Fertility outcomes of patients with early stage endometrial carcinoma.

AIM: Three to five percent of endometrial carcinoma patients are younger than 40 years and may desire fertility. Conservative treatment can be employed in these cases. We aimed to review treatment outcomes of patients who were diagnosed with endometrial carcinoma and who wanted to preserve their fertility. MATERIAL AND METHODS: We reviewed nine patients who were diagnosed with early stage endometrial carcinoma and wanted to spare their fertility. The patients were followed up at Baskent University Adana Research Center from January 2004 to December 2011. RESULTS: In all patients the carcinoma presented as polyps, which were resected by hysteroscopy. After being informed about both surgical and medical therapies, four patients preferred surgery and five preferred medical treatment. The mean number of in vitro fertilization trials after conservative treatment was 3.25. One woman, who was on medroxyprogesterone acetate, delivered a healthy term baby from a fresh cycle. Another woman, who was on dydrogesterone, got pregnant from a thawing cycle, which later ended up in a missed abortus. Of all the patients who chose medical treatment, three had surgery at the end. One woman developed an ovarian tumor during the follow-up; one woman had a recurrence of endometrial carcinoma on dilatation and curettage for missed abortus and one woman tried in vitro fertilization several times and could not get pregnant, thus decided to have surgery. Two women had stage IA endometrial carcinoma and one had stage IIB ovarian carcinoma. CONCLUSION: Conservative treatment of endometrial carcinoma is safe in most cases. However, patients should be well-informed about the risks of conservative treatment because delaying definitive treatment sometimes worsens the prognosis.

Are serum markers altered in first trimester screening in poor ovarian reserve patients?

AIM: To investigate whether serum biochemical markers were altered during first trimester screenings in patients who have diminished ovarian reserve. METHODS: One hundred and fifty-one women who conceived after intracytoplasmic sperm injection were enrolled during the 11- to 14-week scan between June 2006 and July 2008. The normoresponders (Group 1: 125 patients) had >6 oocytes and the poor responders (Group 2: 26 patients) had ≤6 oocytes in oocyte retrieval. The means of the multiples of the median (MoM) of pregnancy-associated plasma protein A (PAPP-A), free ß-human chorionic gonadotropin (ß-hCG) and nuchal translucency of the poor responder and normoresponder groups were compared and a potential relationship between serum markers and poor ovarian reserve was investigated. Data were analyzed with the Student's t-test, χ2-test and Mann-Whitney two sample test (unpaired, nonparametric). P < 0.05 was considered significant. RESULTS: The means of the MoMs of the poor responders and normoresponders were 1.16 ± 0.45 and 1.04 ± 0.32 (P = 0.111) for nuchal translucency, 0.92 ± 0.48 and 0.89 ± 0.61 (P = 0.399) for PAPP-A, and 1.08 ± 0.40 and 1.21 ± 0.95 (P = 0.831) for ß-hCG, respectively. CONCLUSION: There was no statistically significant difference between the groups in serum biochemical markers, nuchal translucency means and screen positive rates during the first trimester screening.

Single versus double intrauterine insemination in multi-follicular ovarian hyperstimulation cycles: a randomized trial.

BACKGROUND: The rationale for double insemination is to create the opportunity for a longer fertilization period as follicle rupture may occur over a wide interval (approximately 22-47 h) after hCG administration in ovarian hyperstimulation (OH) with intrauterine insemination (IUI) cycles. This randomized study evaluates the effectiveness of single versus double IUI in only OH cycles with multi-follicular development. METHODS: We conducted a single center trial, 228 eligible patients were randomized for this study on the day of hCG. Only cycles with multi-follicular development without premature luteinization (progesterone levels >1 ng/ml on the day of hCG), were included in the study. Multi-follicular development has been defined as at least two dominant follicles reaching minimum > or = 15 mm diameter in which one of them is >17 mm. OH cycles with more than five dominant follicles (>15 mm in diameter) were excluded from the study. In the single IUI group (Group 1 = 112 patients) IUI was applied 36 h after the hCG injection and in the double IUI group (Group 2 = 114 patients) the first IUI was performed 18 h after hCG administration and the second IUI was performed 40 h after hCG administration. The primary end-point is to compare live birth rates (LBRs) between single and double IUI arms. RESULTS: LBRs were 10.7% (12/112 patients) in the single IUI group and 12.3% (14/114) in the double IUI group and the difference was not statistically significant (P = 0.835, OR = 1.16, 95% CI: 0.51-2.64). In the unexplained infertility group the LBR was 11.1% (5/45 patients) with single IUI and 18.4% (9/49) with double IUI (P = 0.393). In the mild male factor group this rate was 10.4% (7/67) and 7.7% (5/65) in the single and double IUI groups, respectively (P = 0.764). CONCLUSION: Our study did not find any difference in LBRs between single and double IUI groups in OH cycles with multi-follicular development. To the best of our knowledge this is the first report with this kind of study design. The study was registered at clinicaltrials.gov: NCT 00993902.

Premature progesterone elevation impairs implantation and live birth rates in GnRH-agonist IVF/ICSI cycles.

INTRODUCTION: Our aim was to investigate the clinical significance of premature elevated progesterone levels in women with good ovarian response treated with long gonadotropin-releasing hormone agonist (GnRH-a) cycles and IVF. Premature elevated progesterone levels refer to a rise in serum progesterone levels on the day of human chorionic gonadotrophin (hCG) administration for final oocyte maturation above a threshold level, which is usually arbitrarily defined. MATERIALS AND METHODS: This is a retrospective case study, which consists of 1,045 treatment cycles in women with low P/E2 [progesterone (ng/mL) x 1,000/estradiol (pg/mL)] on the day of hCG. Elevated P levels on the day of hCG administration were defined as >1.1 ng/mL. The data of the control group (< or =1.1 ng/mL, n = 900 patients) were compared with those of the high P group (>1.1 ng/mL, n = 145). RESULTS: Compared with the control group, those in the high progesterone group had higher levels of estradiol on the day of hCG (3,143 vs. 2,382 pg/ml) (p: 0.000) and higher numbers of MII oocytes (14.0 and 12.9) (p: 0.001). The total number of embryos and the number of good-quality embryos transferred did not differ significantly between the groups. Implantation rate (18.1 vs. 24.4%) (p: 0.008), and live birth rate (27.6 vs. 40%) (p: 0.004), were significantly lower in patients with high progesterone levels. OR and 95% CI were 0.57 (0.39-0.84) for the live birth rate. CONCLUSION: In women stimulated with GnRHa and hMG/FSH for IVF, elevated serum progesterone levels on the day of hCG administration were associated with diminished implantation rates and live birth rates regardless of ovarian reserve.

IVF outcomes after hysteroscopic metroplasty in patients with T- shaped uterus.

BACKGROUND: T- shaped uterus may be associated with infertility and adverse pregnancy outcomes. Hysteroscopic metroplasty may improve the reproductivity for these cases. To our knowledge, there is no data in literature about the clinical consequences of in vitro fertilization (IVF) in patients undergoing hysteroscopic metroplasty for T-shaped uterus. The principal objective of the current study is to assess the impact of hysteroscopic metroplasty for T-shaped uterus on the reproductive outcomes of IVF. METHODS: IVF outcomes of 74 patients who underwent hysteroscopic metroplasty for T- shaped uterus and 148 patients without any uterine abnormalities and with diagnosis of unexplained infertility (control group) were retrospectively analyzed. RESULTS: Patients in metroplasty and control groups were comparable with respect to age, BMI, partner's age and duration of infertility. Number of patients with a history of pregnancy beyond 20 weeks of gestation was significantly lower in the metroplasty group (4.1% vs 18.2%; p < 0.05). Number of previous unsuccessful cycles and percentage of patients with ≥3 unsuccessful IVF cycles (35.1% vs 17.6%; p < 0.05) were significantly higher in the metroplasty group. There were no significant differences in the reproductive outcomes such as the pregnancy rate, clinical pregnancy or live birth rate between the metroplasty and control groups. There were non-significant trends for higher rates of miscarriage (18.8% vs 8%, p > 0.05) and biochemical pregnancy (20.0% vs 10.7%, p > 0.05) in the metroplasty group compared to the control group. CONCLUSIONS: Reproductive results of the IVF cycles after hysteroscopic correction of T-shaped uterus were comparable to those of the patients without any uterine abnormalities and with diagnosis of unexplained infertility. Hysteroscopic metroplasty may contribute to improved IVF outcomes in patients with T-shaped uterus.

Effect of cervical mucus aspiration before intrauterine insemination.

OBJECTIVE: To determine whether cervical mucus aspiration before intrauterine insemination (IUI) has any effect on clinical pregnancy rates. METHOD: The outcomes of 186 IUI cycles in 95 consecutive patients in whom mucus was aspired prior to IUI were compared retrospectively with those of 1057 IUI cycles in 505 women. RESULTS: The pregnancy rate was 15.1% (28 pregnancies for 186 cycles) in the cervical mucus aspiration group and 9.9% (105 pregnancies for 1057 cycles) in the control group (P=0.05). Mucus aspiration led to significantly increased pregnancy rates for women with unexplained infertility (24% in the aspiration group vs 9.5% in the control group; P=0.04). CONCLUSION: Cervical mucus aspiration before IUI might improve clinical pregnancy rates by yet-to-be-defined mechanisms.

How best is to discontinue postmenopausal hormone therapy: immediate or tapered?

BACKGROUND: To evaluate the differences between the immediate and tapered cessation protocols of hormone therapy in terms of recurrence of menopausal symptoms. MATERIALS AND METHODS: In this prospective, randomized clinical study 70 consecutive patients in whom hormone therapy was no longer preferred were recruited from the menopause clinic of a university hospital and rank randomized into two groups. In group 1 (n=35) hormone therapy was immediately discontinued and in group 2 (n=35) the medication was tapered. Every patient was questioned about vasomotor symptoms before the initiation of hormone therapy at the first visit, and then revisited at the end of 2 and 4 weeks. RESULTS: We did not find any statistically significant difference between two protocols in terms of symptom severity and frequency at the end of 2 and 4 weeks of discontinuation. Although statistically insignificant, the symptoms tended to recur in fewer patients and in a less severe form in both groups when compared with their pretreatment status. CONCLUSIONS: Tapering or immediate discontinuing of hormone therapy did not affect the recurrence rate and severity of menopausal symptoms at the end of 4 weeks.

Thoracic epidural anesthesia and analgesia for gastric resection at 26 week pregnant woman.

Anesthesia and surgery are required in up to 1.5% to 2% of all pregnancies. Alterations in maternal anatomy and physiology create potential risks for both mother and fetus. The anesthetic considerations for any surgery during pregnancy must take both patients into account. Gastric adenocarcinoma presenting during pregnancy is a rare condition and has a poor prognosis. This report describes anaesthetic management of a woman who was diagnosed with gastric adenocarcinoma at 26 weeks' gestation. Distal subtotal gastrectomy was planned in an attempt to maximize the mother's life expectancy while maintaining the pregnancy until the fetus reached viable gestation. A combination of general anesthesia and thoracic epidural anesthesia was used. The goal was to reduce physiological stress and minimize anesthesia risk for both mother and fetus and also diminish the neuroendocrine response during the surgery. The patient was discharged from the hospital 10 days after the surgery and was then readmitted at 30 weeks' gestation for an elective cesarean section.

Predictive value of glucose-insulin ratio in PCOS and profile of women who will benefit from metformin therapy: obese, lean, hyper or normoinsulinemic?

OBJECTIVE: The aim of the present study is to evaluate sub-groups of PCOS patients who will benefit from metformin therapy and to find out any predictors of ovulation in PCOS sub-groups. METHOD: In the current prospective-randomized, placebo-controlled, double-blind study, PCOS patients (n = 116) were divided into six main groups according to glucose to insulin ratio (G-I ratio mg/10(-4) U) and body mass index (BMI kg/m2) as: Group 1: normoinsulinemic (G-I ratio > or = 4.5 mg/10(-4) U), lean (BMI < 25) (n = 37); Group 2: normoinsulinemic, overweight (BMI: 25-29.9) (n = 19); Group 3: normoinsulinemic, obese (BMI > or = 30) (n = 18); Group 4: hyperinsulinemic (G-I ratio < 4.5 mg/10(-4) U), lean (n = 28); Group 5: hyperinsulinemic, overweight (n = 17); Group 6: hyperinsulinemic, obese (n = 20). Patients in each group were randomized onto placebo or metformin treatments (850 mg two to three times per day according to BMI). The rate of ovulation, biochemical profile, hormonal profile and clinical symptoms of hyperandrogenism were evaluated before and after 6 months of metformin and placebo treatments. RESULT(S): We observed a significant decrease in WHR following metformin therapy in the normoinsulinemic overweight sub-group (P < 0.05). The duration of the menstrual cycle significantly decreased in the normoinsulinemic obese sub-group on metformin therapy (P < 0.05). Metformin had a significant effect on hirsutism scores in hyperinsulinemic lean women (P < 0.05) and decreased DHEAS levels significantly in the lean hyperinsulinemic and normoinsulinemic groups (P < 0.05). Metformin had significant effects on ovulation in only lean hyperinsulinemic women (P < 0.05). CONCLUSIONS: Clinical outcomes of metformin therapy may be categorized on the basis of basal BMI and insulin levels in PCOS patients.

The effects of short-term medroxyprogesterone acetate and micronized progesterone on glucose metabolism and lipid profiles in patients with polycystic ovary syndrome: a prospective randomized study.

In this prospective, randomized study we determined 10-d effects of medroxyprogesterone acetate (MPA) and micronized progesterone (MP) either orally or per vaginally on hormonal parameters, glucose metabolism and lipid profiles in patients with polycystic ovary syndrome (PCOS). Twenty-eight consecutive women with PCOS were randomized to receive 10-d MPA, oral MP, or vaginal MP. Hormonal parameters, insulin levels, oral glucose tolerance test, lipid profiles, and homeostasis model assessment and quantitative insulin sensitivity check indexes were assessed in all groups before and after treatment. Oral MPA and oral MP decreased LH (15.64 +/- 13.17 to 7.27 +/- 4.35 IU/liter, P = 0.028, and 18.85 +/- 11.86 to 10.49 +/- 6.48 IU/liter, P = 0.009, respectively) and total testosterone (5.85 +/- 2.80 to 3.40 +/- 1.72 nmol/liter, P = 0.013, and 5.29 +/- 2.98 to 3.43 +/- 2.10 nmol/liter, P = 0.037, respectively) levels. Hormonal parameters did not change with vaginal MP. Basal insulin (123.42 +/- 97.50 to 87.38 +/- 48.68 pmol/liter; P = 0.021) and homeostasis model assessment levels decreased, and quantitative insulin sensitivity check index increased significantly in the oral MPA group. Low density lipoprotein cholesterol and lipoprotein (a) levels decreased only in the MPA group. In conclusion, short-term oral MP and especially oral MPA might ameliorate insulin sensitivity in patients with PCOS. Vaginal MP has no effect on glucose metabolism and lipid profiles. LH, total testosterone, and insulin levels may be affected from the short-term progesterone treatment.

Intima-media thickness of the carotid arteries is related to serum osteoprotegerin levels in healthy postmenopausal women.

Osteoprotegerin (OPG) regulates bone mass by inhibiting osteoclast differentiation and activation, and also plays a role in vascular calcification. The objective of this study was to evaluate the relationship between serum OPG levels, and carotid artery intima-media thickness (IMT) and carotid plaque formation in healthy postmenopausal women. We recruited 68 healthy postmenopausal women for the study. Carotid plaque presence and IMT were evaluated by high resolution B-mode ultrasound. IMT was positively correlated with presence of plaque, age, menopause age and OPG, and inversely correlated with Apolipoprotein A1 (Apo A1). Serum OPG level was positively correlated with IMT (r = 0.366; p < 0.003) and age (r = 0.324; p < 0.008), and negatively correlated with Apo A1 (r = -0.481; p < 0.0001). We did not observe any significant relation between plaque occurrence and levels of serum OPG. In regression analysis OPG (p < 0.02) and menopause age (p < 0.05) were independent risk factors for IMT, and age (p < 0.05) and IMT (p < 0.05) were independent risk factors for plaque formation. Although the role of OPG in the vascular biology is poorly understood, our results suggest that elevated levels of serum OPG is associated with IMT and may play a role in the pathogenesis of atherosclerotic disease.

The effect of surgical sterilization on ovarian function: a rat model.

OBJECTIVE: To evaluate the effects of various methods of sterilization on ovarian function, in a rat model. STUDY DESIGN: Forty-eight female Whistar albino rats weighing 200-250g are divided equally into four groups. All rats underwent laparotomy, while no specific intervention was made to the first group. Bilateral tubal ligation by Pomeroy's technique, unipolar and bipolar cautery was done to the second, third and fourth groups, respectively. All rats were then individually caged and fed on demand for 6 months. Afterwards, the rats were sacrificed and underwent bilateral oophorectomy. A pathologist blinded to the groups made histological examination by counting number of healthy tertiary follicles and corpora lutea in each ovary. The results of the groups were statistically compared by one-way ANOVA using post-hoc Bonferroni correction. RESULTS: Rats in group 1 had significantly higher number of healthy tertiary follicles than every other group. Rats in group 1 also had significantly more corpora lutea than those in group 3. CONCLUSION: Tubal ligation may affect ovarian function, which in turn may reflect to ovarian histology in rats.

Cerebellar hemangioblastoma in pregnancy. A case report.

BACKGROUND: The incidence of symptomatic hemangioblastoma of the posterior fossa during pregnancy is extremely low. Previous reports have noted that pregnancy seems to aggravate the clinical course of intracranial tumors, but little is known about the possible reasons. Various theories have been proposed to explain the rapid neurologic deterioration of hemangioblastoma patients during pregnancy; however, the pathophysiologic behavior and histogenesis of this vascular tumor are still not well understood. CASE: A case of cerebellar hemangioblastoma was diagnosed during pregnancy. Urgent surgery was required due to rapid development of obstructive hydrocephalus and brainstem compression. CONCLUSION: Obstetricians and neurosurgeons should be aware of the rare clinic entity of hemangioblastoma during pregnancy. Surgery might be indicated as soon as the tumor becomes symptomatic.

Moclobemide in the treatment of hot flashes in postmenopausal women.

This randomized, prospective, double-blind study evaluated the efficacy and tolerability of moclobemide, a reversible, selective inhibitor of monoamine oxidase-A, in reducing the frequency and severity of hot flashes. Thirty postmenopausal women were enrolled, and 28 were allocated to 5 weeks of treatment with moclobemide 150 mg (group 1, n = 10), moclobemide 300 mg (group 2, n = 11), or placebo (group 3, n = 9). Data on hot flashes were recorded in a daily diary. Mean reductions in the hot flash severity score were 24.4% in the placebo group, 69.8% in group 1, and 35.0% in group 2. This large difference suggests that the beneficial effects were not due to a placebo effect. Moclobemide may be a new nonhormonal option for reducing the incidence, severity, and duration of hot flashes in postmenopausal women who do not wish to take estrogen or have contraindications to its use.

Effects of lumbar disc surgery on bone mineral density in women with lumbar disc disease.

This prospective study evaluated 60 reproductive-age and postmenopausal women with lumbar disc disease to demonstrate the short-term effects of lumbar disc surgery on bone mineral density (BMD). Lumbar BMD was measured preoperatively and 3 months postoperatively by dual-energy X-ray absorptiometry (DEXA). Surgery was performed at only one level (L3-L4) and consisted of partial hemilaminectomy, discectomy, and, if necessary, partial facetectomy. Before surgery, 50% of the patients had osteopenia, and 31.7% had osteoporosis. After surgery, BMD decreased 5.5% in L3 vertebrae (P=.07), 14% in L4 vertebrae (P=.003), and 4.6% in L1-L4 (P=.039). Six of 11 patients with normal BMD before surgery became osteopenic postoperatively; 9 of 30 women with osteopenia fulfilled criteria for osteoporosis after surgery. Reproductive-age and postmenopausal women undergoing surgery for lumbar disc disease are at risk of bone loss and should be spared an extensive procedure, which can further increase the amount of bone lost. All women for whom a surgical intervention is planned should be evaluated by DEXA preoperatively and postoperatively.

Absent pulmonary valve syndrome diagnosed by fetal echocardiography.

Prenatal echocardiographic diagnosis of heart defects is important because it permits counseling of the parents with regard to prognosis and treatment options and prepares the medical team for the treatment postnatally. A male infant with absent pulmonary valve syndrome diagnosed prenatally at 22 weeks' gestation is reported. This congenital anomaly is characterized by absent or rudimentary pulmonary valve cusps, conoventricular septal defect, and massive dilatation of the pulmonary arteries. Soon after delivery the infant developed cyanosis and respiratory distress. The infant was placed in prone position for the relief of bronchial compression and nasal continuous positive airway pressure was (CPAP) started. Although the clinical status of the infant improved after supportive treatment, he deteriorated acutely and died at the age of five days. Fetal diagnosis remains an integral part of successful management of children with heart disease. Despite the potential benefits of prenatal diagnosis, it is hard to show significant improvement in mortality, especially in severely affected cases.

Isolated abnormal value during the 3-hour glucose tolerance test: which value is associated with macrosomia?

OBJECTIVE: The aim of this retrospective review was to evaluate obstetric outcomes in patients with an isolated abnormal value on the oral glucose tolerance test (OGTT) at 0, 1, 2, and 3 h. METHODS: From January 2003 through June 2009, all consecutive pregnant women who presented to Baskent University were screened for gestational diabetes mellitus (GDM). Patients with one abnormal value based on findings of the OGTT were grouped according to increased levels of glucose at 0, 1, 2, and 3 h (Group 1  >  95 mg/dl for fasting glucose concentration, Group 2  >  180 mg/dl for the serum glucose concentration in the first hour, Group 3  >  155 mg/dl for the serum glucose concentration in the second hour, Group 4  >  140 mg/dl for serum glucose concentration in the third hour). The four groups were compared for classic GDM risk factors. The primary outcome measures were large for gestational age (LGA) (birthweight  > 95th percentile for gestational age using population birth weight centile charts) and macrosomia. RESULTS: The incidence of LGA baby (Group 1, 10%; Group 2, 3.8%; Group 3 20.3%; Group 4, 13.2%; p = 0.008) was significantly highest in Group 3 and macrosomia (Group 1, 30%; Group 2, 5.1%; Group 3, 18.6%; Group 4, 15.8%; p = 0.039) was significantly higher in Groups 1 and 3. CONCLUSIONS: Our results suggest that even with relatively mild degrees of glucose intolerance at 2 h, no treatment is associated with LGA babies.

In vitro fertilization-intracytoplasmic sperm injection outcomes in single- versus double-lumen oocyte retrieval needles in normally responding patients: a randomized trial.

We compared the retrieval efficiency of single- (direct follicular aspiration) and double-lumen-needle (attained with follicular flushing) procedures in normal-responder IVF-intracytoplasmic sperm injection cycles. This prospective randomized study did not demonstrate a beneficial effect of double-lumen needle retrieval compared with single-needle retrieval in normal-responder IVF-intracytoplasmic sperm injection cycles in terms of retrieved oocytes, clinical pregnancy rates, and live birth rates.