.

OBJECTIVE: This study was designed to evaluate the effects of 3 mg drospirenone/30 µg ethinyl estradiol (OC) alone or combined with 1700 mg metformin on metabolic risk factors. MATERIALS AND METHODS: In this randomized, prospective, controlled study, 87 non-obese (18-30 BMI) women of reproductive age (18-39) with polycystic ovary syndrome (PCOS) were assigned to control (n = 17), OC (n = 21), combination (n = 20) and metformin (n = 29) therapy groups. RESULTS: Adiponectin levels changed -28.27%, -20.37% and 35.78% after OC, combination and metformin therapies, respectively. High sensitive C-reactive protein levels (hsCRP) changed with OC, combination and metformin therapies by 102.32%, 3.2% and -7.14%, respectively. Plasminogen activator inhibitor-1 levels decreased 41.34% in the metformin group. Apolipoprotein-B levels changed in a manner similar to changes in hsCRP levels. The homeostatic model insulin resistance index changed significantly between the groups following treatment (p = 0.001). CONCLUSION: Six cycles of treatments with OC alone may cause metabolic variables to deteriorate in non-obese women with PCOS. The addition of metformin to OC may ameliorate some aspects of this effect.

Systematic review: What is the best first-line approach for cesarean section ectopic pregnancy?

This systematic review aims to analyze the case reports, case series, or clinical studies describing the women with cesarean scar ectopic pregnancy (CSEP), and thus, to determine the efficacy and safety of different primary treatment modalities in the management of CSEP. A thorough search of electronic databases showed that 274 articles on CSEP were published between January 1978 and April 2014. Systemic methotrexate, uterine artery embolization, dilatation and curettage (D&C), hysterotomy, and hysteroscopy were the most frequently adopted first-line approaches. The success rates of systemic methotrexate, uterine artery embolization, hysteroscopy, D&C, and hysterotomy were 8.7%, 18.3%, 39.1%, 61.6%, and 92.1%, respectively. The hysterectomy rates were 3.6%, 1.1%, 0.0%, 7.3%, and 1.7% in CSEP cases that were treated by systemic methotrexate, uterine artery embolization, hysteroscopy, D&C, and hysterotomy, respectively. The ability to achieve a subsequent term pregnancy is related to successful systemic methotrexate treatment (p = 0.001) or hysterotomy (p = 0.009). Future term pregnancy was significantly more frequent in the hysterotomy group (p = 0.001). Hysteroscopy and laparoscopic hysterotomy are safe and efficient surgical procedures that can be adopted as primary treatment modalities for CSEP. Uterine artery embolization should be reserved for cases with significant bleeding and/or a high suspicion index for arteriovenous malformation. Systemic methotrexate and D&C are not recommended as first-line approaches for CSEP, as these procedures are associated with high complication and hysterectomy rates.

The clinical significance of classical and new emerging determinants of adenomyosis.

OBJECTIVE: The present study aims to analyze the diagnostic accuracy of clinical characteristics together with new emerging laboratory markers of adenomyosis. METHODS: This study was a retrospective analysis of clinical and laboratory characteristics of 99 women who underwent hysterectomies with (study group) or without (control group) a diagnosis of adenomyosis, 56 and 43 patients in each group, respectively. RESULTS: The women with adenomyosis were more likely to have younger age (OR = 1.14, 0.789-0.971 95% CI, P = 0.010), higher parity (OR = 1.81, 0.308-0.988 95% CI, P = 0.046), higher number of curettage (OR = 1.90, 1.189-3.041 95% CI, P = 0.007), dysmenorrhea (OR = 117.49, 2.715-5084.883 95% CI, P = 0.013) and elevated mean platelet volume (OR = 5.17, 2.054-13.028 95% CI, P = 0.000). After receiver-operating-characteristics curve analysis, using a cut-point of 8.5 fL, the preoperative mean platelet volume predicted adenomyosis with a sensitivity of 56.6% and specificity of 82.6%. CONCLUSIONS: Those findings suggest gynecologists to give priority on adenomyosis when premenopausal paraous patient with a history of curettages admitted with a complaint of dysmenorrhea and elevated levels of MPV.

Changes in Markers of Ovarian Reserve After Laparoscopic Ovarian Cystectomy.

STUDY OBJECTIVE: This study was conducted to determine the changes in ovarian reserve markers after laparoscopic ovarian cystectomy (LOC). DESIGN: Prospective cohort study (Canadian Task Force classification II-2). SETTING: University teaching hospital. PATIENTS: Fifty 50 patients who underwent LOC were prospectively examined to determine the changes in serum markers of ovarian reserve, starting from 1 month before and 3 months after consecutive operations. INTERVENTIONS: Changes in serum markers were compared between the following groups: endometrioma cysts (n = 26) versus nonendometrioma cysts (n = 24), unilateral cystectomy (n = 38) versus bilateral cystectomy (n = 12), and bilateral endometrioma extirpation (n = 10) versus other cystectomy operations (n = 40). MEASUREMENTS AND MAIN RESULTS: A significant change was noticed between the preoperative and postoperative antimüllerian hormone (AMH) levels (2.67 ± 2.67 ng/mL vs 1.84 ± 1.72 ng/mL, p < .0001). Serum AMH levels were found to be significantly decreased in endometrioma (p = .002), nonendometrioma (p = .019), unilateral cystectomy (p = .001), bilateral cystectomy (p = .005), bilateral endometrioma (p = .011), and cysts other than bilateral endometrioma (p = .000) groups. CONCLUSION: The ovarian reserve was found to be diminished after LOC regardless of the presence of endometrioma that could be distinguishable by serum AMH levels.

Recurrent pregnancy loss is associated with increased red cell distribution width and platelet distribution width.

AIM: The present study aims to evaluate how components of complete blood count are altered in women with a history of recurrent pregnancy loss. MATERIAL AND METHODS: This was a retrospective evaluation of 60 women who had a history of recurrent pregnancy loss, 60 healthy women who had a first trimester pregnancy and 60 healthy parous women. RESULTS: When compared with pregnant women and healthy controls, the women with a history of recurrent pregnancy loss had significantly higher red cell distribution width (RDW) and platelet distribution width (PDW) (P = 0.001 for both). Thrombophilia was detected in 31.7% of the women who had a history of recurrent pregnancy loss (19 out of 60). When compared to the women without thrombophilia, the women with thrombophilia had significantly lower body mass index (P = 0.034) but significantly higher RDW, PDW and plateletcrit (respectively, P = 0.043, P = 0.001 and P = 0.002). There were significant and positive correlations between RDW and PDW (r = 0.615, P = 0.001), RDW and plateletcrit (r = 0.343, P = 0.007) and PDW and plateletcrit (r = 0.340, P = 0.008) in women with a history of recurrent pregnancy loss. CONCLUSION: An elevation in PDW and RDW values was found to be associated with recurrent pregnancy loss.

The status of telomerase enzyme activity in benign and malignant gynaecologic pathologies.

BACKGROUND: Telomeres are essential for the function and stability of eukaryotic chromosomes. Telomerase consists of three subunits: human telomerase reverse transcriptase (hTERT), human telomerase RNA (hTR), and telomerase protein 1 (TP1). The hTERT subunit determines the activity of telomerase as an enzyme and is detected in most human tumors and regenerative cells. Telomerase activity is a useful cancer-cell detecting marker in some types of cancers. AIMS: The aim of this study was to assess of telomerase hTERT mRNA in gynaecological tumors for diagnosis of malignancy. STUDY DESIGN: Cross-sectional study. METHODS: A total of 55 gynaecologic tumor samples (35 ovarian, 13 endometrial, 6 cervical and 1 placental site trophoblastic tumor tissue) were obtained at the time of surgery. Quantification of hTERT mRNA was performed in a real-time reverse transcriptase polymerase chain reaction (RT-PCR) using the LightCycler TeloTAGGG hTERT Quantification Kit. RESULTS: It was histopathologically detected that 18 of the tissue samples were malignant and 37 of the samples were benign. 16 of the malignant tissue samples (88.9%) and 3 (8.1%) (endometrial tissue in proliferative phase, mucinous cyst adenoma and endometriosis) of the benign tissue samples were found to be hTERT positive. With the presence of these data, sensitivity and specificity of hTERT for the diagnosis of malignancy were calculated to be 88.9% and 91.9%, respectively. CONCLUSION: It was suggested that the measurement of telomerase activity in gynaecologic tumors, except for endometrial tissue in the reproductive phase, is a valuable method for pathological investigation.

Increasing the stimulation dose of rFHS in unexpected poor responders is not associated with better IVF outcome.

OBJECTIVES: The aim of this retrospective study is to determine whether increasing the stimulation dose of rFSH in unexpected poor responders is associated with better IVF outcome or not. METHODS: A total of forty eligible women who fulfilled our definition of poor responders (< or = 3 follicles, < 4 oocytes or E2 levels < or = 500 pg/ml on day of hCG administration) and who did not achieve an ongoing pregnancy in the first cycle and who returned for a second higher rFSH dose IVF cycle with a long-agonist protocol were included to the study. The first-low dose cycles and the second-high dose cycles were compared to each other. Each patient functioned as her own control. Main outcome measures of the study were daily and total dose of rFSH, duration of stimulation, number of follicles, number of oocytes retrieved, number of embryos and E2 level on day of hCG injection. RESULTS: The first-low dose cycles and the second-high dose cycles were comparable regarding patient characteristics. There were no significant differences in duration of stimulation, number of follicles, number of oocytes retrieved, number of embryos and E2 level on day of hCG injection between the first-low and second-high dose cycles. Daily and total dose of rFSH were significantly higher in the second-high dose cycles. Fewer cycles were cancelled during the second higher gonadotrophin dose after first unexpected poor response. CONCLUSIONS: Increasing the starting dose of gonadotrophin after an unexpected poor response in the first IVF cycle is not an effective approach. It may increase the oocyte retrieval rates and embryo transfer rates, but will not add any significant improvement in the number of oocytes retrieved and the number of transferable embryos. The only important benefit of increasing the dose was the low cancellation rate.

Postabortion Doppler evaluation of the uterus: incidence and causes of myometrial hypervascularity.

OBJECTIVE: The aim of this study was to investigate the incidence and causes of uterine hypervascular lesions showing low-impedance, high-velocity flow on color Doppler sonography (CDS) after first-trimester dilation and curettage (D&C). METHODS: This was a prospective study of 65 consecutive women who underwent first-trimester termination of pregnancy. Color Doppler sonography of the uterus was performed on days 3 and 10 after D&C. If the myometrial hypervascularity (MH) persisted on day 10, a second D&C was performed, and then the patients were followed with weekly Doppler examinations. RESULTS: In 16 of 65 women (24.6%), MH was detected with CDS on day 3 after D&C. In 3 cases, MH resolved spontaneously by postabortion day 10. In the remaining 13 patients, the second D&C performed on day 10 revealed retained products of conception (RPOC) in 8 patients (61.5%), a hydatidiform mole in 2 (15.4%), endometritis in 1 (7.7%), and no abnormality in 2 (15.4%). Complete resolution of the MH occurred in all cases. The mean period to the resolution of MH after the second D&C +/- SD was 16.54 +/- 11.06 days (range, 7-48 days). Univariate analysis revealed that gestational age at D&C (P = .012) and a history of any uterine surgery (P = .044) were significantly associated with postabortion MH. On binary logistic regression analysis, gestational age at D&C was the only independent predictive factor for MH (P = .016; odds ratio, 1.47; 95% confidence interval, 1.08-2.02). CONCLUSIONS: The presence of hypervascular areas within the myometrium is a common finding in the postabortion period, and in most cases, the cause of this finding is RPOC.

Longitudinal study of platelet size changes in gestation and predictive power of elevated MPV in development of pre-eclampsia.

OBJECTIVES: The aim of this cohort is to investigate whether any haematologic changes detectable by simple complete blood count (CBC) precede pre-eclampsia development and the diagnostic value of these markers in clinical practice for prediction of pre-eclampsia. METHODS: All pregnant women, in the first trimester, attending to GATA Haydarpasa Teaching Hospital Obstetric Outpatient Clinic for routine obstetric care were enrolled. Routine obstetric care consisted of monthly visits until 32nd week, bimonthly visits between 32nd and 36th week, and weekly thereafter. According to the study, protocol CBC was taken from women at each visit and recorded. After delivery, outcome data were obtained. RESULTS: A total of 1336 women were included into the statistical analysis and 107 (8%) of them developed pre-eclampsia. Parameters of CBC were similar between groups other than mean platelet volume (MPV) values. MPV values of pre-eclamptic women were significantly higher than normotensive counterparts from 24th gestational week up to gestational week at birth. In pre-eclamptic group, mean gestational age of diagnosis was 33.8 weeks and significant MPV increase was detected to precede the diagnosis by approximately 4.6 weeks (range 2.8-5.9 weeks). CONCLUSIONS: Our study provides evidence that MPV gradually increases in pregnant women affected by pre-eclampsia compared to women with normal pregnancies.

Comparison of the risk of malignancy index and self-constructed logistic regression models in preoperative evaluation of adnexal masses.

OBJECTIVE: The aim of this study was to evaluate women with adnexal masses in the preoperative period by creating 2 logistic regression models, 1 including sonographic morphologic characteristics and the other including both morphologic and color Doppler characteristics, to compare the diagnostic accuracy of these 2 models with the risk of malignancy index (RMI). METHODS: This prospective study included 38 malignant, 7 borderline, and 244 benign ovarian masses. The menopausal status, presence of septa, presence of papillary projections, location of the tumor, presence of ascites, presence of metastases, cancer antigen 125 level, tumor volume, septa thickness, and percentage of the solid component were included in the initial analysis. A second regression analysis was performed with the addition of Doppler parameters (location of blood flow and lowest resistive index) in the data set. Diagnostic performance of the 2 regression models and RMI were described and compared by generating receiver operating characteristic curves for each model. RESULTS: The area under the curve values for the morphologic model (model 1), Doppler model (model 2), and RMI were 0.907, 0.971, and 0.889, respectively. Significance levels of model 1 and the RMI were similar (P = .23), whereas model 2 had a significantly higher area under the curve compared with both model 1 (P = .037) and the RMI (P = .018). CONCLUSIONS: The addition of Doppler parameters in the regression model significantly increases the predictive performance. Nevertheless, in low-resource settings, the RMI remains the method of choice for distinguishing adnexal masses and referral to gynecologic oncology clinics.

Second trimester amniotic fluid annexin A5 levels and subsequent development of intrauterine growth restriction.

OBJECTIVE: The purpose of this study was to investigate the levels of annexin A5 in second trimester amniotic fluid, and evaluate its correlation with subsequent development of intrauterine growth restriction (IUGR). METHOD: A total of 264 women undergoing mid-trimester amniocentesis between January 2007 and December 2007 were enrolled for the study. Amniocentesis was performed for routine indications. After delivery, outcome data were obtained. RESULTS: Maternal age, frequency of nulliparity, fetal sex and gestational week at amniocentesis were similar between groups. As expected, prevalence of smoking was higher in IUGR developing mothers. Significant positive correlations were present between annexin A5 levels and gestational age at amniocentesis (P = 0.02) and maternal age (P = 0.01). Linear regression analysis revealed that annexin A5 levels were positively correlated with patient's age. Smoking women had significantly lower annexin A5 levels in the mid-trimester amniotic fluid (9.9 +/- 2.3 and 10.7 +/- 1.3 ng/mL, P = 0.01). Logistic regression analysis demonstrated that after controlling for gestational age at amniocentesis, smoking, maternal age, and maternal hypertension, annexin A5 was not significantly associated with IUGR (P = 0.07). CONCLUSION: Amniotic fluid annexin A5 levels in the mid-trimester are not associated with IUGR at birth after controlling for maternal smoking and other confounders.

Could mean platelet volume be a predictive marker for gestational diabetes mellitus?

BACKGROUND: Gestational diabetes mellitus is defined as any degree of glucose intolerance with onset or first recognition during pregnancy. Early diagnosis of this complication and appropriate treatment aimed at tight control over maternal glucose levels may positively influence the perinatal outcome. There are studies, which suggest platelets play a role in the pathogenesis of gestational diabetes mellitus. AIM: The aim of this study is to compare the platelet count and other platelet parameters in gestational diabetic and normal pregnant women and to investigate whether these parameters have a predictive significance in gestational diabetes mellitus. MATERIALS AND METHODS: Thirty four women with gestational diabetes mellitus and 45 normal pregnant women were enrolled into the study. RESULTS: Women with gestational diabetes mellitus had lower platelet counts and higher mean platelet volume (MPV) values which were statistically significant (p <0.006 and p <0.0001), respectively. CONCLUSION: Our results indicate that platelet count and MPV play an important predictive role in gestational diabetes mellitus.

Placental mesenchymal dysplasia associated with trisomy 13: sonographic findings.

Placental mesenchymal dysplasia (PMD) is a rare placental abnormality with sonographic and macroscopic features similar to those seen in a partial hydatidiform mole, and which has usually been reported with a normal female karyotype. We report a case of prenatally suspected PMD associated with trisomy 13. Sonography performed at 17 weeks' gestation showed multiple cystic spaces in the placenta resembling molar tissue, and a fetus with postaxial polydactyly and an atrial septal defect. An amniocentesis revealed a fetal karyotype of 46,XY,der(13), t(13;13)(q11;q11)[20]/47,XY,+13[11], consistent with trisomy 13. Cordocentesis confirmed the cytogenetic diagnosis. Histopathologic examination of the placenta following termination of the pregnancy at 22 weeks' gestation showed enlarged stem villi with loose connective tissue and cistern formation and no evidence of trophoblastic hyperplasia or stromal trophoblastic inclusions, which was consistent with PMD. PMD should be considered in the differential diagnoses of a placenta showing multiple cystic lesions on prenatal sonography, and karyotypic analysis should be performed.

First trimester screening for Down syndrome in rhesus negative women.

OBJECTIVES: To explore the effect of maternal rhesus status on first-trimester screening markers for Down syndrome. METHODS: We accessed a database of singleton pregnancies undergoing first-trimester genetic screen with maternal Rh status documented and pregnancy outcome information available. Excluded were cases of fetal chromosomal or structural abnormalities, or maternal systemic disease. Results of maternal serum pregnancy-associated plasma protein A (PAPP-A) and beta-human chorionic gonadotrophin (beta-hCG) adjusted for gestational age were compared between Rh-negative and Rh-positive women with p < 0.05 considered significant. RESULTS: Two thousand two hundred and two pregnancies fulfilled the study criteria, and 160 of them (7%) were Rh negative. Only free beta-hCG corrected multiples of the median (MoM) values were statistically increased in Rh-negative women (p < 0.009). Using a cut-off of 1:300, screen-positive rates of maternal serum biochemistry were not significantly different between Rh-negative and Rh-positive women (12.5 vs 10.4%, p = 0.41). CONCLUSION: The present study focused on measurements of beta-hCG and PAPP-A in the sera of women with Rh-negative blood group. Women with Rh-negative blood type have similar first-trimester serum PAPP-A MoM values as Rh-positive women, but significantly higher beta-hCG MoM values. However, there was no significant difference in the screen-positive rate for Down syndrome between the two groups.