Comparison of markers of ovarian reserve between patients with complete müllerian agenesis and age-matched fertile and infertile controls.

OBJECTIVE: To investigate ovarian reserve in complete müllerian agenesis (CMA) patients and to compare the ovarian reserve of CMA patients with that of age-matched fertile and infertile controls. DESIGN: Prospective cohort study. SETTING: University gynecology outpatient clinic. PATIENT(S): Fifty-eight typical CMA (type A) patients, 8 atypical CMA (type B) patients, 39 fertile patients, and 38 infertile patients were compared for ovarian reserve. INTERVENTION(S): Ovarian reserve was evaluated via antimüllerian hormone (AMH) levels and antral follicle counts (AFCs). MAIN OUTCOME MEASURE(S): Investigation of ovarian reserve in CMA patients and a comparison of the ovarian reserve of the CMA patients with that of age-matched fertile and infertile controls. RESULT(S): Fifty-eight type A and eight type B CMA patients and 39 fertile and 38 infertile control patients were assessed for ovarian reserve. The mean (±SD) ages of the type A and type B CMA patients and the fertile and infertile groups were 25.8 ± 5.3, 33.3 ± 5.9, 32.6 ± 4.8, and 33.9 ± 3.3 years, respectively. After age standardization of the groups, AMH levels and AFCs were found to be lower in the atypical CMA group. The differences in AMH levels and AFC were found to be highly significant. CONCLUSION(S): The present study showed that atypical CMA patients had decreased ovarian reserve compared with age-matched fertile and infertile controls.

A retrospective analysis of pregnancy outcomes after kidney transplantation in a single center.

BACKGROUND: We reported pregnancy outcomes after kidney transplantation in a single transplant center. METHODS: We reviewed the perinatal outcomes of female kidney transplant patients of reproductive age (18-40 years) from 1987 to 2011. RESULTS: A total of 246 patients were reviewed. Of these, 43 women registered a pregnancy following kidney transplantation. The mean patient age was 31.3 ± 4.2 years (range 24-40). The mean transplant-conception interval was 35.9 ± 12.6 months (range 24-120); 9 patients had a cadaveric allograft. The human leukocyte antigen match was ≥3/6 for 34 patients. The rate of live births was 29/43 (67.4%), miscarriage 10/43 (23.2%), preterm delivery 7/29 (24.1%), preeclampsia 5/29 (17.2%), and intrauterine growth retardation 2/29 (6.9%). Overall, 3/29 patients (10.3%) received a blood transfusion during pregnancy due to persistent symptomatic anemia, despite iron replacement and erythropoietin therapy; 24 patients (82%) had a cesarean section delivery; 3 patients had kidney rejection during pregnancy, with 2 occurring during the 6th postpartum month. CONCLUSION: Pregnancy should be considered a high risk in renal transplant recipients, necessitating close follow-up.

Assessment of women who applied for the uterine transplant project as potential candidates for uterus transplantation.

AIM: To review the medical charts of women who applied for the uterine transplant project from June 2008 to June 2011 in our hospital retrospectively (18-40 years). METHODS: The data for 144 women were retrieved, and information was collected on the etiology of uterine factor infertility(UFI); ovarian reserve tests; and accompanying anatomic, infectious, genetic and endocrinological problems. RESULTS: There were 119 patients with primary amenorrhea and uterovaginal agenesis and 25 patients with a history of hysterectomy. The complete Müllerian agenesis patients formed the largest group of the UFI patients with better anti-Müllerian hormone levels and antral follicle count. Anatomical anomalies such as a solitary pelvic kidney may accompany Mayer-Rokitansky-Kuster-Hauser syndrome (MRKH) and impede surgery. The mean ages in MRKH, hysterectomy and complete androgen insensitivity syndrome (CAIS) cases were 24.7, 35.0 and 34.4 years, respectively. The karyotype analysis showed 46XX (MRKH) in 109 patients and 46XY (CAIS) in 10 of the primary amenorrhea patients. CONCLUSION: Hysterectomy may deteriorate ovarian blood flow and decrease ovarian reserve. Fertility preservation may be considered in young woman undergoing hysterectomy.

Sexual function and long-term results following vaginal reconstruction with free vascular jejunal flap.

INTRODUCTION: Sexual adjustment and long-term results following vaginal reconstruction with free vascular jejunal flap are not well known. AIMS: The study aims to investigate sexual adjustment and long-term results among patients who underwent vaginal reconstruction with free vascular jejunal flap. METHODS: A total of 34 women, aged 16-31 years (mean 23.5), who underwent vaginal reconstruction with a vascular jejunal flap between 2005 and 2011 were evaluated. Indications for reconstruction included the following: Mayer Rokitansky Kuster Hauser syndrome (29 patients), isolated vaginal agenesis (2 patients), androgen insensitivity syndrome (2 patients), and (1) history of gynecologic-oncologic surgery. MAIN OUTCOME MEASURES: The study evaluates the perioperative results, complications, satisfaction with sexual function, length and width of the neovagina. RESULTS: All of the surgeries were completed without any intraoperative complications. Three patients required reoperation because of postoperative venous compromise in the grafts. The flap success rate was 100%, and no infection was observed for any case. The mean follow-up was 50 months (between 20 and 87 months). The mean vaginal depth and diameter were satisfactory for all cases. Postoperatively, six patients complained of jejunal hypersecretion, one patient complained of mucosal prolapse, and one patient complained of vaginal constriction. The neovaginal prolapse was repaired via minor surgery. Twenty-seven were married and sexually active. Twenty patients completed the questionnaire on sexual function. Sexual function was assessed using the Female Sexual Function Index (FSFI). Eleven patients were satisfied with their sexual lives after surgery (FSFI scores≥25). CONCLUSION: Based on our results, satisfactory sexual function was achieved using the free jejunal vascular flap.

Clinical pregnancy after uterus transplantation.

OBJECTIVE: To present the first clinical pregnancy after uterus transplantation. DESIGN: Case study. SETTING: Tertiary center. PATIENT(S): A 23-year-old Mayer-Rokitansky-Kuster-Hauser syndrome patient with previous vaginal reconstruction and uterus transplantation. INTERVENTION(S): Eighteen months after the transplant, the endometrium was prepared for transfer of the thawed embryos. MAIN OUTCOME MEASURE(S): Implantation of embryo in an allografted human uterus. RESULT(S): The first ET cycle with one day 3 thawed embryo resulted in a biochemical pregnancy. The second ET cycle resulted in a clinical pregnancy confirmed with transvaginal ultrasound visualization of an intrauterine gestational sac with decidualization. CONCLUSION(S): We have presented the first clinical pregnancy in a patient with absolute uterine infertility after uterus allotransplantation. Although the real success is the delivery of a healthy near-term baby, this clinical pregnancy is a great step forward and a proof of concept that the implantation phase works.

Comparison of intravaginal progesterone gel and intramuscular 17-α-hydroxyprogesterone caproate in luteal phase support.

The main objective of this study was to compare the pregnancy rates of intramuscular (IM) 17-α-hydroxyprogesterone caproate (17-HPC) and intravaginal (IV) progesterone gel administration in in vitro fertilization-embryo transfer (IVF-ET) cycles. The IM 17-HPC and IV progesterone groups included 632 (66.4%) and 320 (33.6%) women undergoing the first cycles of IVF-ET treatment, respectively. Multivariate analyses annotated for all potential confounders showed that the use of IV progesterone retained a predictive value for the total ß-human chorionic gonadotropin (hCG) positivity and clinical pregnancy rates [adjusted odds ratio (OR), 1.97; 95% confidence interval (CI), 1.28-3.03; P=0.002; and OR, 1.66; 95% CI, 1.07-2.60; P=0.03, respectively]. However, biochemical and on-going pregnancy rates did not differ significantly between the groups (OR, 1.85; 95% CI, 1.00-3.41; P=0.05; and OR, 1.43, 95% CI, 0.89-2.30; P=0.14, respectively). Luteal phase support (LPS) with IV progesterone gel in comparison with IM 17-HPC appears to be associated with higher clinical pregnancy rates in IVF-ET cycles. However, this benefit is clinically irrelevant in terms of on-going pregnancy outcomes.

Uterine preservation and vaginal reconstruction in a patient with congenital vaginal agenesis presenting with cyclic menouria.

Herein we report the case of a patient with primary amenorrhea and cyclic menouria. The patient was a 20-year-old woman with primary amenorrhea and inability to achieve sexual intercourse. Clinical examination revealed normally developed labia majora and minora, clitoris, and external urethral orifice, but no vaginal opening. A mature female pubic hair pattern was present, and axillary hair development was normal. Breasts were normally developed. Abdominopelvic magnetic resonance imaging demonstrated a remnant upper vagina and unicornuate uterus filled with fluid, and left-sided renal agenesis. Intraoperatively, a congenital vesicouterine fistulous tract was observed. The fistulous tract was completely resected. Vaginal reconstruction using a sigmoid colon pedicled flap was performed. The proximal part of the neovagina was connected to the remnant cervix, and a Foley catheter was left in the uterine cavity for 7 days to prevent obstruction. The patient has been menstruating regularly since the operation. Menouria might be an early sign of congenital vesicouterine fistula. Resection of the fistulous tract with uterine preservation might be considered in patients with vaginal agenesis.

Term delivery following transvaginal drainage of bilateral ovarian abscesses after oocyte retrieval: a case report.

BACKGROUND: Severe postovum retrieval complications such as tuboovarian abscess are rare. We present an early pelvic infection case following egg retrieval. CASE: A 31-year-old woman with unexplained infertility developed early pelvic infection subsequent to transvaginal oocyte retrieval (TVOR). Broad spectrum antibiotics were administered. Upon persistence of fever and ultrasonographic appearance of probable abscess, transvaginal ultrasound-guided drainage was performed on post-TVOR day 9 as well as posterior colpotomy and T-drain replacement into the cul de sac. Signs and symptoms of pelvic infection improved following drain replacement. Her beta-hCG was found to be positive in the following days. Drain was removed after 3 weeks. Her pregnancy follow-up was uncomplicated. She delivered a healthy baby vaginally at 38 gestational weeks. CONCLUSION: Early diagnosis with prompt administration of antibiotics and drainage may prevent poor pregnancy outcome in ovarian abscess patients subsequent to transvaginal oocyte retrieval.

Reconstruction of vaginal agenesis.

Vaginal ageneses are by no means rare anomalies. Complete Mullerian agenesis is the most common reason for vaginal agenesis requiring reconstruction. Patients usually present with pain, hematocolpos, or hematometra in puberty, and later with amenorrhea and dyspareunia. Detailed information is given here regarding etiologies, timing of surgery, and current treatment options for vaginal agenesis. Outcomes and short- and long-term complications of recent treatment options are also discussed.

Early postoperative small bowel obstruction after laparoscopic myomectomy.

OBJECTIVE: To describe an early small bowel obstruction after robotic-assisted laparoscopic myomectomy with the Davinci system. DESIGN: Case report. SETTING: Academic medical center. PATIENT(S): Two days after a robotic-assisted laparoscopic myomectomy, a 35-year-old nulligravid African-American woman developed a small bowel obstruction due to retained myoma fragments that had implanted on and subsequently kinked loops of the small bowel. INTERVENTION(S): The patient was managed conservatively for 4 days with bowel rest and IV hydration. Due to worsening clinical symptoms and supportive radiologic findings, exploratory laparotomy was performed to lyse adhesions and remove the implanted myoma pieces. MAIN OUTCOME MEASURE(S): Clinical resolution of small bowel obstruction symptoms. RESULT(S): No bowel resection was needed for this patient. CONCLUSION(S): Prompt recognition and operative treatment of the small bowel obstruction prevented the need for intestinal resection. To reduce the risk of ectopic implantation of myoma fragments, meticulous care should be taken to remove all remnants of morcellated tissue. Immediate postoperative complications, such as bowel obstruction, and long-term complications related to recurrent myomas may then be avoided.

Falling FSH levels predict poor IVF pregnancy rates in patients whom the gonadotropins are withheld.

AIM: To determine whether monitoring follicle stimulating hormone (FSH) levels in over-responding patients whom the gonadotropins were withheld would predict pregnancy outcome. METHODS: A group of 33 female infertility patients aged between 20-40 years who had to be coasted during controlled ovarian hyperstimulation were recruited for this study. The FSH concentrations on human chorionic gonadotropin (HCG) day and on the four preceding days were measured to determine the threshold FSH concentration for follicular growth and conception. Mean and standard deviation were used for presenting parametric data. Student's t test and the Mann Whitney U test were used for statistical analysis. Two-tailed P < 0.05 was taken as significant. Receiver-operating characteristic (ROC) curves were performed to identify the cutoff level for FSH and E2 at HCG day and four preceding days. RESULTS: Of 33 cycles, 16 were stimulated with recombinant FSH and 17 with recombinant FSH and human menopausal gonadotropin (HMG). The basal and mean coasting FSH levels of FSH and FSH + HMG cycles did not reveal any differences. FSH concentrations decreased the day after coasting began in 26 cycles and fell by 30.2 +/- 2.7% (range 2-53). In 7 cycles, we observed 34.5 +/- 7.4% (range 6-56) declines in FSH levels beginning 2 days after coasting. Of the 31 women who received HCG, 21 conceived during in vitro fertilization and embryo transfer (IVF-ET). Gestational sac and fetal heart activity were visualized in 14 patients. ROC analysis releaved a cutoff value of 4.9 in FSH level at HCG day discriminative of conception or nonconception. CONCLUSION: The results from this study show that monitoring serum FSH levels during coasting may be helpful in predicting the pregnancy outcome.

Septate uterus with a double cervix and longitudinal vaginal septum.

OBJECTIVE: To report the clinical features of 9 cases and review the previously reported 8 cases of an uncommon müllerian anomaly, characterized by the presence of a complete uterine septum with cervical duplication and represent a a longitudinal vaginal septum. STUDY DESIGN: Retrospective clinical study. RESULTS: Nine patients aged 21-32 presented to our clinic with complaints of dyspareunia, dysmenorrhea, and primary or secondary infertility. All 9 patients displayed a single uterus with smooth fundal contour, double cervix and longitudinal vaginal septum. Some additional abnormal findings were associated with these anomalies in some patients: polycystic ovaries in 3 cases and different degrees of endometriosis in 2 cases. Most of the patients had normal tubal patency. CONCLUSION: According to a MEDLINE search, only 8 cases of septate uterus with cervical duplication and a longitudinal vaginal septum have been reported to date. We report 9 more cases, which suggest that this atypical septate uterus type is probably more frequent than reported. These cases support the bidirectional müllerian theory and may imply the presence of another type of mullerian anomaly.

Emergency peripartum hysterectomy.

OBJECTIVE: To review the incidence, indications, risk factors, and complications associated with emergency peripartum hysterectomy. STUDY DESIGN: We analyzed retrospectively 38 cases of emergency peripartum hysterectomy operations performed between January 1996 and June 2001 at Zekai Tahir Burak Women's Health Research and Education Hospital. The indications, risk factors and the associated complications were noted. Standard tests were used to calculate odds ratios (ORs) and their 95% confidence intervals (CI). RESULTS: Thirty-eight cases of postpartum hysterectomy were performed. All of these cases were referred to our center from rural areas. The rate of peripartum hysterectomy was 1/3736 deliveries. The main indications for hysterectomy were placenta accreata, uterine rupture and uterine atony. There were four maternal deaths. CONCLUSION: Peripartum hysterectomy is a necessary life saving operation. Timely operation minimizes the morbidity and mortality.

Reproductive outcome of septate uterus after hysteroscopic metroplasty.

We evaluated the reproductive outcome after hysteroscopic metroplasty in the patients with septate uterus. The reproductive performance of 361 patients with septate uterus during the follow-up period of 18 months after the surgery was analyzed retrospectively for a period of 10 years. A total of 180 (49.8%) pregnancies were achieved after metroplasty during the follow-up period of 18 months. Of the 180 pregnancies 117 (57.2%) reached to term and 34 (18.8%) ended in preterm delivery and the remaining 29 (16%) resulted in abortion. Of the preterm babies 18 (52.9%) were able to live. We obtained 135 (75%) live babies totally. Hysteroscopic metroplasty improves the reproductive performance of septate uterus significantly especially in the cases with recurrent pregnancy loss and should be considered highly as a corrective approach for such patients.