Adnexal masses and pregnancy: a single-center experience of 9 years.

PURPOSE: This study aims to analyze the experience of a tertiary health center about the management of adnexal masses that have been diagnosed during pregnancy or detected accidentally during cesarean delivery. METHODS: This is a retrospective review of 160 women who underwent concurrent surgery for adnexal mass during cesarean section, 24 women who delivered vaginally and subsequently had surgery due to the prenatal diagnosis of adnexal mass and 10 women who underwent surgery for adnexal mass during pregnancy. Corresponding to the delivery and surgery times, 200 women who had no diagnosis of pregnancy-associated adnexal mass served as controls. RESULTS: The women in the control group and study groups had statistically similar gestational age at delivery, birth weight and preterm delivery (p > 0.05 for all). Miscarriage was significantly more frequent in women undergoing surgery for adnexal mass during pregnancy (p = 0.001). The women who had surgery for adnexal mass during pregnancy, at the time of cesarean section and following delivery were statistically similar with respect to surgery type and histopathological diagnosis (p > 0.05 for both). Malignancy was detected in none of the patients who underwent surgery for adnexal mass during pregnancy. Acute abdomen was the indication for the emergency surgery in six patients (3.5%) who had surgery for adnexal mass during pregnancy. Four patients (2.4%) had surgery for adnexal mass during pregnancy due to the high index of suspicion for malignancy. CONCLUSION: The risk of malignancy was relatively lower in this cohort of adnexal masses detected during pregnancy and cesarean delivery. Surgical management of adnexal masses should be postponed to postpartum period as such management leads to an increased risk of miscarriage. Unless there is a need for emergent surgery or cancer staging, vaginal delivery should be encouraged in women diagnosed with adnexal mass during pregnancy.

Evaluation of endometrial receptivity in recurrent pregnancy loss and recurrent implantation failure.

Objective: The cause of implantation defects in patients with recurrent implantation failure (RIF) and recurrent pregnancy loss (RPL) has not been clearly established. We aimed to evaluate the immunohistochemical changes in HOXA-11, ß1 integrin, focal adhesion kinase (FAK), cluster of differentiation 44 (CD44), and extracellular matrix protein 1 (ECM1) molecules during the receptive endometrial period in patients with RIF and RPL. Materials and Methods: This study was retrospectively conducted at a university hospital. After the exclusion of cases with pathology that may cause a change in the level of receptors in the endometrium, biopsies performed during the receptive period were selected, and the patients were categorized into RPL (n=15), RIF (n=16), control (n=16) groups. All preparations were immunohistochemically stained for HOXA-11, ß1 integrin, FAK, CD44, and ECM1. Results: HOXA-11 and ß1 Integrin expression changes were similar between the RIF and control groups. However, FAK expression was significantly increased in the RIF group (p<0.01). Additionally, ECM1 and CD44 expressions were significantly decreased in the RIF group compared with the control group (p<0.01). There was no significant difference in the endometrial staining of HOXA-11, FAK, and ECM1 in patients with a history of RPL. However, ß1 Integrin and CD44 levels were significantly decreased in the RPL group compared with the control group (p<0.05). Conclusion: Implantation is a complex process, and altered adhesion mechanisms involved in endometrial receptivity may be related to defective implantation in patients with RIF and RPL. Among the adhesion molecules, the expression of CD44, ß1 integrin, FAK, and ECM1 molecules varies in inappropriate implantation compared with the normal population.

Serum LH level prior to progestin administration is significant on pregnancy and live birth in programmed frozen-thawed embryo transfer cycles.

Purpose: To evaluate the impact of serum LH levels prior to progestin administration on the outcomes of programmed frozen-thawed embryo transfer (FET) cycles. Methods: Retrospective cohort study was conducted to compare the treatment outcomes between four groups based on the 25 percentiles of serum LH levels before progestin administration in 596 cycles of 518 patients undergoing artificial endometrial preparation protocols for FET. Primary outcome measures were ongoing and live birth rates. Secondary outcome measures were the pregnancy rates, clinical pregnancy rates, and pregnancy loss rates. Results: The trends in clinical pregnancy (CPR) and live birth rates (LBR) increased from the first to the fourth quartile (Q1 to Q4) of serum LH levels prior to progestin administration (37,0% to 48,3%, p = 0.042, and 22.6% to 39.5%, respectively, p = 0.003). Pregnancy loss rates (PLR) were higher in group Q1, although the difference was not statistically significant. Based on a multivariate logistic regression analysis, a low serum LH level before progestin initiation was found to be the most significant predictor associated with a negative effect on live birth (OR: 0,421, 95% CI 0,178 - 0,994, p=0,048). The day of estrogen initiation was significantly correlated with serum LH levels and quartiles of serum LH levels before progestin administration (r=0,200, p=0,015 and r=0,215, p=0,009, respectively). Conclusion: The serum LH level prior to progestin administration significantly affects pregnancy and live birth rates in patients undergoing an artificial endometrial preparation protocol for FET. LH monitoring should be incorporated into the follow-up, in addition to assessing endometrial thickness and morphology in artificial FET cycles.

In Vitro Fertilization Outcomes With a Dual Trigger in Normoresponders in Antagonist Cycles.

Objectives To evaluate whether the dual trigger of ovulation with a gonadotropin-releasing hormone (GnRH) agonist and the standard dose of recombinant human chorionic gonadotropin (hCG) (dual trigger) is better than hCG alone in in vitro fertilization (IVF) cycles of patients who responded well to ovarian stimulation. Methods Between January 2013 and December 2021, 5593 antagonist cycles of patients were reviewed. This study included women who had an antral follicle count of 5 or more and exhibited a normoresponse to ovarian stimulation using the GnRH antagonist protocol, as determined by the follicular output rate (FORT). The primary outcome indicators consisted of the quantities of retrieved oocytes and mature oocytes. The secondary outcome markers included live birth rates, clinical pregnancy rates, and continued pregnancy rates. Results A total of 1244 normoresponder women who met the inclusion criteria were identified from the scanned files and subsequently enrolled in the GnRH antagonist protocol. A total of 383 cycles were observed in the group that was given the standard hCG trigger while 861 cycles were observed in the group that was given the dual trigger. The number of mature oocytes and top-quality embryos was significantly higher in the dual trigger group. The maturation rate in the hCG group was 74.8% while it was 76.9% in the dual trigger group (p=0.018). The dual trigger group exhibited an ongoing pregnancy rate of 37.6%, whereas the hCG group had a rate of 30.1% (p = 0.02). The dual trigger group exhibited a slightly higher live birth rate (34.3% vs 29.2%, p = 0.11), although this difference did not reach statistical significance. Conclusion Dual trigger of ovulation was superior to hCG alone in terms of the number of mature oocytes yielded, top quality of embryos, maturation rates, and ongoing pregnancy in IVF cycles of normoresponders having ovarian stimulation on the GnRH antagonist protocol.

Is the First-Trimester Systemic Immune-Inflammation Index Associated With Preeclampsia?

OBJECTIVE: Preeclampsia (PE) is a serious and common pregnancy issue. There is a systemic inflammation in PE and it is accompanied by increased oxidative stress, but the clear etiology has not been revealed. We aimed to predict PE with the systemic immune-inflammation index (SII) value calculated in the first trimester. MATERIAL AND METHODS:  This is a retrospective study. One hundred fifty-seven pregnant women were included in the study. Twenty-seven pregnant women were excluded from the study. Age, gravida, parity, and hemogram values were recorded in the patients' first visit file records. The time and mode of delivery, birth weight, and APGAR scores were obtained from the file records of the patients. SII was created using the formula (neutrophil x platelet/lymphocyte).  Result: The study group included 30 pregnant women who had been diagnosed with PE. The control group consisted of the remaining 100 pregnant women. There was a statistically significant difference between PE and control groups in terms of SII (p=0.03). The SII level cut-off value for predicting PE was determined to be 836.83. This value's area was found to be 0.635 (0.519-0.752). Furthermore, the selectivity is 0.60 and the sensitivity is 0.40 for these values.  Conclusion: SII was found to be significantly higher in people with PE in the study. We showed that the SII value measured in the first trimester can be used to predict PE. It might make sense to combine this marker with the patient's history and other risk factors due to its low selectivity and sensitivity.

The relationship between thyroid autoimmunity and poor response to ovarian stimulation in in vitro fertilization women with infertility.

INTRODUCTION: Thyroid autoimmunity (TAI) is the most common autoimmune disorder. Patients with TAI are usually euthyroid, and the presence of anti-thyroid peroxidase (anti-TPO) in patients with or without thyroid dysfunction is associated with infertility, recurrent embryo implantation failure, and early pregnancy loss. We aimed to investigate the relationship between low ovarian reserve, pregnancy outcomes, and TAI. MATERIAL AND METHODS: This retrospective cohort study was conducted in in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) patients between 2010 and 2018. All patients (n = 1400) for whom thyroid autoantibody testing was requested were detected. A study group was formed from patients with anti-TPO positivity (n = 363). The control group (n = 555) comprised euthyroid anti-TPO negative patients matched to the study group regarding age and body mass index (BMI). RESULTS: Mean serum TSH value was 2.35 ± 1.70 mIU/mL in anti-TPO-positive patients and 1.81 ± 1.2 mIU/mL in controls, and the difference was significant (p < 0.05). Total dose of gonadotropins used in ovulation induction in anti-TPO-positive and control patients were 3000 IU and 2700 IU, respectively, and the difference was statistically significant (p < 0.05). The number of metaphase 2 oocytes was significantly lower in the anti-TPO-positive group (p < 0.05). Embryo transfer number and embryo grade were significantly lower in the anti-TPO-positive group (p < 0.01). Poor ovarian response was significantly higher in anti-TPO-positive patients (40%) as compared to anti-TPO-negative controls (30%) (p < 0.01). Clinical pregnancy rate was significantly lower in the anti-TPO-positive group (29.2%), as compared to the antibody-negative group (38.4%) (p < 0.01). CONCLUSIONS: There are controversial data regarding the impact of antithyroid antibodies on ovarian reserve and pregnancy outcome after IVF treatment. The results of this study indicate that there was a relationship between TAI and poor ovarian response, and that TAI adversely affects IVF outcomes. Further investigations are required to explore the mechanism behind these effects.

Comparison of natural and artificial cycles in frozen-thawed embryo transfer: A retrospective analysis of 1696 cycles.

Objective: This study aimed to compare the pregnancy outcomes of natural cycles (NC) and artificial cycles (AC) in patients undergoing endometrial preparation for frozen-thawed embryo transfer (FET). Materials and Methods: This retrospective cohort study was conducted in a private infertility clinic between September 2016 and January 2021 and reviewed 1696 FET cycles. Among these FET cycles, endometrial preparation protocols that are performed as the NC (group 1) and AC (group 2) were analyzed. Outcome measures were live birth rates (LBR), clinical pregnancy rates (CPR), implantation rates (IR), and miscarriage rates (MR). Results: The mean serum estradiol level before progesterone supplementation was significantly higher in group 2, whereas endometrial thickness before progesterone supplementation was higher in group 1 (p<0.05). The mean number of transferred embryos and embryo quality score rates regarding cleavage and blastocyst stages were similar in both groups. The IR and MR were similar between groups (p>0.05). Additionally, CPR and LBR were similar in groups 1 (39.2% and 32.8%) and 2 (37.3% and 28.5%) (p=0.517, p=0.134, respectively). Multivariate logistic regression analyses revealed that female age at embryo freezing time and the number of transferred embryos were predictable variables of live birth [odds ratio (OR): 0.970, confidence interval (CI): 0.948-0.991, p<0.05, and OR: 1.359, CI: 1.038-1.780, p<0.05, respectively]. Conclusion: Suitable endometrial preparation is essential to obtain successful pregnancy rates; however, no superiority was determined in NC or AC protocols in frozen-thawed cycles. One of these protocols may be performed depending on menstrual regularity and clinical experience.

Assessment of a Novel Fixation Method of a Frameless Intrauterine Contraceptive Device Inserted during Cesarean Delivery as a Means of Preventing Displacements and Expulsions: A Prospective Observational Study.

The primary objective of this study was to assess the novel fixation method of a frameless copper-releasing intrauterine device inserted following placental delivery during cesarean section and analyze its impact in reducing device displacement and expulsion during and after uterine involution. We hypothesized that the dual-anchoring technique could reduce the risk of intrauterine device displacement and expulsion during and after the uterine involution. The study was conducted at the Gazi University Medicine Faculty Hospital in Ankara, Turkey. Twenty-one pregnant women were enrolled. Insertion was performed following placental removal. To confirm the proper placement and good retention of the device, the distance between the fundal serosa (S) and device anchor knot (A) was measured (S-A) during follow-ups, by ultrasound. There were significant differences in the S-A, as observed by ultrasound at discharge and at 6 weeks post-delivery, which is consistent with the tissue contractions associated with uterine involution. Notwithstanding the uterine involution, no device displacements or expulsions occurred, which indicated a good retention of the frameless device. This innovative retention method of the frameless intrauterine device ensures a well-tolerated, long-term contraception, allowing for immediate contraception and proper pregnancy spacing for cesarean scar healing, and overcomes the issue of expulsion encountered with conventional intrauterine systems.

Dual trigger with the combination of gonadotropin-releasing hormone agonist and standard dose of human chorionic gonadotropin improves in vitro fertilisation outcomes in poor ovarian responders.

The study aimed to evaluate the impact of the dual trigger with the combination of GnRH agonist and standard dose of recombinant hCG on IVF outcomes in poor ovarian responders with GnRH antagonist protocol. 1283 cycles of 1010 poor responder patients according to Bologna criteria were retrospectively analysed in terms of final oocyte maturation: dual trigger group (250 µg hCG + 0.2 mg triptorelin) or standard group (250 µg hCG). Primary outcome measures were the number of retrieved and mature oocytes. The secondary outcome measures were clinical pregnancy rates and live birth rates.The number of retrieved oocytes, mature oocytes, and the top-quality embryos transferred were significantly higher in the dual trigger group (p < .001). Fertilisation rates (73.6% vs 69.6%, p = .009), implantation rates (18.7% vs 14.6, p = .039), clinical pregnancy rate per embryo transfer (27.5% vs. 19.9%, p = .010) and live birth rate per embryo transfer (21.6% vs. 14.9%, p = .011) were also significantly higher in the dual trigger group as compared to the hCG trigger group. The usage of dual trigger with a GnRH agonist and a standard dosage of hCG could improve clinical pregnancy rates and live birth rates in poor ovarian responders undergoing GnRH antagonist IVF/ICSI cycles.IMPACT STATEMENTWhat is already known on this subject? Dual trigger with standard dose of hCG has been the subject of trials in normal responders to optimise IVF outcomes. The results of these studies showed significant improvements in implantation and pregnancy rates with an increase in the number of mature oocytes retrieved. As a result, dual trigger has become a popular ovulation trigger option in GnRH antagonist cycles.What do the results of this study add? There is limited data about the use of dual trigger in poor ovarian responders (PORs). According to our study, increasing the number of retrieved oocytes, mature oocytes, the number of fertilised oocytes, the number of transferred embryos and top quality embryos transferred by using dual trigger in patients with PORs have a positive impact on pregnancy outcomes.What are the implications of these findings for clinical practice and/or further research? These findings implies potential advantages of dual trigger usage for improving IVF outcomes in PORs. With large sample sized prospective randomised trials, dual trigger with combination of GnRHa and a standard dose of hCG might replace the traditional ovulation trigger with hCG in PORs.

Subsequent IVF outcomes following antibiotic therapy for chronic endometritis in patients with recurrent implantation failure.

AIM: The aim is to identify the chronic endometritis (CE) incidence in recurrent implantation failure (RIF) patients undergoing in vitro fertilization (IVF) treatment and compare the IVF outcomes of RIF patients with CE following antibiotic therapy with RIF patients without CE. Another purpose is to compare the IVF outcomes of described RIF patients with patients undergoing the first cycle of IVF. METHODS: In this retrospective cohort study, CE was diagnosed with CD-138 immunohistochemical staining. Among RIF patients, two groups were formed as group 1, including patients diagnosed with CE and treated by antibiotics (n = 129), and group 2, including patients without CE (n = 103). Patients with the first IVF cycle having similar infertility etiologies with RIF patients were reviewed as group 3 (n = 932). RESULTS: CE was diagnosed in 55.6% of RIF patients. The number of oocytes retrieved was not different between groups. Implantation rates (IR) were similar after antibiotic treatment in RIF patients with or without CE. However, Group 3 had a higher IR (41.1%) than group 1 and 2 (23.1% and 30.1%, respectively) (p < 0.001). Clinical pregnancy (CPR) and live birth rates (LBR) were comparable between RIF groups. However, CPR and LBR were significantly higher in group 3 (48.6% and 40.5%) than group 1 (36.4% and 27.9%), and group 2 (37.9% and 30.1%) (p = 0.007 and p = 0.005, respectively). CONCLUSION: Unidentified endometrial factors except CE may also affect the implantation process, although CE is a frequent finding in patients with RIF. Reproductive outcomes may not be improved only with antibiotics in RIF patients with CE.

Analysis of 2438 cycles for the impact of endometrioma and its surgery on the IVF outcomes.

OBJECTIVE: Management of ovarian endometrioma before IVF treatment is still challenging. We aimed to assess the effect of the pre-cycle surgical removal of endometriomas on IVF outcomes in a large number of cycles in patients undergoing IVF/ICSI treatment. Besides this, we also proposed to compare the cycle outcomes within both normo and poor responder patients to evaluate the impact of endometrioma and its surgery. STUDY DESIGN: A retrospective cohort study was conducted in a private IVF clinic between September 2014 and December 2018. A total of 2438 IVF/ICSI cycles of 1936 patients were reviewed. Patients who had previous endometrioma surgery (Group 1), patients with non-operated endometrioma (Group 2), and patients without endometriosis, including tubal factor infertility confirmed by laparoscopy and unexplained infertility without endometrioma (Group 3) were analyzed in this study. RESULTS: Total dose of gonadotropins was significantly higher in group 1 than others (p < 0.05). However, antral follicle counts, estradiol levels on the day of hCG trigger, the number of retrieved and metaphase II oocytes were significantly lower in group 1 than in other groups (p < 0.05). Poor response to gonadotropins was more frequent in group 1 as compared to other groups (47.9%, 34.3%, 35.5%, respectively) (p < 0.05). Cycle cancellation rates were significantly higher in group 1 than in other groups (6.7%, 1.4%, and 2.8%, respectively) (p < 0.05). Clinical pregnancy (CPR) and live birth rates (LBR) per cycle and embryo transfer were not different among groups. However, CPR per cycle and embryo transfer were significantly higher in the operated endometrioma group within unexpected poor responders (p = 0.023, p = 0.010, respectively). CPR and LBR per cycle and per embryo transfer were similar within normo-responder patients. Multiple logistic regression analysis revealed that female age and poor response to gonadotropins were the significant variables in predicting live birth (OR: 0.946, CI: 0.926-0.966, p < 0.001 and OR: 3.294, CI: 2.336-4.645, p < 0.001, respectively). CONCLUSION: Pre-cyle removal of endometrioma may have an adverse impact on ovarian reserve, and pregnancy outcomes seem to be similar with or without surgery in patients undergoing IVF treatment. However, endometrioma surgery may be considered in the subsequent IVF cycles of patients with lower than expected ovarian response.

IVF Outcomes of Microdose Flare-up, GnRH Antagonist, and Long Protocols in Patients having a Poor Ovarian Response in the First Treatment Cycle.

OBJECTIVE: To compare the IVF outcome of patients assumed to be poor responders before their first cycle treated by microdose flare-up or GnRH antagonist protocols with patients who had a poor ovarian response after their first cycle stimulated with long GnRH protocol. STUDY DESIGN: Observational cohort study. PLACE AND DURATION OF STUDY: Department of Obstetrics and Gynecology, IVF Unit of Gazi University Faculty of Medicine, from September 2014 to February 2019. METHODOLOGY: Patients treated with the first cycle of IVF and diagnosed as poor responders after ovarian stimulation were evaluated according to the treatment protocol, including microdose flare-up (Group 1: 136 patients), GnRH antagonist (Group 2: 105 patients), and long GnRH agonist (Group 3: 77 patients). RESULTS: Basal FSH level was significantly lower in group 3 compared to other groups (p<0.05). The number of oocytes retrieved, the number of metaphase II oocytes were similar between groups, although the mean AFC was significantly higher in group 3 than in group1 and 2 (p<0.05). Clinical pregnancy rates per patient were higher in group 3 (20.8%) than in group 1 (12.5%) and group 2 (13.3%), but the difference was not statistically significant (p=0.230). The live birth rate per patient was statistically higher in group 3 (19.5%) as compared to other groups (8.8%, 9.5%, respectively; p<0.05). CONCLUSION: Long protocol may be an option in poor responders undergoing IVF. Ovarian reserve markers are essential factors with stimulation protocol for the success of IVF in poor responder patients. Key Words:  Infertility, Ovulation induction, Ovarian reserve, Fertilisation in-vitro, Oocyte retrieval, Pregnancy outcome, Reproductive techniques, Assisted.

Comparison of frozen-thawed embryo transfer protocols in patients with previous cycle cancellation due to uterine peristalsis: a pilot study

Background/aim: To investigate the optimal protocol for frozen-thawed embryo transfer (FET) cycles in patients who previously had a cycle cancellation due to uterine peristalsis (UP). Materials and methods: Thirty-four patients with previous embryo transfer (ET) cancellation due to UP during artificial cycle (AC) were included retrospectively. In the proceeding cycle, endometrium was prepared with AC (n: 23) in AC-FET group or with stimulated cycle that contains letrozole (L) (n: 11) in L-FET group. Intravenous bolus dose of 6.75 mg atosiban (Tractocile; Ferring Pharmaceuticals, Switzerland) injection was performed to all patients of AC-FET group due to UP ≥ 4/min on the planned ET day of proceeding cycle. Atosiban was not used in L-FET group. Primary outcome was live birth rate (LBR) per ET. Secondary outcomes were clinical pregnancy rate (CPR) per ET, implantation rate (IR), cycle cancellation rate. Results: The baseline characteristics such as age, body mass index, antral follicle count, duration of infertility, and the number of prior in vitro fertilization attempts of each group were similar. The IR, CPR per ET, LBR per ET, CPR per cycle and LBR per cycle were significantly higher; cycle cancellation rates were significantly lower in L-FET group as compared to the AC-FET group. Conclusion: Endometrial preparation with letrozole significantly improves CPR and LBR in FET cycles of patients with previous cycle cancellations due to UP.

Impact of timing on wound dressing removal after caesarean delivery: a multicentre, randomised controlled trial.

We compared wound dressing removal at 24 hours versus 48 hours following low-risk caesarean deliveries. This multicentre, randomised, controlled study included patients 18-44 years of age with low-risk term, singleton pregnancies. The randomisation was done weekly. Scheduled caesarean deliveries without labour were included. For comparison, the Additional treatment, Serous discharge, Erythema, Purulent exudate, Separation of deep tissues, Isolation of bacteria, Stay in hospital > 14 days (ASEPSIS) score for wound healing assessment was modified. The absolute scores were obtained based on a one-day reading rather than the five-day reading used in ASEPSIS. Zero ("0") was assigned as a complete healing. Higher scores were associated with more severe disruption of healing. The patients were enrolled between March 2015 and February 2017. The demographics were not statistically different. The wound scoring was similar in the groups at discharge and first-week evaluation. At the six weeks post-surgery, the wound scoring was significantly less in the 48-hour (3.9%) versus the 24-hour group (9%; p = .002). Dressing removal at 48 hours had a lower scoring in the low-risk population with scheduled caesarean deliveries.IMPACT STATEMENTWhat is already known on this subject? Surgical dressings are used to provide suitable conditions to heal caesarean incisions. There has been a limited number of studies on the evaluation of ideal timing on wound dressing removal after a caesarean delivery. These studies concluded there are no increased wound complications with removal at six hours versus 24 hours or within or beyond 48 hours after surgery.What do the results of this study add? The postoperative removal of the wound dressing at 48 hours had a lower wound score at six weeks than the removal at 24 hours for women with uncomplicated scheduled caesarean deliveries.What are the implications of these findings for clinical practice and/or further research? Early discharge after caesarean delivery is becoming more common. Dressing removal at 24 hours versus 48 hours becomes more crucial and needs to be clarified. Besides, high-risk populations, different skin closure techniques, and patients in labour should be addressed separately.

Impact of the sexual abstinence period on the production of seminal reactive oxygen species in patients undergoing intrauterine insemination: A randomized trial.

AIM: To evaluate whether the duration of sexual abstinence has impact on oxidative stress in semen samples. METHODS: Oxidative reaction was tested for different levels of reactive oxygen species (ROS) by nitro blue tetrazolium assay in 90 patients with the diagnosis of unexplained or male factor infertility that were grouped into 3 groups as 0-2 (group 1), 3-4 (group 2) and >4 days (group 3) of duration of sexual abstinence. Subsequently, the remaining semen was prepared by gradient method for ovarian stimulation and intrauterine insemination (IUI) cycles to compare pregnancy rates in terms of different levels of ROS and different abstinence periods. RESULTS: Increased staining pigment intensity was related to higher level of ROS in >4 days' group as compared to groups 0-2 and 3-4 days (70% vs 43.3% and 50%, P = 0.013 and P = 0.014, respectively). Pregnancy rates significantly decrease with prolonged abstinence period (26.7%, 16.7% and 6.7% in groups 1, 2 and 3, respectively, P = 0.039). Progressive motile sperm count after gradient method of sperm preparation for IUI was highest in 3-4 days of abstinence period than shorter and longer abstinence groups. CONCLUSION: Longer duration of sexual abstinence causes higher oxidative stress and decreases pregnancy rates in IUI cycles.

Isolated tubal torsion: Successful preoperative diagnosis of five cases using ultrasound and management with laparoscopy.

Our aim was to evaluate the presentation and diagnostic evaluation of patients with isolated tubal torsion and to evaluate the surgical approach to these patients. We also aimed to define the ultrasonographic diagnostic criteria. Five patients with isolated tubal torsion who were admitted to our gynecology department between January 2014 and January 2017 were evaluated and included in this study. All cases were diagnosed through ultrasonographic imaging alone. The preoperative findings of the patients were similar to those described in the literature. No further imaging modality was used for diagnosis and all patients were managed with laparoscopy. The clinical findings and ultrasonographic findings were consistent with literature. It may be difficult to preoperatively diagnose isolated tubal torsion, which is a rare clinical entity. Evaluation of these patients by an experienced sonographer and knowledge of the ultrasonographic findings of isolated tubal torsion may have vital preventive measures.

Nifedipine increases fetoplacental perfusion.

AIM: Our aim is to evaluate the effect of nifedipine on fetoplacental hemodynamic parameters. METHODS: A retrospective study was conducted at a tertiary center with 30 patients for whom nifedipine treatment was used as a tocolytic therapy for preterm labor. Initiation of this treatment was at 31.6±2.5 weeks of gestation. We combined the pulse Doppler imaging parameters with grayscale imaging via the Bernoulli theorem, which is called the "continuity equation", to get the fetoplacental perfusion (FPP). Evaluated parameters were the resistance index (RI), the pulsatility index (PI), systole/diastole ratios (S/D), the velocity-time integral of the umbilical artery (VTI), the radius of the umbilical artery, the peak systolic velocity and the mean pressure gradient in the umbilical artery. From these parameters, the FPP was acquired. RESULTS: We found that the RI, the PI and the S/D ratio did not change after treatment with nifedipine. The mean pressure gradient, the VTI and the peak systolic velocity increased after treatment with nifedipine. Nifedipine increases FPP from 166±73.81 beat.cm3/min to 220±83.3 beat.cm3/min. DISCUSSION: Although nifedipine had no effect on the PI, the RI or the S/D, it increased the mean pressure gradient, the VTI and FPP.

Molar pregnancy in cesarean section scar: A case report.

Cesarean scar ectopic pregnancies and molar pregnancies are two very rare obstetric pathologies. In both cases, serious morbidities are involved that require careful management. The coexistence of the two clinical conditions is far less common and there are a limited number of cases in the literature. In this case report, a 34-year-old patient with previous cesarean section was diagnosed as having a molar pregnancy in a cesarean scar through ultrasonography. The patient was asymptomatic at that time. Ultrasonography revealed a protruding mass at the cesarean section and her human chorionic gonadotropin level was measured as 59.705 mIU/mL. Due to the risk of severe bleeding, cesarean section scar excision and revision were performed via laparotomy after counselling the patient. Removal of all trophoblastic tissue was observed as a result of the frozen pathology and the operation was terminated. After the definite pathology result came as a complete molar pregnancy, the patient was followed up according to molar pregnancy follow-up protocols and cured completely. Despite the alternative treatment options (methotrexate application, curettage, uterine artery embolization) in such patients, the decision for surgery was made after counselling the patient. In this very rare clinical condition, patients should be closely monitored and the appropriate treatment option should be applied as soon as possible, taking into consideration the bleeding risks of both pathologies.

Obstetric outcomes of isolated oligohydramnios during early-term, full-term and late-term periods and determination of optimal timing of delivery.

AIM: Our aim was to evaluate the obstetric outcomes of isolated oligohydramnios during the early-term, full-term, and late-term periods, and to determine the optimal timing of delivery. METHODS: A retrospective study was performed at a tertiary center. Isolated oligohydramnios cases were divided into early-term, full-term, and late-term groups. Evaluated outcomes were fetal birthweight, 5-min Apgar score < 7, meconium-stained amniotic fluid, neonatal intensive care unit admission, transient tachypnea of newborn (TTN), requirement of ventilator, newborn jaundice, mode of delivery, induction of labor, and undiagnosed small-for-gestational-age fetus before delivery. Composite outcome was defined as perinatal outcomes taken together (neonatal intensive care unit admission, TTN, requirement of ventilator, and newborn jaundice). RESULTS: The study period included 1213 cases of term isolated oligohydramnios. Within this cohort there were 347 early-term, 781 full-term and 85 late-term patients. The cesarean rate and the rate of newborn jaundice were higher in early-term cases (37.8% and 3.5%, respectively) than in full-term cases (30.1% and 0.9%, respectively). Meconium-stained amniotic fluid was higher in late-term than full-term cases. Timing of delivery did not affect occurrence of TTN, 5-min Apgar score < 7, ventilator requirement, or composite outcome. In total, 15-17% of isolated oligohydramnios cases involved undetected small-for-gestational-age fetuses. CONCLUSION: As this study was not a randomized controlled trial, a decisive conclusion may not be possible. However, until well-designed controlled studies are conducted, expectant management may be appropriate up to the full-term period and induction of labor may be appropriate management when the full-term period is reached.

The impact of premature progesterone rise on the outcome of intrauterine insemination cycles with controlled ovarian hyperstimulation in unexplained infertility.

OBJECTIVE: To ascertain the incidence of premature progesterone P rise and its impact on outcomes in controlled ovarian hyperstimulation and intrauterine insemination (COH-IUI) cycles, and also to identify variables related with premature P rise. STUDY DESIGN: Four hundred sixty cycles of 460 couples with unexplained infertility having COH-IUI treatment with a starting dose of 75IU recombinant FSH enrolled in this prospective study. Serum P levels were determined on the day of hCG trigger. Premature P rise was defined as progesterone ≥1ng/mL. The primary outcome measure was live birth per cycle with regard to P levels of ≥1ng/mL and ≥1.5ng/mL. Secondary outcome measures were cycle characteristics associated with P rise. RESULTS: The incidence of premature P rise was 22.0%. P levels on hCG day were significantly lower in cycles with live birth as compared to cycles without live birth 0.49±0.51 vs. 0.73±0.82ng/mL. Live birth rates were significantly lower in cycles with hCG day P levels ≥1.0ng/mL (%7.9 vs. %22.6) and ≥1.5ng/mL (%6.4 vs. %20.8). Among age, number of dominant follicles, estradiol, LH and P levels on the day of hCG trigger, it was found that P levels was the only significant variable to predict live birth on multivariate analysis. The number of dominant follicles on hCG day and premature LH surge were the only significant variables related with premature P rise. CONCLUSION: Premature P is a frequent feature of COH-IUI cycles and associated with decreased live birth rates.