Fetal Splenic Artery Pulsatility Index May Predict the Need for Neonatal Intensive Care in Gestational Diabetes Class A1 Cases.

The fetal splenic artery pulsatility index is a parameter that reflects fetal well-being and has been used as a predictor of adverse pregnancy outcomes. The aim of this study was to investigate the predictive value of the splenic artery pulsatility index in gestational diabetes mellitus class A1 cases for intensive care unit admission. In this prospective case-controlled study, only sixty single pregnancy cases diagnosed with gestational diabetes mellitus class A1 were evaluated. Fetal splenic artery Doppler parameters such as peak systolic velocity, pulsatility index, resistivity index, and end-diastolic velocity were measured in all cases. The rate of requirements for the neonatal intensive care unit was noted. In cases requiring fetal intensive care, the fetal splenic pulsatility index was found to be statistically significantly lower than in healthy cases without it (0.94 ± 0.29 vs. 1.70 ± 0.53, respectively, p < 0.001, Student's t-test). When the fetal splenic PI cutoff value was selected as 1.105 cm3, the sensitivity was calculated as 97.9% and the specificity as 58.3% for predicting the need for fetal intensive care (AUC 0.968, p < 0.001, 95% CI 0.929-0.998). The use of a low fetal splenic artery PI parameter is a significant and good indicator for predicting the need for fetal intensive care according to the binary logistic regression analysis result (p = 0.006). This study suggests that evaluation of fetal splenic artery Doppler in mothers with gestational diabetes mellitus may be used to predict neonates requiring a newborn intensive care unit. Therefore, it is recommended that obstetricians use this simple, rapid, and valuable evaluation of fetal splenic artery Doppler and alert the neonatologist that a newborn intensive care unit may be required.

In vitro fertilization pregnancy may cause fetal thymic volume involution: A case-control study.

Background: The effect of modern infertility treatment modalities on fetal thymic volume has not been well known. Objective: 3-dimensional (3D) fetal thymus volumes of 18-24 wk in vitro fertilization (IVF) pregnancies and spontaneous pregnancy cases were compared. Materials and Methods: 135 cases were evaluated in this prospective case-control study. The study was conducted between July 2019 and July 2020 at a university hospital in Trabzon, Turkey. Fetal thymus volume was calculated in the pregnant cases included in the study with the help of the virtual organ computer-assisted analysis system included in the advanced ultrasonography system. The fetal thymus volumes were compared between pregnant women with IVF and spontaneous pregnant women. Results: The fetal thymus size was significantly lower in the IVF pregnancy group than in spontaneous pregnancy cases (p < 0.001). It was found that the fetal complications, such as non-reassuring fetal health status and requirement for neonatal intensive care, were higher in cases who became pregnant after IVF treatment. It was also found that the rate of any pregnancy complication was significantly higher in IVF pregnancy group (p = 0.02). Conclusion: In light of these results, it may be concluded that small fetal thymus size may be another fetal complication of IVF pregnancies.

Prenatal Sonographic Three-dimensional Virtual Organ Computer-assisted Analysis Thymic Volume Calculation May Predict Intrauterine Growth Restriction.

Background: Intrauterine growth restriction (IUGR) refers to fetuses that are small for their gestational age. There is no effective test to predict this disease. The aim of our study is whether fetal three-dimensional (3D) ultrasonography (USG)-assisted thymus volume (TV) measurement predicts IUGR cases. Methods: Fetal 3D USG thymus measurement between 15 and 24 weeks of gestation was performed in a total of 100 women of reproductive age. Fetal TV was measured using the virtual organ computer-assisted analysis system program. All cases were followed up in terms of pregnancy complications until delivery. Results: IUGR was developed in six cases in total. In cases with IUGR, mean fetal TV was found to be statistically significantly lower than in healthy cases without it. When the fetal TV was taken as 0.1645, the sensitivity was calculated as 89.5% and the specificity as 50% for predicting IUGR. The use of low fetal volume parameters is a significant and good indicator for predicting IUGR according to the binary logistic regression analysis result. Conclusion: According to the results of this study, 3D fetal TV measurement may be used in routine second-trimester sonographic anomaly screening to predict the development of fetal IUGR. In this way, fetal mortality and morbidity caused by IUGR may be reduced.

Evaluation of the height of the corpus callosum body region in fetal meningomyelocele malformation.

PURPOSE: To investigate height of the corpus callosum (CC) in order to describe the corpus callosum anomalies in fetuses with meningomyelocele (MMC) and compare these findings with the corpus callosum of healthy fetuses. METHODS: In this study, fetal MRI examinations were performed on 44 fetal MMC malformation cases. As the control group, 34 fetal MRI examinations, which were anatomically normal, were evaluated retrospectively. In the study group, lateral ventricle diameter, the level and diameter of the MMC defect, and CC height were measured. In the control group, CC height and lateral ventricular diameter were measured. RESULTS: The mean CC body height was 1.36 mm in the study group, and 2.48 mm in the control group. The height of the CC body region of the study population was inclined to be thinner compared with the control population (p<0.001). CONCLUSIONS: The fact that the height of the CC body region was found to be thinner in fetal MRI in cases of MMC compared with normal fetuses suggests that various callosal anomalies are uncertain, investigation of additional callosal anomalies may be beneficial in the decision for the continuation of pregnancy, and termination or intrauterine surgery in cases with MMC. Further large case group studies are needed.

Serum MUC3 Protein as a Novel Marker of Gestational Hypertensive Disorders.

Background: This study aimed to investigate the serum levels of mucoprotein 3 in hypertensive diseases of pregnancy. Methods: In total, 60 consecutive women with gestational hypertensive diseases (gestational hypertension (n = 20), severe preeclampsia (n = 20), HELLP syndrome (n = 20)) and 20 pregnant women without any gestational hypertensive diseases were included for this prospective controlled study. Serum MUC3 protein levels were measured with commercially available ELISA kits. Results: Serum MUC3 protein level was the lowest in normal pregnant women (0.1047 ± 0.0295 ng/ml); while the severity of the disease increases, it significantly increased in severe preeclampsia (0.2700 ± 0.0199 ng/mL) and HELLP syndrome group (0.3494 ± 0.0455 ng/mL), but less in the gestational hypertension (0.2172 ± 0.0354 ng/mL) group. Mean serum MUC3 protein level differences were found the least in gestational hypertension (0.1125 ± 0.0107, p < 0.001), the most in HELLP syndrome (-0.2546 ± 0.0107, p < 0.001) compared with the pregnant control group. Conclusion: The increase in serum MUC3 protein concentration in these women supported the argument that serum MUC3 protein may be used as a marker indicating the severity of the gestational hypertensive diseases.

First trimester fetal thymus volume may predict preeclampsia.

OBJECTIVE: The immunological factors have role in the development of preeclampsia. The thymus is one of the main organs of the fetal immune system. The aim of this prospective clinical study was to investigate the association between fetal thymus volume and preeclampsia by adding the 3-dimensional measurement of thymus volume to the routine fetal ultrasound scan at 11-14 week of gestation. STUDY DESIGN: Totally 72 pregnant women in their first trimester of pregnancy were included and 3-D fetal thymus volume was measured with sonographic VOCAL programme. All women gestational period was followed. The data of women with preeclampsia (n = 10, study group) and without preeclampsia (n = 62, control group) were compared. MAIN OUTCOME MEASURES: Fetal thymus volume, preeclampsia development. RESULTS: Fetal thymus volume, mean gestational age at birth and newborn birthweight were found to be statistically lower in cases with preeclampsia compared with those without any complications. When the fetal thymus volume measured by the VOCAL programme in the study group was used as a marker for preeclampsia development, the limit value was 0.0375 cm3; sensitivity was 87.1% and specificity was 50% (AUC 85.3%, P < .001, 95% CI 0.751-0.949). As a result of binary logistic regression analysis; the low fetal thymus volume measured at 11-14 gestational weeks can be used as a predictive factor for preeclampsia (P < .001). CONCLUSIONS: According to the results of this study; the development of preeclampsia may be predicted by measuring 3-D fetal thymus volume at the first trimester.

Serum ischemia-modified albumin level returns to its premenopausal level with 1-year hormone therapy in healthy menopausal women.

INTRODUCTION: To assess the effect of hormone therapy (HT) on serum ischemia modified albumin (IMA) levels in healthy menopausal women. MATERIAL AND METHODS: Thirty surgical menopausal women who were admitted to our menopausal polyclinic during a 1-year period and diagnosed with menopause and planned to have HT for menopausal symptoms were enrolled in this prospective study. The serum IMA levels were recorded before and after (3 months, 6 months, 12 months later) hormone treatment (2 mg estradiol hemihydrate). RESULTS: The mean age of women was 47.60 ± 2.34 years. The mean serum IMA levels were 0.610 ± 0.096 absorbance units (ABSU) at the beginning and 0.484 ± 0.080 ABSU after 3 months of hormone therapy. Following 6 months of hormone therapy, serum IMA level was 0.546 ± 0.075, and reached 0.580 ± 0.089 ABSU following 12 months of therapy. CONCLUSIONS: These findings suggest that HT may not block the menopause induced ischemia process. Although HT had a positive effect on serum IMA levels following 3 months' use, serum IMA levels returned to baseline levels after 12 months' use. Based on this study's findings, long-term use of HT may not have a positive effect on cardiovascular disease protection.

Carbon Dioxide Pneumoperitoneum May Alter Ovarian Apoptosis: An Experimental Study.

OBJECTIVES: The aim of this study was to evaluate ovarian immunohistochemical CD95 expression in a rabbit carbon dioxide pneumoperitoneum model. MATERIALS AND METHODS: The study group including seven rabbits was subjected to intra-abdominal pressure (IAP) (12 mmHg); the control group was not subjected to IAP (the sham group, n = 7). At the end of the experiment, ovariectomy was performed. Immunohistochemical stained histologic specimen of the ovary with CD95 was evaluated. Based on the degree of cytoplasmic or membranous staining for CD95 from 0 (none) to 3 (severe), a microscopic apoptosis scoring system was used. RESULTS: Statistically significantly higher apoptosis scores in ovarian surface epithelial cells (2.57 ± 0.53, vs. 1.14 ± 0.38, P = 0.002, Mann-Whitney U-test, respectively), follicular epithelial cells (2.85 ± 0.38, vs. 1.85 ± 0.38, P = 0.002, Mann-Whitney U-test, respectively), and stromal cells (2.71 ± 0.49, vs. 1.29 ± 0.49, P = 0.002, Mann-Whitney U-test, respectively) were observed in pneumoperitoneum group, compared with no-pneumoperitoneum group. CONCLUSION: Even at safe IAP (12 mmHg) for an acceptable operation time period, there was a significant increase in apoptosis of ovarian cells.

The effect of low-dose combined hormone therapy (oestradiol and norethindrone acetate) on serum C-reactive protein levels and life quality in natural menopause women.

INTRODUCTION: To assess the effect of low-dose combined oestradiol and norethindrone acetate hormone therapy (HT) on serum C-reactive protein (CRP) levels and life quality in natural menopause women. MATERIAL AND METHODS: Forty-five natural menopause women admitted to the clinic during a 1-year period and diagnosed as menopause, who planned to have HT for menopausal symptoms, were enrolled in this prospective study. The serum CRP levels were measured, and vasomotor symptoms scores were graded according to the Blatt-Kupperman menopause index, and life quality scores according to the Menopause-Specific Quality of Life Questionnaire (MENQOL) were recorded before and after (3 months later) hormone therapy. RESULTS: The Blatt-Kupperman menopause index and MENQOL scores were significantly decreased after 3 months of low-dose treatment. No significant difference was found between white blood cell counts and serum CRP levels before and after 3 months of hormone therapy. CONCLUSIONS: Considering all HT types and biochemical effects, low-dose HT, which had positive results in terms of quality of life, was a safe treatment and could be preferred to conventional-dose preparations in cases without contraindications. Low-dose combined HT containing oestradiol and norethindrone acetate did not alter the serum CRP level in postmenopausal cases.

Effect of methotrexate on embryonal implantation: an experimental rat model.

The aim of this study is to investigate the methotrexate (MTX) in rat embryonal implantation and its association with Glycodelin A (GdA) and Mucin-1 (MUC-1) expression. For this purpose, 32 pregnant rats were divided into four equal groups: non-pregnant rats in group I (n = 8, control) and pregnant rats in group III (n = 8) were injected intraperitoneal with single dose of normal saline, non-pregnant rats in group II (n = 8) and pregnant rats in group IV (n = 8) were given 0.2 mg i.m. injection of MTX before three months of pregnancy. The dams were killed on 5th day of gestation and uterine horn samples were removed. Following dissection and routine histological preparation, immunohistochemical analysis was carried out. During immunohistochemical examination of the tissue samples prepared from the control and experimental groups, a statistically significant difference was observed between the groups in the luminal-glandular-decidualized epithelium of the uterus with GdA and MUC-1. Finally, in light of our findings, MTX adversely affected the expression of two molecules in Wistar Albino rats embryonal implantation model.

Biotin deficiency in hyperemesis gravidarum.

The aim of this study was to determine the serum biotin levels in patients with hyperemesis gravidarum (HG). Ninety pregnant women with HG (mild (n = 30), moderate (n = 30) and severe (n = 30)), and 80 pregnant women without HG were included for this study. In both groups, serum biotin levels were measured. There were no statistically significant differences in demographic and clinical characteristics between the HG groups and the control group except for PUQE scores. Serum biotin levels in all hyperemesis gravidarum groups were statistically significantly lower than control group. Negative statistically significant correlation between hyperemesis gravidarum severity and serum biotin levels was noted. This is the first study that shows low serum biotin levels in women with hyperemesis gravidarum. Impact statement What is already known on this subject? Almost 80% of pregnant women have nausea and vomiting. If nausea and vomiting became severe and the symptoms combined with weight loss and ketonuria; the diagnosis should be hyperemesis gravidarum (HG). The etiopathogenetic factors of this unwanted condition have not been exactly known. Biotin is an essential water-soluble vitamin. Biotin catabolism increases in pregnancy. Marginal biotin deficiency occurs in approximately 50% of the gestations despite the "normal" biotin intake on the diet. What do the results of this study add? Current study results elucidated that serum biotin levels were lower in HG cases compared to non HG cases. This study is the first study that reports the association between low serum level of biotin and HG. What are the implications of these findings for clinical practice and/or further research? Further research is needed to show the importance of biotin supplementation in women with hyperemesis gravidarum.

Comparison of the effect of isotretionin and alitretionin on endometriotic implants and serum vascular endothelial growth factor level: an experimental study.

OBJECTIVE: To compare the effects of alitretionin and isotretionin on endometrial peritoneal implants and serum vascular endothelial growth factor (VEGF) levels. STUDY DESIGN: Forty-eight female Sprague Dawley rats were used. Initially surgical rat endometriosis model was done. The endometrial implant volume was measured and rats were randomly divided into four groups. Group 1: Control group (rats did not get any drug but having endometriotic implants), group 2: rats receiving po isotretionin 10 mg/kg per day for 10 d, group 3: rats receiving po isotretionin 20 mg/kg per day for 10 d and group 4: rats receiving po alitretionin 80 mg/kg per day for 10 d. After 1-week medication, rats were sacrificed and size, histopathology of endometriotic implant and levels of VEGF were evaluated. RESULTS: Volumes of peritoneal endometrial implants were significantly decreased in Group 2 and Group 3 compared with initial values. However, there were no significant changes in histopathological scores and serum VEGF levels in all groups. CONCLUSIONS: This study finding may suggest the possible medical treatment modality of isotretionin on endometriosis. However, alitretionin (potent retinoid) does not have potent regressive effect on endometriotic implants as in isotretionin.

Circulating parameters of oxidative stress and hypoxia in normal pregnancy and HELLP syndrome.

BACKGROUND: The HELLP syndrome (Hemolysis, Elevated Liver enzymes and Low Platelets) is a complication of severe pre-eclampsia, a condition characterized by oxidative stress elevation caused by disequilibrium between lipid peroxidation and antioxidant defense mechanisms, which, in turn, results in endothelial compromise and free radical-mediated cell damage. While several studies have examined the relationship between pre-eclampsia and oxidative stress, research investigating oxidative and hypoxic status in HELLP syndrome is limited. OBJECTIVES: The aim of this study was to compare the levels of oxidative stress markers - total oxidant status (TOS), total antioxidant status (TAS), oxidative stress index (OSI), and malondialdehyde (MDA) - and a hypoxia marker - carbonic anhydrase IX (CA IX) - in patients with HELLP syndrome and in healthy pregnant women. MATERIAL AND METHODS: A total of 23 women with HELLP syndrome and 30 healthy pregnant women were included in the study. Serum levels of oxidative stress markers were determined using colorimetric methods, while serum levels of CA IX were measured using an enzyme-linked immunosorbent assay (ELISA) kit. RESULTS: The TOS, OSI, MDA, and CA IX levels were significantly higher in women with HELLP syndrome than in the controls (p = 0.0001, p = 0.0001, p = 0.0001, and p = 0.008, respectively). CONCLUSIONS: Increased levels of oxidative stress and hypoxia markers in women with HELLP syndrome suggest that oxidative stress and hypoxia may be significantly involved in the pathophysiology of the disease. Further follow-up studies are now needed to investigate the prognostic roles of these parameters in patients with HELLP syndrome.

Is the measurement of serum ischemia-modified albumin the best test to diagnose ovarian torsion?

AIM: The aim of this study is to evaluate the diagnostic value of serum oxidative stress marker levels (ischemia-modified albumin, IMA; malondialdehyde, MDA) and total oxidant status (TOS), total antioxidant status (TAS) and oxidative stress index (OSI) levels that occur in ovarian torsion and to determine the threshold value of these markers in the diagnosis of ovarian torsion. METHODS: In this prospective case-control study, 34 women (the study group) with acute pelvic pain (20 with and 14 without ovarian torsion) and 40 control subjects were included. The diagnosis of ovarian torsion was confirmed with laparoscopy in all cases. Preoperative serum samples were collected in the study group. Serum oxidative stress marker levels (IMA and MDA) and TOS, TAS and OSI levels were measured. RESULTS: Serum MDA, TOS and IMA concentrations were significantly higher in women with ovarian torsion than in the healthy control group. However, serum TAS, TOS and OSI concentrations were significantly higher in women without ovarian torsion than within the healthy control group. Only IMA significantly distinguished patients with or without ovarian torsion. The best IMA value, according to the receiver operating characteristic curve, was 0.7045 absorbance units, with 90.00% sensitivity and 92.31% specificity. The patients in the ovarian torsion group had significantly lower serum TAS and OSI levels compared with patients without ovarian torsion. CONCLUSION: The elevated serum IMA levels with high sensitivity-specificity values observed in women with ovarian torsion seem to have a potential role as a serum marker in the preoperative diagnosis of ovarian torsion in emergency settings.

Is resveratrol a potential substitute for leuprolide acetate in experimental endometriosis?

OBJECTIVE: Resveratrol, a phytoalexin polyphenol, has anti-angiogenic, antioxidant, anti-inflammatory properties. We aimed to compare the anti-inflammatory and anti-angiogenic effects of resveratrol and leuprolide acetate (LA) in an experimental endometriosis model. STUDY DESIGN: A prospective experimental study was conducted in a University Surgical Research Center. Thirty-three non-pregnant female Sprague-Dawley rats, in which experimental model of endometriosis were surgically induced were randomly divided into four groups. Group 1 was administered 30 mg/kg resveratrol i.m. for 14 days, group 2 was given 1mg/kg s.c. single dose LA, group 3 was administered both resveratrol and LA, and group 4 had no medication. After two weeks medication rats were sacrificed and size, histopathology and immunreactivity to matrix metalloproteinase (mmp)2, mmp9, vascular endothelial growth factor (VEGF) of the endometriotic implants were evaluated. Plasma and peritoneal fluid levels of interleukin (IL)-6, IL-8, and tumor necrosis factor-α (TNF-α) were analyzed. RESULTS: The endometriotic implant volumes, histopathological grade and immunreactivity to mmp2, mmp9 and VEGF were significantly reduced (p<0.001), and plasma and peritoneal fluid levels of IL-6, IL-8 and TNF-α were significantly decreased in group 1 and group 2 in comparison to group 3 and group 4 (p < 0.001). CONCLUSION: Resveratrol alone is a potential agent for the treatment of endometriosis and may be an alternative to LA. In contrast, the combination of LA and resveratrol decreased the anti-inflammatory and anti-angiogenic effects of each agent. Since resveratrol is widely used as an alternative therapy for a variety of conditions, it can undermine the effectiveness of LA. Therefore, caution should be exercised when used in combination with other agents.

Multicenter analysis of gestational trophoblastic neoplasia in Turkey.

BACKGROUND: To evaluate the incidence, diagnosis and management of GTN among 28 centers in Turkey. MATERIALS AND METHODS: A retrospective study was designed to include GTN patients attending 28 centers in the 10-year period between January 2003 and May 2013. Demographical characteristics of the patients, histopathological diagnosis, the International Federation of Gynecology and Obstetrics (FIGO) anatomical and prognostic scores, use of single-agent and multi-agent chemotherapy, surgical interventions and prognosis were evaluated. RESULTS: From 2003-2013, there were 1,173,235 deliveries and 456 GTN cases at the 28 centers. The incidence was calculated to be 0.38 per 1,000 deliveries. According to the evaluated data of 364 patients, the median age at diagnosis was 31 years (range, 15-59 years). A histopathological diagnosis was present for 45.1% of the patients, and invasive mole, choriocarcinoma and PSTTs were diagnosed in 22.3% (n=81), 18.1% (n=66) and 4.7% (n=17) of the patients, respectively. Regarding final prognosis, 352 (96.7%) of the patients had remission, and 7 (1.9%) had persistence, whereas the disease was mortal for 5 (1.4%) of the patients. CONCLUSIONS: Because of the differences between countries, it is important to provide national registration systems and special clinics for the accurate diagnosis and treatment of GTN.

Tubal pregnancy associated with endometrial carcinoma after in vitro fertilization attempts.

Endometrial carcinoma is rarely seen during reproductive ages and commonly related to infertility, polycystic ovarian syndrome (PCOS), and obesity. Pregnancy associated endometrial carcinoma is even rarer and this is the second case reported in the literature concerning tubal pregnancy associated endometrial carcinoma. We present a case of a 36-year-old woman with a history of PCOS, infertility, and several attempts of ovulation induction and in vitro fertilization, who was diagnosed with tubal pregnancy and a well differentiated endometrial carcinoma. We also review the literature about pregnancy associated endometrial carcinoma in the first trimester.

The Diagnostic Value of ß-Human Chorionic Gonadotropin, Progesterone, and Ischemia-Modified Albumin and Their Combined Use in the Prediction of First Trimester Abortions.

Objective. To investigate serum levels of free ß-HCG, progesterone, and ischemia-modified albumin (IMA) and their combined use in the prediction of first trimester abortions. Methods. A total of 156 pregnant women between 5 and 13 weeks of gestational age were included in this study. At admission, serum levels of free ß-HCG, progesterone, and IMA were noted and all cases were divided into two groups; Group I (n = 77) resulted in abortion including missed abortion, incomplete/complete abortion, and inevitable abortion whereas Group II (n = 79) included normal pregnancies. Results. Compared to Group II, the significantly decreased value of free ß-HCG progesterone and significantly increased value of IMA were found in Group I (P < 0.01, P < 0.01, P < 0.01, resp.). When combining all three parameters, sensitivity 75%, specificity 99%, PPV 98%, and NPV 76% were obtained. The multivariate logistic regression analysis revealed the free ß-HCG, progesterone, and IMA independent factors in the prediction of abortions. Conclusions. The combined use of free ß-HCG, progesterone, and IMA levels can be useful in the prediction of first trimester spontaneous abortions.

Endometrial injury may increase the clinical pregnancy rate in normoresponders undergoing long agonist protocol ICSI cycles with single embryo transfer.

OBJECTIVE: To investigate the effect of endometrial injury on the clinical pregnancy rate in normoresponders undergoing long agonist protocol intracytoplasmic sperm injection (ICSI) cycles with single embryo transfer. STUDY DESIGN: Prospective case-control study. METHODS: One hundred and eighteen women (age <35 years, normoresponders with Grade I or II embryos for transfer) were included. Women in the intervention group (n=56) underwent endometrial biopsy on Day 3 of the menstrual cycle following downregulation. Women in the control group (n=62) did not undergo endometrial biopsy. RESULTS: The clinical and embryological characteristics were comparable in the two groups, and no significant difference was found in the fertilization rates (66.32% in the intervention group vs. 70.23% in the control group). The clinical pregnancy rate was 48.2% in the intervention group and 29.0% in the control group (p=0.025). Endometrial injury may increase the clinical pregnancy rate (odds ratio 2.27). The 'take home baby' rates were 33.9% and 17.7% in the intervention and control groups, respectively (p=0.035). CONCLUSION: Assisted reproductive technology treatment that is preceded by endometrial injury may increase the clinical pregnancy rate in women undergoing long agonist protocol ICSI cycles with single embryo transfer.