Hormonal changes in consecutive clomiphene citrate stimulation cycles and their effect on pregnancy rates.

Objective: To determine the relationship between the cumulative effect of sequential clomiphene citrate (CC) treatments in unexplained infertile women with intercycle and intracycle serum hormone changes. Materials and Methods: Patients who received CC 50 mg in the first cycle (group I, n=34) as ovulation induction and those who received CC 50 mg in the second consecutive cycle (group II, n=18) were compared. Basal (cycle days 2-5) and trigger day (the day that recombinant human chorionic gonadotropin is given) levels of gonadotropin and steroid hormones were measured. Results: The 17OHP increase on trigger day was found to be statistically significantly higher in group II compared to the basal day (p=0.083). The testosterone (T) response on the trigger day of the patients in group II was found to be statistically significantly higher than that in group I (p=0.023). The number of selected follicles was negatively correlated with a follicle-stimulating hormone decrease and positively correlated with an estradiol increase. Endometrial thickness was positively correlated with a luteinizing hormone increase, and cycle cancelation was positively correlated with decreased estradiol. Conclusion: Based on this study, it was concluded that the reason for the increased efficiency rate in successive cycles of CC may be the cumulative increase in T and 17OHP levels. However, this result was found not to affect the clinical pregnancy rate.

Abdominal Hysterectomy with a Uterine Manipulator Minimizes Vaginal Shortening: A Randomized Controlled Trial.

BACKGROUND: We aimed to investigate the impact of adopting an uterine manipulator (UM) on the postoperative (VL) and female sexual function index (FSFI) in patients undergoing abdominal hysterectomy (AH) for benign gynecological disease. MATERIALS AND METHODS: Hysterectomies were performed with the Richardson technique; two variations, a UM or digital guidance, in this technique were used during the colpotomy step. Subjects were randomized and allocated to either hysterectomy with UM guidance (study group) or conventional hysterectomy (control group). Pre- and postoperative VL and FSFI were recorded for each patient. Additionally, surgeons' and residents' satisfaction in locating the colpotomy site was also scored by the surgical team postoperatively. RESULTS: There was a significant reduction in the VL (10.2 ± 1.2 cm vs. 8.3 ± 0.7 cm, p < 0.001) and FSFI score (21.0 ± 4.1 to 17.1 ± 3.6, p < 0.001) between the pre-operation stage and three months post-operation in the control group. However, no such significant changes were observed in the study group. Additionally, surgeons' and residents' satisfaction scores (SSS) for locating the colpotomy site were significantly higher in the study group as compared to the control group (p < 0.001). CONCLUSION: Our findings revealed that implementation of an UM in AH prevented unintended shortening of the postoperative VL and avoided a decline in the sexual function as compared to the standard AH procedure. These benefits were probably due to the precise determination of the colpotomy site that resulted from the use of UM in AH.

Decidualized juvenile cystic adenomyoma mimicking a cornual pregnancy.

OBJECTIVE: To demonstrate the laparoscopic excision technique of a juvenile cystic adenomyoma and show how the decidualization of ectopic endometrial tissue can lead to the misdiagnosis of a focus of ectopic pregnancy. DESIGN: Description and step-by-step demonstration of the surgical procedure using a video recording (Canadian Task Force Classification 3). SETTING: Teaching and research hospital. PATIENT(S): A 27-year-old gravida 2 parity 1 patient with one previous caesarean delivery presented to the emergency department with symptoms of pelvic pain and delayed menses. Her beta-human chorionic gonadotropin level was 2,161 mIU/mL. On transvaginal ultrasonography the uterine cavity appeared empty without any signs of a gestational sac, and a 42×45 mm heterogeneous mass was observed on the right cornual area. An 18×21 mm cystic area was observed within the mass. A diagnosis of cornual pregnancy was made and two doses of systemic methotrexate treatment were administered. On the 12th day following medical treatment, the patient reported increasing abdominal pain and free fluid was observed in the pouch of Douglas on ultrasonography. The decision to perform laparoscopic cornual excision was made. MAIN OUTCOMES AND MEASURE(S): On laparoscopic exploration a tubal ectopic pregnancy was observed within the left fallopian tube. The presence of two simultaneous ectopic pregnancies, located in the left fallopian tube and the right cornual area, was suspected. However, upon careful inspection, the right fallopian tube appeared normal and the mass initially thought to be a right cornual pregnancy appeared more like a degenerated fibroid. A left salpingectomy was performed and the excision of the mass in the right cornual area was planned. An incision was made over the mass and the cystic inner area containing chocolate-brown colored fluid was drained. As there was no pseudo capsule surrounding the mass, the diagnosis of focal adenomyosis instead of degenerated fibroid was made. No endometriotic foci were observed within the pelvis. Different from the enucleation of a fibroid, the mass was dissected from the middle into two halves until healthy myometrium was reached on the floor of the mass. The two halves of the mass were resected totally by dissecting the adenomyotic tissue from the myometrium starting from the caudal end towards the cranial end. The first layer of the remaining myometrial defect was sutured extracorporeally with No.1 polyglactan sutures. The second and third layers were sutured intracorporeally with V-loc sutures. The resected left fallopian tube containing the ectopic pregnancy and the adenomyotic mass were externalized through a posterior colpotomy incision. RESULT(S): The patient was discharged 24 hours postoperatively without any complications. A diagnosis of juvenile cystic adenoma was made upon histopathological examination. The patient reported subsiding of her dysmenorrhea on the postoperative third month. CONCLUSION(S): Juvenile cystic adenomyosis (JCA), is a rare form of focal adenomyosis which is usually located in close proximity to the uterine insertion of the round ligament, contains a cystic inner area larger than 1 cm and is encountered before the age of 30 years. Some authors reported JCA to be an accessory and cavitated uterine mass (ACUM) anomaly developing as a result of gubernaculum dysfunction. The only difference between the two conditions is reported to be the presence of a denser area of adenomyosis surrounding the cystic area lined with endometrium in JCA than in ACUM. This case has shown that decidual changes observed in ectopic endometrial tissue within an adenomyotic area may be misdiagnosed as a focus of ectopic pregnancy. Atypical endometriomas demonstrating decidual changes may also be misdiagnosed as ovarian malignancies. In non-emergency situations, waiting for the decidualization effect of ectopic endometrium to subside can help in the definitive diagnosis of such cases. Our technique for JCA excision is different from enucleation of a fibroid and may aid in the total resection and dissection of the adenomyotic tissue from healthy myometrium.

Laparoscopic Blinded Endometrial Cavity Resection for Robert's Uterus.

STUDY OBJECTIVE: To demonstrate that laparoscopic excision of the endometrial tissue of a blind endometrial cavity in a patient with a Robert's uterus who did not consent to hysteroscopic surgery due to her virgin state and religious beliefs was an effective alternative treatment option for progressive dismenorrhea and pelvic pain. DESIGN: Presentation of a rare müllerian anomaly and a step-by-step demonstration of a laparoscopic excision technique in the endometrium of a blind uterine cavity (educative video) (Canadian Task Force classification III). SETTING: Robert's uterus is a rare müllerian anomaly characterized by the presence of a blind endometrial cavity and an asymmetric septum. Endometriosis may be encountered in 40% of patients with this anomaly. A 15-year-old virgin patient with progressive dysmenorrhea was diagnosed with a Robert's uterus anomaly on magnetic resonance imaging. Hysteroscopic surgery was suggested to form a communication between the blind endometrial cavity and the hemiuterus; however, the patient refused to undergo any vaginal surgery due to her virgin state and religous beliefs. A decision to excise the endometrial tissue of the blind cavity laparoscopically instead of performing a hemihysterectomy was made to prevent any adverse effects on the ovarian blood supply and damage to the myometrial wall of the unicornuate uterus. INTERVENTION: Laparoscopic resection of the blind endometrial cavity in a patient with a Robert's uterus anomaly. CONCLUSION: Laparoscopic resection of a blind endometrial cavity is a safe and effective surgical alternative in patients who refuse vaginal surgery.

Predictors of failure of the commonly used single-dose methotrexate protocol for treating tubal ectopic pregnancies.

OBJECTIVES: This study identified patients who would benefit from an earlier additional medical intervention and/or continuing close surveillance even if commonly used parameters indicated sufficient medical treatment to determine markers of treatment failure. MATERIALS AND METHODS: A retrospective analysis of patients with a preliminary diagnosis of ectopic pregnancy treated with the single-dose methotrexate protocol. Group 1: cases cured with a single dose of methotrexate; Group 2: cases who required more than one dose of methotrexate or surgery following the first dose. Demographics, clinical/sonographic findings, observation period, and ß-human chorionic gonadotropin (hCG) levels were compared among the two groups. Thresholds were defined and a regression analysis was performed to define independent predictors of failure. RESULTS: Data from 120 patients were analyzed: Group 1 (n = 92); Group 2 (n = 28). ß-hCG levels measured at all time points, and day (0-4) and day (4-7) changes, presence of adnexial masses, and infertility were significantly different among the two groups. Only the day (0-4) and day (4-7) changes in ß-hCG levels were independent predictors of failure. CONCLUSION: Day (0-4) thresholds or newly defined day (4-7) thresholds were not more sensitive than the conventional day (4-7) criteria. Day (0-4) ß-hCG levels increased by more than 9.7% in half the patients who required additional methotrexate doses or surgery despite fulfillment of the conventional day (4-7) criteria. In contrast, no cases of treatment failure were observed if the day (0-4) decrease was >26.6%.

Preoperatively Assessable Clinical and Pathological Risk Factors for Parametrial Involvement in Surgically Treated FIGO Stage IB-IIA Cervical Cancer.

OBJECTIVE: Determining the risk factors associated with parametrial involvement (PMI) is of paramount importance to decrease the multimodality treatment in early-stage cervical cancer. We investigated the preoperatively assessable clinical and pathological risk factors associated with PMI in surgically treated stage IB1-IIA2 cervical cancer. METHODS: A retrospective cohort study of women underwent Querleu-Morrow type C hysterectomy for cervical cancer stage IB1-IIA2 from 2001 to 2015. All patients underwent clinical staging examination under anesthesia by the same gynecological oncologists during the study period. Evaluated variables were age, menopausal status, body mass index, smoking status, FIGO (International Federation of Obstetrics and Gynecology) stage, clinically measured maximal tumor diameter, clinical presentation (exophytic or endophytic tumor), histological type, tumor grade, lymphovascular space invasion, clinical and pathological vaginal invasion, and uterine body involvement. Endophytic clinical presentation was defined for ulcerative tumors and barrel-shaped morphology. Two-dimensional transvaginal ultrasonography was used to measure tumor dimensions. RESULTS: Of 127 eligible women, 37 (29.1%) had PMI. On univariate analysis, endophytic clinical presentation (P = 0.01), larger tumor size (P < 0.001), lymphovascular space invasion (P < 0.001), pathological vaginal invasion (P = 0.001), and uterine body involvement (P < 0.001) were significantly different among the groups with and without PMI. In multivariate analysis endophytic clinical presentation (odds ratio, 11.34; 95% confidence interval, 1.34-95.85; P = 0.02) and larger tumor size (odds ratio, 32.31; 95% confidence interval, 2.46-423.83; P = 0.008) were the independent risk factors for PMI. Threshold of 31 mm in tumor size predicted PMI with 71% sensitivity and 75% specificity. We identified 18 patients with tumor size of more than 30 mm and endophytic presentation; 14 (77.7%) of these had PMI. CONCLUSIONS: Endophytic clinical presentation and larger clinical tumor size (>3 cm) are independent risk factors for PMI in stage IB-IIA cervical cancer. Approximately 78% of the patients with a tumor size of more than 3 cm and endophytic presentation will require adjuvant chemoradiation for PMI following radical surgery. Considering clinical tumor presentation along with tumor size can enhance the physician's prediction of PMI in early-stage cervical cancer.

Androstenedione response to recombinant human FSH is the most valid predictor of the number of selected follicles in polycystic ovarian syndrome: (a case-control study).

BACKGROUND: We aimed to test the hypothesis that the correlation of the changes in the blood Androstenedione (A4) levels to the number of selected follicles during ovulation induction with low-dose recombinant human follicle stimulating hormone (rhFSH) is as strong as the correlation to changes in the blood Estradiol (E2) levels in polycystic ovary syndrome (PCOS). METHODS: Prospective Case-control study conducted from October 2014 to January 2016. 61 non-PCOS control (Group I) and 46 PCOS (Group II) patients treated with the chronic low-dose step up protocosl with rhFSH. A4, E2, progesterone blood levels and follicular growth were monitored.. Univariate and hierarchical multivariable analysis were performed for age, BMI, HOMA-IR, A4 and E2 (with the number of selected follicles as the dependent variable in both groups). ROC analysis was performed to define threshold values for the significant determinants of the number of selected follicles to predict cyle cancellations due to excessive ovarian response. RESULTS: The control group (Group I) was comprised of 61 cycles from a group of primary infertile non-PCOS patients, and the study group (Group II) of 46 cycles of PCOS patients. The analysis revealed that the strongest independent predictor of the total number of selected follicles in Group I was the E2(AUC) (B = 0.0006[0.0003-0.001]; P < 0.001); whereas for Group II, it was the A4 (AUC) (B = 0.114[0.04-0.25]; P = 0.01). Optimum thresholds for the A4 related parameters were defined to predict excessive response within Group II were 88.7%, 3.1 ng/mL and 5.4 ng*days for the percentage increase in A4, the maximum A4 value and area under the curve values for A4, respectively. CONCLUSION: A4 response to low-dose rhFSH in PCOS has a stronger association with the number of follicles selected than the E2 reponse. A4 response preceding the E2 response is essential for progressive follicle development. Monitoring A4 rather than E2 may be more preemptive to define the initial ovarian response and accurate titration of the rhFSH doses. TRIAL REGISTRATION: The study was registered as a prospective case-control study in the ClinicalTrials.gov registry with the identifier NCT02329483 .

The influence of the systematic birth preparation program on childbirth satisfaction.

PURPOSE: The primary purpose of this study was to assess the influence of a systematic multidisciplinary birth preparation program on satisfaction with childbirth experience. A secondary aim was to detect factors that affect the childbirth satisfaction. METHODS: In this prospective study, 77 pregnant women who completed the 4-month birth preparation program (Group 1) and 75 women in the control group (Group 2) were asked to fill out two questionnaires with face-to-face interviews within 48 h after labor. One of the questionnaires was the translated form of Salmon's Item List German (SIL-Ger), and SIL-Ger scores ≥70 was accepted as a satisfactory experience. RESULTS: There was no statistically significant difference between the groups in terms of sociocultural and intrapartum characteristics, and obstetric outcome parameters. The women who received antenatal education experienced significantly less pain (p = 0.01), had a better communication with midwife or obstetrician during delivery (p = 0.001), and participated more actively in decision-making before, during, and after childbirth (p < 0.001 for all). SIL score was significantly higher in Group 1 (105.7 ± 2.2 vs 80 ± 2.5, p < 0.01), and significantly more women had a SIL score ≥70 (96.1 vs 73.3%, p < 0.01). In multivariate logistic regression model, attending the birth preparation program and the level of pain perceived during labor were found to have a significant effect on the birth satisfaction. CONCLUSION: Systematic birth preparation program improves satisfaction with childbirth experience by enabling women to communicate better with healthcare providers and to participate in decision-making during labor, as well as by decreasing the perception of labor pain.

Primary Endometrial Adenocarcinoma with Signet-Ring Cells: A Rarely Observed Case and Review of the Literature.

An extremely rare case of a "primary endometrial adenocarcinoma with signet-ring cells" is presented in this study with microscopical images of the characteristic coexistence of the tumour and intermediate precancerous areas containing signet-ring cells.