Comparison of fixed and flexible progestin-primed ovarian stimulation protocols to prevent premature luteinization in patients with diminished ovarian reserve.

PURPOSE: Flexible progestin-primed ovarian stimulation (PPOS) protocol is demonstrated to be effective in suppressing premature luteinization in few studies. We aimed to compare fixed and flexible PPOS protocols in preventing premature luteinization in patients with diminished ovarian reserve. METHODS: This retrospective cohort study included patients with a diminished ovarian reserve who were administered PPOS protocols for pituitary suppression during ovarian stimulation in a tertiary center in between January 2019 and June 2022. At fixed protocol, 20 mg/day dydrogesterone was started in cycle day two or three along with gonadotropins and continued until trigger day. In contrast, at flexible protocol, 20 mg/day dydrogesterone was commenced when the leading follicle reached 12 mm or serum estradiol (E2) level was > 200 pg/mL. RESULTS: A total of 125 patients, of whom 83 were administered fixed PPOS protocol and 42 were administered flexible PPOS protocol, were included in the analysis. Both groups had similar baseline characteristics and cycle parameters, including total days of gonadotropin administration and total gonadotropin dose (p > 0.05). Premature luteinization occurred at 7.2% and 11.9% of patients in fixed and flexible PPOS protocols, respectively (p = 0.505). Retrieved oocytes numbers, metaphase II oocyte numbers, and 2PN numbers were also similar (p > 0.05). Clinical pregnancy rates per transfer were 52.5% in fixed and 36.4% in flexible protocols (p = 0.499). CONCLUSION: Both fixed and flexible PPOS protocols had statistically similar outcomes in preventing premature luteinization and other cycle parameters. The flexible PPOS protocol seems to be as effective as the fixed PPOS protocol for patients with diminished ovarian reserve; however, further prospective studies should be conducted to validate the results of our research.

Feasibility of hyperthermic intraperitoneal chemotherapy (HIPEC) in ovarian cancer during COVID-19 pandemic.

OBJECTIVE: This study aims to evaluate the effect of the COVID-19 pandemic and related restrictions on patients who underwent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) for ovarian cancer. METHODS: We retrospectively evaluated ovarian cancer patients who underwent HIPEC following complete cytoreductive surgery performed during the outbreak of the COVID-19 pandemic in three different centers specializing in gynecological oncology. All patients who underwent cytoreduction plus HIPEC for a primary, interval, and recurrent surgery were evaluated. Primary outcomes was postoperative 30-day morbidity and mortality. The secondary outcome was infection of patient and/or related staff with COVID-19 during the perioperative or early postoperative period. RESULTS: We performed a total of 35 HIPEC procedures during the pandemic: 15 (42.9%) patients underwent primary/interval surgery, while 20 (57.1%) patients had recurrent disease. Grade 3-4 complications occurred in one patient (2.9%) (chronic renal failure), while mortality did not occur in any patient. Neither the patients nor related staff were infected with the coronavirus during the perioperative or early postoperative period. One patient, who was diagnosed with COVID-19 pneumonia on postoperative day 80 died from the infection. Another patient died on postoperative day 85 due to progressive ovarian cancer, a disorder in vital functions, and organ failure. CONCLUSION: HIPEC during the COVID-19 pandemic seems a safe and feasible procedure, with acceptable morbidity and mortality rates. Careful selection of patients is important and precautions should be taken before the procedure.

Single- or double-layer uterine closure techniques following cesarean: A randomized trial.

INTRODUCTION: Cesarean deliveries are commonly performed throughout the world. Although the uterine closure technique following this procedure may influence how the uterine scar heals, there is insufficient evidence for choosing the appropriate technique and so preventing long-term negative consequences. This prospective, randomized study examined the effects of single- and double-layer uterine closure techniques on uterine scar healing following cesarean delivery. MATERIAL AND METHODS: This study assessed a total of 282 women aged 18-45 years who were in gestational weeks 24-41 of singleton pregnancies. None had previously undergone uterine surgeries. These participants completed their first cesarean deliveries at the time of study and were randomized into the following two treatment groups: single-layer closure with locking and double-layer closure with locking in the first layer, but not in the second layer (NCT03629028). However, the decidua was not included for treatment in either group. Participants were evaluated at 6-9 months after cesarean section by saline infusion sonohysterography to assess cesarean delivery scar defects. These procedures were conducted by experienced sonographers who were not aware of the uterine closure technique. RESULTS: Of the 225 final participants, 109 received the single-layer closure technique, whereas 116 received the double-layer technique. The niche rates were 37% (n = 40) for the single-layer group and 45.7% (n = 53) for the double-layer group (P = .22, relative risk 1.4, 95% CI = 0.8-4.4). CONCLUSIONS: The single- and double-layer closure techniques did not produce different impacts on uterine scar niche development.

Role of prophylactic and therapeutic red blood cell exchange in pregnancy with sickle cell disease: Maternal and perinatal outcomes.

BACKGROUND AND AIM: The incidence of fetomaternal complications during pregnancy is high for women with sickle cell disease (SCD), which is the most common hematologic genetic disorder worldwide. Prophylactic red blood cell exchange (pRBCX) has been shown to be efficient, safe, and feasible for preventing complications. The aim of this study was to observe maternal, perinatal, and neonatal outcomes of pregnancies in which pRBCX was. METHOD: This was a single-center, retrospective, cross-sectional study, which recruited 46 consecutive adult pregnant women with SCD between January 2012 and June 2019. Obstetric features, SCD-related complications, and fetomaternal outcomes were compared between the 27 patients who received prophylactic exchange and the 19 who did not (therapeutic exchange was performed in 7 and was not performed in 12 cases). RESULTS: Painful crises, preeclampsia, and preterm birth rates were significantly higher in the group that did not receive prophylactic exchange (control group; P = .001, P = .024, and P = .027, respectively). There was one maternal mortality in the control group (P = .41). Incidence of adverse fetal or maternal complications was significantly higher in the control group (P = .044 and P = .007, respectively). CONCLUSIONS: Our center's experience over a 7.5-year period, as described above, demonstrates that pRBCX in SCD affects the course of pregnancy positively by ameliorating negative fetomaternal outcomes.

Accuracy of intra-operative frozen section in guiding surgical staging of endometrial cancer.

PURPOSE: Surgery consists the main treatment of endometrial cancer; however, decision of lypmhadenectomy is controversial. Intra-operative frozen section (FS) is commonly used in guiding surgical staging; nevertheless, there are different reports regarding its adequacy and reliability. Aim of this study is to assess accuracy of FS in predicting paraffin section (PS) results in patients with endometrium cancer. METHODS: Data of 223 cases, who were operated for endometrial cancer at a tertiary hospital in 2012-2019, were analyzed retrospectively. Histological type, grade, tumor diameter, depth of myometrial invasion, and cervical and adnexal involvement in frozen and paraffin section were evaluated. Positive and negative predictive values and accuracy of frozen results in predicting paraffin results for each parameter was assessed. Statistical significance was taken as 0.05 in all tests. RESULTS: Accuracy of FS in predicting PS results were 76.23% for histology, 75.45% for grade, 85.31% for depth of myometrial invasion, and 95.45% for tumor diameter. Surgery, based on FS results, caused undertreatment in 4 patients, while metastatic lymph node ratios were found in only 35.3-50.0% of cases who had high risk parameters at FS. CONCLUSION: Our FS results have reasonable accuracy rates in predicting PS results, in comparison with the previous literature. However, even if the high risk parameters detected in FS predict PS accurately, absence of lymph node involvement in all cases with high risk parameters indicates that FS-based triage cannot prevent unnecessary lymphadenectomies.

What is the predictive value of preoperative CA 125 level on the survival rate of type 1 endometrial cancer?

Background/aim: To investigate the utility of preoperative serum cancer antigen 125 (CA 125) levels in type 1 endometrial carcinoma (EC) as a marker for determining poor prognostic factors and survival. Material and methods: All patients with endometrial cancer, who had been treated between 2012 and 2020, were retrospectively reviewed, and finally, 256 patients with type 1 endometrium carcinoma were included in the study. The relationship between the clinicopathological characteristics, CA 125 level, and survival rates were analyzed. The cut-off value for the preoperative serum CA 125 level was defined as 16 IU/L. Results: The median serum CA 125 levels were significantly higher in patients with deep myometrial invasion, lymph node metastasis, lymphovascular space invasion, cervical stromal and adnexal involvement, advanced stage, positive peritoneal cytology, recurrence, and adjuvant therapy requirement. Serum CA 125 cut-off values determined according to clinicopathologic factors ranged from 15.3 to 22.9 IU/L (sensitivity 61%­77%, specificity 52%­73%). The disease-specific survival rate was significantly higher in patients with CA 125 levels < 16 IU/L (P = 0.047). Conclusion: The data showed that choosing a lower threshold value for the CA 125 level (16 IU/L) instead of 35 IU/L, could be more useful in type 1 EC patients with negative prognostic factors.

Lumbosacral discitis as a rare complication of laparoscopic sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: Sacrocolpopexy is considered to be the gold-standard procedure for apical compartment prolapse. However, complications such as sacral hemorrhage, small bowel obstruction, port site herniation, mesh erosion, mesh exposure, and occasionally discitis may occur. The aim of this study is to show laparoscopic treatment of L5-S1 discitis 3 months following laparoscopic sacrocolpopexy. METHODS: Two surgical interventions of a case with narrated video footage is presented. RESULTS: Laparoscopic sacrocolpopexy following hysterectomy in the first part and re-laparoscopy because of a diagnosis of discitis refractory to medical treatment, and removal of mesh along with anterior L5-S1 discectomy for curative debridement in the second part is demonstrated. CONCLUSION: Frequency of postoperative discitis has been increased by the widespread use of a laparoscopic approach. In order to reduce the complication rate, surgical technique allowing the needle to penetrate only the depth of the anterior longitudinal ligament and usage of monofilament suture for mesh attachment is recommended. In treatment, removal of the sacral mesh, and even extensive tissue debridement, may be necessary.

The effect of suture materials with different absorption times on isthmocele: a retrospective study.

OBJECTIVES: With the increasing rate of cesarean operations, the formation of niches and related early and late complications have been observed more frequently. In this study, we examined the effects of using a suture material that can be absorbed faster than conventional sutures on the formation of niches. MATERIAL AND METHODS: This study was designed as a retrospective study and completed with a total of 101 patients. During the cesarean operation, the uterus was closed with Rapide Vicryl® in 49 patients and Vicryl® in 52 patients. The uterine niche was measured with a sonohysterogram 6 months after the operation. The primary outcome of the study was determined as uterine niche formation and the secondary outcome was the post-menstrual spotting (PMS) rate. RESULTS: Duration of surgery, intraoperative/postoperative blood loss, and hospitalization time were similar between the two groups. Niche formation was significantly lower in the Rapide Vicryl group (22.4%) when compared to the Vicryl group (42.3%) (p = 0.046). Also, PMS was observed significantly lower in the Rapide Vicryl group (16.2% and 52.8% in Rapide Vicryl and Vicryl groups, respectively; p = 0.002). CONCLUSIONS: The formation of niches and associated PMS rates were less with suture materials that were absorbed faster.

Prevention of preterm delivery by cervical cerclage; a comparison of prophylactic and emergency procedures

Objective: Prophylactic or emergency type cervical cerclage procedures are being used for treatment of cervical insufficiency. The aim was to review and compare the outcomes of these cerclage types and identify factors affecting outcomes. Material and Methods: Retrospective review of seventy-five patients in whom transvaginal cervical cerclage procedures were performed over a seven-year period in a tertiary referral center. Results: Twenty seven of 75 (36%) patients were in the emergency cerclage group and 48 (64%) of them were in the prophylactic group. Mean body mass index (BMI), hospitalization time and gestational week at cerclage were significantly higher, whereas latency period was significantly shorter for the emergency group. Mean gestational ages at delivery were 35.6±4.5 and 33.6±5.9 weeks in the prophylactic and emergency groups, respectively (p=0.117). Delivery rates under 34th gestational week were 20.8% and 37.0% in the prophylactic and emergency groups, respectively (p=0.175). Birthweight, and delivery ≥34th gestational week was higher in the prophylactic group, whereas complication rate was higher in the emergency group, but these differences were not significant. High BMI was associated with more deliveries before 34-week in the prophylactic group. Pre-cerclage cervical length was shorter in patients who delivered before 34 gestational weeks at delivery. Conclusion: Prophylactic and emergency cerclage procedures have comparable results regarding gestational week at delivery. High BMI and low pre-cerclage cervical length may have adverse effects on success of cerclage procedures.

Laparoscopic para-aortic lymphadenectomy: Technique and surgical outcomes.

OBJECTIVE: Pelvic and para-aortic lymph node dissection is an important part of staging surgery. Aim of this study is to evaluate perioperative outcomes of patients, who underwent laparoscopic para-aortic lymphadenectomy for gynecological cancer in a single center over a period of 7 years, based on body mass index (BMI), and to present the surgical technique in steps. METHODS: Data of patients who underwent para-aortic lymphadenectomy at gynecological oncology department of a tertiary center in between March 2013 and July 2020 were analyzed retrospectively. Patients were evaluated in two groups according to their BMI (< 30 kg/m2 as non-obese and ≥ 30 kg/m2 as obese groups). Surgical technique is described in steps. Perioperative outcomes of the two groups were evaluated. RESULTS: A total of 230 patients were included in the study. BMI was ≥30 at 58.46 % of the patients. Peri-operative features were not significantly affected by the patient's BMI with the presented surgical technique, however, collected para-aortic lymph node numbers were higher in the group with BMI < 30, though sufficient number of lymph nodes were achieved in both groups. CONCLUSION: Although some technical difficulties may be encountered, laparoscopic para-aortic lymphadenectomy is feasable in gynecologic oncological surgery independent of BMI. However, surgical experience is important.

The efficacy of dydrogesterone use to suppress premature luteinizing hormone surge on cycle outcomes in controlled ovarian stimulation

Objective: Progestins are used as an alternative to gonadotropin releasing hormone (GnRH) antagonists to suppress premature luteinizing hormone (LH) surge and a flexible protocol has been defined recently. The aim of this study was to compare the efficacy of flexible protocols with dydrogesterone and GnRH antagonist in suppressing LH surge. Material and Methods: This retrospective, case-control study, was conducted in an infertility unit of a tertiary university hospital. A daily dose of 40 mg dydrogesterone was compared with GnRH antagonist (GnRHant) in controlled ovarian hyperstimulation cycles between July 2018 and July 2019. Dydrogesterone was started when the leading follicle was 12 mm or serum estradiol was over 300 pg/mL. A subgroup analysis of poor responder patients was also performed. Results: In total there were 105 subjects aged between 23 and 41 years, 52 in the dydrogesterone group and 53 in the GnRHant group. Duration of pituitary suppression was longer in dydrogesterone group. Premature ovulation was observed in 11.5% (6/52) and 0% in the dydrogesterone and GnRHant groups, respectively. However, collected oocyte counts and metaphase II oocyte counts were found to be similar between the groups. The six patients with premature ovulation were in poor responder subgroup. Conclusion: Dydrogesterone can be used as an alternative to antagonist regimen in patients where embryo transfer is not planned in the same cycle. However, flexible regimen may not be appropriate in patients with diminished ovarian reserve, as advanced follicular maturation and delayed suppressive effect of oral progesterone may cause premature ovulation. Randomized controlled trials in particular patient groups are required to determine the most effective minimum dose and time of application to ensure treatment success.

Does abnormal ductus venosus pulsatility index at the first-trimester effect on adverse pregnancy outcomes?

AIM: The ductus venosus pulsatility index for veins (DV PIV) has become a popular marker of the first-trimester scan. The aim of this study is to search for any difference between groups with normal and abnormal DV PIV values in terms of adverse pregnancy outcomes. METHODS: We retrospectively evaluated 556 women whose first-trimester scan was performed. The ductus venosus pulsatility indices were examined at singleton pregnancies between 11 and 14 weeks of gestation. Patients were categorized as Group-I with normal DV PIV (DV PIV ≥ 0.73, ≤1.22) and as Group-II with abnormal DV PIV. Group-II was subgrouped as Group-IIA which composed of patients with DV PIV < 0.73 and as Group-IIB with DV PIV > 1.22. RESULTS: There were 451 subjects in Group-I and 105 subjects in Group-II (Group-IIA = 32 and Group-IIB = 73). The comparisons between major groups revealed a statistically significant increase about miscarriage (p = 0.002), stillbirth (p < 0.001), small for gestational age (p = 0.033), low birth weight (p < 0.001), fetal growth restriction (p = 0.048), and major congenital heart defect (p=<0.001) in Group-II. This difference is mainly due to Group-IIB. There is no difference in preterm delivery, preeclampsia and gestational diabetes between Group I and II. CONCLUSION: Routinely monitoring DIV PIV as a first-trimester screening should provide valuable information regarding adverse pregnancy outcomes such as miscarriage, stillbirth, small for gestational age, low birth weight, fetal growth restriction and major congenital heart defect.

Pregnancy of patients with idiopathic thrombocytopenic purpura: maternal and neonatal outcomes

Objective: Thrombocytopenia occurs in 7% of pregnant women. Along with other causes, idiopathic thrombocytopenic purpura (ITP), which is an autoimmune disease with autoantibodies causing platelet destruction, must be considered in the differential diagnosis. Antiplatelet antibodies can cross the placenta and cause thrombocytopenia in the newborn. The aim of our study was to assess the management of ITP in pregnancy, and to investigate neonatal outcomes. Material and Methods: This retrospective study was conducted in a tertiary center including 89 pregnant patients with ITP followed between October 2011 and January 2018. Patients were evaluated in two groups according to diagnoses of ITP and chronic ITP. Age, obstetric history, ITP diagnosis, and follow-up period, presence of splenectomy, platelet count during pregnancy and after birth, treatment during pregnancy, route of delivery, weight and platelet count of newborn, sign of hemorrhage, and fetal congenital anomaly were assessed. Results: Considering the ITP and chronic ITP groups, no significant difference was seen with respect to parity, timing of delivery, preoperative and postoperative platelet counts, and hemoglobin values. Route of delivery, birth weight, APGAR scores, newborn platelet count, and congenital anomaly rates were also similar. The timing of treatment was different because patients whose diagnoses were established during pregnancy were mostly treated for preparation of delivery. Treatment modalities were similar. Conclusion: Probability of severe thrombocytopenia at delivery is higher in patients with ITP who are diagnosed during pregnancy when compared with patients who received prepregnancy diagnoses. ITP is an important disease for both the mother and newborn. Patients should be followed closely in cooperation with the hematology department.

Reference values of the ductus venosus pulsatility index for pregnant women between 11 and 13+6 weeks of gestation.

Purpose: The ductus venosus pulsatility index velocity (DV PIV) has become a popular ultrasonographic measurement during the first trimester of pregnancy. The value of the DV PIV has been the topic of ongoing discussion in the literature, and its reference value in the normal population has not yet been established. Therefore, we aimed to determine a reference value for the DV PIV.Materials and Methods: We retrospectively evaluated our records of first-trimester ultrasonography performed between 2016 and 2017. Our inclusion criteria were as follows: singleton pregnancy; crown-rump length (CRL) between 45 and 84 mm; absence of structural abnormalities on the ultrasound examination; and absence of chromosomal abnormalities. Records of 820 patients were evaluated. According to the inclusion criteria, records of 458 patients were included in this study. All ultrasound examinations were performed by a single operator with the Voluson E8 (5- to 8-MHz 3 D transducer; General Electric Healthcare, Little Chalfont, UK) via the transabdominal route. Gestational weeks were designated according to CRL measurements at the beginning of the examination. Nuchal translucency (NT), nasal bone visualization (NB), tricuspid valve regurgitation (TR), "a"-wave pattern, DV PIV, S-wave (peak systolic velocity), D-wave (peak diastolic velocity), a-wave (atrial contraction in late diastole), and time-averaged maximum velocity (TAMXV) measurements were performed. To evaluate the DV Doppler images, a mid-sagittal view of the fetal profile was obtained. Color Doppler and pulse Doppler gate were used in the distal portion of the umbilical sinus, and at least three typical DV waveforms were detected. The SPSS 21.0 statistical program (IBM, Armonk, NY) was used to analyze variables.Results: The mean age, body mass index, CRL, gestational age, and NT values were 30.3 years (range, 18-45), 23.9 kg/m2 (range, 15.5-46.6), 59.5 mm (range, 45-79), 12.3 weeks (range, 11.2-13.6), and 1.58 mm (range, 0.73-2.62), respectively. The median gravidity and parity were 2 (1-8) and 0 (0-4), respectively. The "a"-wave pattern was identified in all cases, but TR was not detected in any of the cases. Measurements of DV PIV with a Gaussian distribution were suitable according to the Shapiro-Wilk test (p = .252). The mean DV PIV was 0.98, and the fifth and 95th percentiles were 0.73 and 1.22 (±2 SD), respectively. A statistical analysis of our cohort revealed that DV PIV values less than 0.73 and more than 1.22 were beyond the normal range. The mean S-wave, D-wave, a-wave, and TAMXV values were 31.18, 25.64, 8.68, and 22.72 cm/s, respectively.Conclusions: The value of DV PIV measurements is debated in the literature. Using our cohort, we defined the means and ranges of DV PIV. Determining the normal ranges of DV PIV could be helpful to anticipate congenital or chromosomal abnormalities. Further studies are needed to demonstrate the clinical importance of DV PIV, especially for patients with abnormal DV PIV measurements.

Is fetal magnetic resonance imaging indicated in patients with isolated ventriculomegaly?

OBJECTIVE: Ventriculomegaly is one of the most common anomalies encountered at obstetric ultrasound and it necessitates follow up. Fetal magnetic resonance imaging (MRI) can be used to confirm the ultrasound diagnose or to detect additional anomalies. Aim of this study is to assess follow up and management of fetal ventriculomegaly shown by ultrasound, and to evaluate additional diagnostic contribution of MRI. STUDY DESIGN: This study was conducted retrospectively including 89 patients who had fetal MRI subsequent to ultrasound diagnose of ventriculomegaly in between 2011-2017. Medical records of patients were investigated and accompanying anomalies, congenital infection, chromosomal examination, degree and progression of ventriculomegaly, neonatal imaging and diagnose, and neurodevelopmental findings on follow up were evaluated. Patients were classified in two groups as isolated and nonisolated ventriculomegaly, and subgroups mild, moderate, severe were formed according to their findings. SPSS 23.0 programme was used for statistical analysis. RESULTS: Ultrasound and following MRI was performed in a range of 18-35th gestational weeks, diagnoses were isolated ventriculomegaly for 56 patients and nonisolated ventriculomegaly for 33 patients. Progression and neurodevelopmental delay was higher in severe nonisolated ventriculomegaly group. There was not significant contribution of MRI in the follow up of isolated ventriculomegaly (p < 0.001), and diagnostic imaging findings declined in neonatal period with proceeding normal neurodevelopment in 92.7% of patients followed with diagnosis of isolated ventriculomegaly. CONCLUSION: When isolated ventriculomegaly is detected, ultrasound performed by an experienced team is mostly sufficient. MRI can be used in suspicious cases or when ventriculomegaly progresses.

Reproductive outcomes of office hysteroscopic metroplasty in women with unexplained infertility with dysmorphic uterus.

OBJECTIVE: The correlation between dysmorphic uterus and infertility still remains enigmatic. We evaluated the reproductive outcomes of metroplasty via office hysteroscopy in unexplained infertile women with dysmorphic uteri. MATERIALS AND METHODS: In this retrospective cohort study, metroplasty via office hysteroscopy using a bipolar system was performed to 272 women with unexplained infertility with dysmorphic uteri from January 2013 to January 2016. Of all the patients, 162 had primary infertility, and 110 had secondary infertility. RESULTS: In the primary infertility group, the clinical pregnancy rate was 45.68% (74/162) and the live birth rate was 38.9% (63/162), and in the secondary infertility group, the clinical pregnancy rate was 55.45% (61/110) and the live birth rate was 49% (54/110) after metroplasty. In the secondary infertility group, the miscarriage rate and especially the ectopic pregnancy rate declined dramatically [from 84.5% (93/110) to 9.8% (6/61) and from 15.5% (17/110) to 1.6% (1/61), respectively] (p<0.01). CONCLUSION: Reproductive outcome can be impaired by Müllerian anomalies, hence, infertile women with dysmorphic uteri should undergo hysteroscopy to improve reproductive outcomes. Our study demonstrated that office hysteroscopic metroplasty of a dysmorphic uterus might improve fertility, particularly in patients with unexplained infertility with dysmorphic uteri, which was an ignored factor previously. Office hysteroscopy is an alternative option in terms of non-invasive procedure.