Random-start controlled ovarian hyperstimulation with letrozole for fertility preservation in cancer patients: case series and review of literature.

The aim of this case series was to describe our experience with random-start controlled ovarian hyperstimulation (RS-COH) with the use of letrozole for fertility preservation. GnRH antagonist and letrozole cycles were started in three patients with a diagnosis of cancer and had a limited time window for fertility preservation for COH before initiating cancer therapy. Cycles were started in the late follicular or luteal phase, and the duration of COH ranged between 7-8 days. A total of 4-14 oocytes were retrieved, the peak E2 levels were 252-354 pg/ml and the saved time for start of the cancer treatment were 16-26 days for each patient. In conclusion, RS-COH with letrozole cycle is a reasonable option for fertility preservation in cancer patients for whom the treatment window may be narrow. Also, the use of a letrozole for COH may decrease the potential risk of ovarian hyperstimulation syndrome.

Effect of a low dose of gonadotropin releasing hormone antagonist on in vitro fertilization outcomes.

PURPOSE: This study aims to determine whether a low dose of the gonadotropin releasing hormone antagonist, cetrorelix, prevents a premature luteinizing hormone (LH) surge and affects in vitro fertilization (IVF) outcomes compared to the standard dose of 0.25 mg/day. METHODS: In this study, 45 IVF/intracytoplasmic sperm injection patients were stimulated with recombinant follicle stimulation hormone from day 2 of the cycle. Cetrorelix was injected daily from day 6 of gonadotropin administration. Twenty-two patients received cetrorelix at a dose of 0.25 mg/day, whereas 23 participants received half dose. RESULTS: The mean consumption of gonadotropins was significantly higher in patients receiving 0.25 mg/day of cetrorelix (2,213 vs. 1,350 U; p = 0.046). The clinical pregnancy rates were similar in both groups (31.8 vs. 47.8 %; p = 0.273). Premature LH surge was detected in 9.1 % of the patients receiving cetrorelix 0.25 mg/day and in 13 % of the patients receiving cetrorelix 0.125 mg/day (p > 0.05). The difference between two groups was not statistically significant (p > 0.05). CONCLUSIONS: Our results suggest that there is no difference between a cetrorelix dose of 0.125 or 0.25 mg/day in preventing premature LH rise during ovarian stimulation for IVF.

Antimullerian hormone levels after laparoscopic endometrioma stripping surgery.

OBJECTIVE: To evaluate whether a change takes place in antimullerian hormone (AMH) levels reflecting the ovarian reserve after laparoscopic endometrioma stripping surgery and to demonstrate if there is any correlation between AMH levels and the sizes of endometriomas. METHOD: Fourty-seven women participated as the study group in this prospective controlled trial, 33 of whom (70.2%) had unilateral and 14 (29.7%) of whom had bilateral endometriomas. Pre- and post-operative serum AMH levels were measured and compared with 17 normo-ovulatory control cases and also correlated with endometrioma sizes. RESULT(S): Mean pre-operative AMH levels of the study group and the normo-ovulatory control cases did not reveal a statistically significant difference (1.62 +/- 1.09 ng/ml and 2.06 +/- 0.51 ng/ml, P > 0.05). Mean level of post-operative serum AMH of the study group decreased from 1.62 +/- 1.09 to 1.39 +/- 1.16. However, this reduction was not statistically significant. (P > 0.05). Pre- and post-operative AMH levels do not reveal a correlation with the size of endometrioma in both group of patients with either unilateral or bilateral endometrioma. CONCLUSION(S): The presence of the endometrioma does not impair the AMH levels. Laparoscopic endometrioma stripping surgery do not appear to cause a damage in the AMH secreting healthy ovarian tissue, in the short-term follow-up. Laparoscopic stripping surgery of endometriomas in experienced hands is currently a valid approach.

Successful twin pregnancy achieved by assisted reproductive technology in a patient with polycystic ovary syndrome with complex atypical endometrial hyperplasia treated with levonorgestrel-releasing intrauterine system.

Polycystic ovary syndrome (PCOS) is one of the most common reproductive endocrinopathy and a major cause of infertility. PCOS may be associated with chronic anovulation and endometrial hyperplasia. Conservative treatment should be considered in young women wishing to preserve their fertility. Standard treatment for complex endometrial hyperplasia is the use of high-dose progesterone, whereas we preferred levonorgestrel-releasing intrauterine system (LNG-IUS) as a last resort in our patient who was resistant to oral gestagens. We present a case with complex atypical endometrial hyperplasia treated conservatively in a long-term period first by oral gestagens, then by LNG-IUS. In our case, LNG-IUS was more effective than oral systemic progestins, not only for reducing the menstrual blood loss but also for improving the pathological findings. After extraction of LNG-IUS rapid achievement of pregnancy was carried out by intracytoplasmic sperm injection and embryo transfer and she took home twin babies. To the best of our knowledge, this is the first successful twin pregnancy case with ICSI and ET in a patient with oral gestagen resistant endometrial complex/atypical hyperplasia achieved after application of LNG-IUS. In complex atypical hyperplasia, LNG-IUS should be kept in mind as an effective alternative treatment modality before assisted reproductive technology (ART).

Continuous vaginal and bilateral thoracic fluid drainage for management of severe ovarian hyperstimulation syndrome.

Severe ovarian hyperstimulation syndrome (OHSS) is a serious and potentially fatal complication of ovarian stimulation. A 29-year-old nulligravid patient with anovulatory infertility was treated with in vitro fertilization. Six days after embryo transfer, the patient presented with complaint of abdominal bloating, nausea, vomiting and shortness of breath. Severe late-onset OHSS, with massive ascites and pleural effusion, was diagnosed. Posterior colpotomy was performed under general anesthesia, a Foley catheter was inserted into the posterior cul-de-sac, and bilateral chest drainage tubes were left for continuous drainage. In total, 13.2 liters of ascites and 6.1 liters of pleural fluid were drained in 8 days. Continuous drainage of ascites and pleural effusion improved the patient's comfort without need for repeated transvaginal and thoracic aspirations.

Percutaneous management of ureteral injuries that are diagnosed late after cesarean section.

OBJECTIVE: We wanted to present the results of percutaneous management of ureteral injuries that were diagnosed late after cesarean sections (CS). MATERIALS AND METHODS: Twenty-two cases with 24 ureteral injuries that were diagnosed late after CS underwent percutaneous nephrostomy (PN), antegrade double J (DJ) catheter placement and balloon dilatation or a combination of these. The time for making the diagnosis was 21 +/- 50.1 days. The injury site was the distal ureter in all cases (the left ureter: 13, the right ureter: 7 and bilateral: 2). Fifteen complete ureteral obstructions were detected in 13 cases. Ureteral leakage due to partial (n = 4) or complete (n = 3) rupture was noted in seven cases. Two cases had ureterovaginal fistula. All the cases were initially confirmed with antegrade pyelography and afterwards they underwent percutaneous nephrostomy. Balloon dilatation was needed in three cases. Antegrade DJ stents were placed in 10 cases, including the three cases with balloon dilatation. Repetition of percutaneous nephrostomy with balloon dilatation and DJ stent placement was needed in one case with complete obstruction. All the cases were followed-up with US in their first week and then monthly thereafter for up to two years. RESULTS: Eighteen ureters (75%) were managed by percutaneous procedures alone. A total of six ureter injuries had to undergo surgery (25%). CONCLUSION: Percutaneous management is a good alternative for the treatment of post-CS ureteral injuries that are diagnosed late after CS. Percutaneous management is at least preparatory for a quarter of the cases where surgery is unavoidable.

Retrieval of zona-free immature oocytes in a woman with recurrent empty follicle syndrome: a case report.

BACKGROUND: Different ovulation trigger methods such as gonadotropin releasing hormone-agonist (GnRH-a) and recombinant human chorionic gonadotropin (r-hCG) plus rescue oocyte retrieval might reveal oocytes in patients with recurrent empty follicle syndrome. CASE: Endogenous luteinizing hormone was triggered with a GnRH-a (Buserelin [Suprefact pro-injection, Aventis-Pharma, Turkey], 250 microg subcutaneously) in a GnRH antagonist (Cetrorelix [Cetrotide 0.25, SeronoTurkey], 0.25 mg/d, starting on day 6), down-regulated cycle. At the first scheduled retrieval, 3 cumulus-oocytecorona complexes were recovered from the left ovary. During chemical denudation with hyaluronidase, 2 of them underwent lysis. The third was a zona-free, germinalvesicle-stage oocyte after mechanical denudation. Oocyte pickup was stopped, and recombinant human chorionic gonadotropin (hCG) (250 microg subcutaneously) was injected. Five cumulus-oocyte-corona complexes were retrieved from the right ovary 24 hours after rescue with recombinant hCG. Only mechanical denudation was done, and 4 zona-free oocytes with germinal vesicle breakdown were seen. All oocytes underwent intracytoplasmic sperm injection, and none of them were fertilized. CONCLUSION: Oocyte maturation defects should be included in etiologic mechanisms for counseling patients with empty follicle syndrome.

Outcome of in vitro fertilization and ovarian response after endometrioma stripping at laparoscopy and laparotomy.

OBJECTIVE: To add further data on in vitro fertilization (IVF) outcome and ovarian response after endometrioma stripping via either laparoscopy or laparotomy. STUDY DESIGN: IVF outcome and ovarian response parameters in patients who had undergone unilateral endometrioma stripping at laparoscopy (n=28) or laparotomy (n=10) before IVF were retrospectively compared. RESULTS: Fertilization rates, number of embryos transferred and pregnancy rates did not differ between the groups. Significantly more recombinant FSH was used to induce folliculogenesis, and fewer metaphase II oocytes were retrieved in the laparotomy group. The laparotomy-postcystectomy ovaries were significantly smaller and malpositioned. In both stripping groups, significantly smaller operated-on ovaries with lower numbers of antral and mature follicles were observed as compared to intact ovaries. CONCLUSION: A higher amount of FSH is needed to achieve an acceptable IVF outcome after unilateral endometrioma surgery. Indications for surgical treatment of patients having larger and bilateral cysts with an expectation for future fertility should be cautiously reviewed

Is uterine artery embolization prior to myomectomy for giant fibroids helpful?

PURPOSE: To determine whether uterine artery embolization (UAE) prior to myomectomy is more effective than myomectomy alone. MATERIALS AND METHODS: The study included 15 consecutive infertile women with uterine fibroids > 10 cm (Group I) that underwent UAE with spherical particles using a microcatheter technique and a unilateral femoral approach between March 2005 and January 2007. The day after embolization all cases underwent myomectomy since the protocol for large fibroids in our hospital is myomectomy only. The control group was composed of 15 patients who underwent myomectomy only (Group II). Group II was established based on fibroid size (14 +/- 3 cm). Operating time, estimated blood loss and transfusion, complications, and hospital stay were calculated by retrospective chart reviews, and comparisons were made between the groups with Student's t-test. RESULTS: Mean operating time was 138 min in Group I and 240 minutes in Group II (P < 0.01). Mean estimated blood loss was 250 ml in Group I and 690 ml in Group II (P < 0.01). There was no need for transfusion in Group I, while transfusion was needed in 2 cases (13%) in Group II. Mean hospital stay in Group I was 5 days versus 8 days in Group II. Complications, including subsequent hysterectomy, were seen in 2 cases and bowel-bladder injuries in 1 case in Group II (a total of 20%), while no complications were observed in Group I. One of the cases in Group I later conceived and gave birth to a healthy child. CONCLUSION: UAE prior to myomectomy is more effective than myomectomy alone.

Pregnancy outcomes in a university hospital after legal requirement for single-embryo transfer.

OBJECTIVE: To present our in vitro fertilization outcomes after implementation of the Turkish government policy limiting the number of transferred embryos to one, in women under the age of 35, and two, in women over age 35; and to demonstrate the feasibility of this policy. STUDY DESIGN: We retrospectively reviewed the records of 423 patients who underwent ovarian stimulation, oocyte pick-up, intracytoplasmic sperm injection and embryo transfer due to primary or secondary infertility over a 22-month time interval. Clinical pregnancy was defined as a fetal heartbeat in the seventh gestational week. Embryo transfers were carried out on day 3 or 5. Descriptive statistics are given as the number of subjects and percentages. RESULTS: A total of 353 embryo transfers were performed: 261 (73.9%) were single-embryo transfer (244 (69.1%) elective and 17 (4.8%) non-elective) and 92 (26.1%) were double-embryo transfer. Of the 244 elective single-embryo transfers, 6.6% (n=16) were performed using frozen-thawed embryos. The average patient age was 29.6±4.5 years in the single-embryo group and 36.5±2.4 years in the double-embryo group. The cumulative pregnancy rates per oocyte pick-up were similar in both groups: 41% (n=107) in the single-embryo group and 43.4% (n=40) in the double-embryo group (p=0.678). The cumulative live birth rate of the single-embryo group (32.1%) was not statistically different from the double-embryo group (35.8%) (p=0.518). The twin pregnancy rate after single-embro transfer was significantly lower than with double-embryo transfer (2.8% (n=3) vs. 32.5% (n=13); p<0.001) and 62.5% of the twin pregnancies occurred in women 35 years or older who underwent double-embryo transfer. No significant difference in the spontaneous abortion rates was recorded between the single- and double-embryo transfer groups (16 (6.1%) vs. 6 (6.5%); p=0.894). CONCLUSION: Single-embryo transfer results in a pregnancy rate comparable to double-embryo transfer, with a significantly reduced multiple pregnancy rate. Double-embryo transfer in patients over age 35 should be reconsidered because of the resulting high rate of multiple pregnancy.

Ultrasonographic evaluation and anti-mullerian hormone levels after laparoscopic stripping of unilateral endometriomas.

OBJECTIVE: To evaluate the ovarian reserve after laparoscopic stripping of unilateral endometriomas by comparing the operated and non-operated ovaries. STUDY DESIGN: Bilateral ovarian volumes, antral follicle counts, and stromal blood flows were assessed by ultrasonography and anti-mullerian hormone (AMH) levels were analysed in 36 patients who had undergone laparoscopic cystectomy for unilateral ovarian endometrioma. RESULTS: Mean antral follicle counts (AFC) of the operated side ovaries were significantly lower on the second postoperative day (3.1 ± 2.4 vs 5.2 ± 3.7; p<0.05) and in the third month (3.7 ± 2.1 vs 6.4 ± 2.7; p<0.05). Pulsatility indices of the operated ovaries were significantly decreased on the second postoperative day (2.22 ± 0.46 vs 1.76 ± 0.51; p<0.05) while resistance indices were increased (0.81 ± 0.06 vs 0.88 ± 0.13; p<0.05). Doppler parameters had recovered and a non-significant decrease in AMH levels of the patients was recorded in the third month after surgery (2.03 ± 0.41 ng/mL vs 1.95 ± 0.62 ng/mL; p>0.05). CONCLUSION: Although laparoscopic stripping of endometriomas seems to affect the ovarian reserve in terms of AFCs, it does not have a significant negative impact at the end of three months as assessed by ovarian volumes, Doppler indices and AMH levels. Endometrioma surgery techniques are important in preserving normal functioning ovaries and further studies are necessary for optimising these surgical approaches.

Percutaneous treatment of hepatic hydatid cyst in pregnancy: long-term results.

PURPOSE: To present the long-term results of percutaneous treatment of hepatic hydatid cyst in pregnancy. MATERIAL AND METHODS: Six pregnant patients (age range 19-28 years; mean age 23 years) with six hepatic hydatid cysts underwent percutaneous treatment without albendazole prophylaxis. Puncture, aspiration, injection and reaspiration (PAIR technique) were used to treat the cysts. Hypertonic saline solution was used as cytotoxic agent. Follow-up was mainly by sonography every 2 weeks during pregnancy, every third month post-partum for the first year, every 6 months for the second year, and once a year thereafter. The mean follow-up time was 57.5 months. RESULTS: Before the treatment, average hydatid cyst volume was 2,145 ml that was reduced to 145 ml post-treatment at the time of delivery. The first five cases of the study had solid appearance of the cyst remnant (indicating complete cure) in 22 months. Cystobiliary fistula was suspected in the sixth case three months after delivery. After confirmation of the cystobiliary fistula with cystography, a percutaneous catheter was placed into the postresidual cavity and a nasobiliary catheter was placed into the common bile duct after syphincterotomy. The fistula was closed in 2 weeks. This patient has a follow-up time of 1 year so far without any problem. No mortality, morbidity, fetal loss, abdominal dissemination, or tract seeding was observed among our cases. CONCLUSION: Percutanous treatment of hydatid cysts in pregnancy is an efficient and safe procedure in cases where percutaneous treatment is indicated.

Comparison of three sperm retrieval techniques in spinal cord-injured men: pregnancy outcome.

AIM: To compare pregnancy outcomes between three sperm retrieval techniques - electroejaculation, testicular sperm extraction (TESE) and prostatic massage - in spinal cord-injured men. METHOD: Forty-four patients who became paraplegic due to spinal cord injuries by land mines and bullets, and who underwent infertility treatment during 1998-2005, were included. Eight men were treated with rectal probe electroejaculation, 26 with TESE and ten with prostatic massage. The pregnancy rate and live birth rate resulting from the embryo transfers of all cycles were calculated. RESULTS: Eight singleton pregnancies were achieved, two in the electroejaculation group, four in the TESE group and two in the prostatic massage group. Live birth rate was not significantly different between the three groups. CONCLUSION: Our results show that the different sperm retrieval techniques used to obtain semen in spinal cord-injured men resulted in similar pregnancy outcomes.