Cem Somer Atabekoğlu

Microdose gonadotropin-releasing hormone agonist flare-up protocol versus multiple dose gonadotropin-releasing hormone antagonist protocol in poor responders undergoing intracytoplasmic sperm injection–embryo transfer cycle

OBJECTIVE To compare the efficacy of microdose GnRH agonist (GnRH-a) flare-up and multiple dose GnRH antagonist protocols in patients who have a poor response to a long luteal GnRH-a protocol. DESIGN Prospective, randomized, clinical study. SETTING University hospital. PATIENT(S) Forty-two poor responder patients undergoing intracytoplasmic sperm injection (ICSI)-embryo transfer cycle. INTERVENTION(S) Twenty-one patients received microdose leuprolide acetate (LA) (50 microg twice daily) starting on the second day of withdrawal bleeding. The other 21 patients received 0.25 mg of cetrorelix daily when the leading follicle reached 14 mm in diameter. MAIN OUTCOME MEASURE(S) Serum E(2) levels, number of growing follicles and mature oocytes, embryo quality, dose of gonadotropin used, cancellation, fertilization, implantation rate and pregnancy rate (PR). RESULT(S) The mean serum E(2) concentration on the day of hCG administration was significantly higher in the microdose GnRH-a group than in the GnRH antagonist group (1,904 vs. 1,362 pg/mL). The clinical PRs per started cycle of microdose GnRH-a and GnRH antagonist groups were 14.2% and 9.5%, respectively. There were no statistically significant differences in the other ovulation induction characteristics, fertilization and implantation rates. CONCLUSION(S) Microdose GnRH-a flare-up protocol and multiple dose GnRH antagonist protocol seem to have similar efficacy in improving treatment outcomes of poor responder patients.

Extracellularly Signal-Regulated Kinase Activity in the Human Endometrium: Possible Roles in the Pathogenesis of Endometriosis

CONTEXT Endometriosis is an estrogen-dependent disease characterized by the presence of endometrial tissue outside of the uterine cavity, causing pelvic pain and infertility in 10% of reproductive-aged women. It is unclear why ectopic endometrium remains viable in only a subset of women. ERK1/2 plays key intracellular roles in activating cellular survival and differentiation processes. OBJECTIVE We sought to determine ERK1/2 activity in patients with endometriosis and its possible roles in regulating endometrial cell survival. DESIGN ERK1/2 phosphorylation and expression throughout the menstrual cycle were evaluated in vivo in normal and endometriotic human endometrium, and in vitro techniques assessed the steroidal regulation of ERK1/2 and its effect on endometrial cell survival. RESULTS Total ERK1/2 remained constant in normal and endometriotic endometrium throughout the menstrual cycle. Phospho-ERK1/2 was high in the late proliferative and secretory phases in normal endometrium (P < 0.05). In endometriotic glandular cells, there was no cyclical variation in phospho-ERK1/2. In endometriotic stromal cells, there was also a reduction in phospho-ERK1/2 variation, with higher levels in the early-mid secretory phase (P < 0.05). In cultured endometrial stromal cells (ESCs), estrogen plus progesterone increased ERK1/2 phosphorylation within 15 min (P < 0.05). Although estrogen alone did not induce ERK1/2 phosphorylation in normal ESCs, there was a significant response to estrogen in ESCs isolated from eutopic endometriotic endometrium (P < 0.05). ERK1/2 inhibition in ESCs reduced proliferation and increased apoptosis (P < 0.05). CONCLUSION Abnormally high levels of ERK1/2 activity may be involved in endometriosis, possibly by stimulating endometrial cell survival.

The role of low-molecular-weight heparin in recurrent implantation failure: a prospective, quasi-randomized, controlled study.

Low-molecular-weight heparin did not provide any beneficial effect on pregnancy outcomes in patients with two or more implantation failures. Further trials are needed to confirm a trend in favor of low-molecular-weight heparin in the subgroup with women with three or more implantation failures.

Depot-medroxyprogesterone acetate in anticoagulated patients with previous hemorrhagic corpus luteum

Objective To investigate the safety of depot-medroxyprogesterone acetate (DMPA) in women of reproductive age with prosthetic heart valves, as well as the impact of DMPA on the prevention of hemorrhagic corpus luteum in these patients with previous bleeding events. Methods In this prospective study we enrolled 13 patients who were receiving chronic anticoagulation for prosthetic heart valves, and who suffered from ovarian bleeding. After the initial bleeding episode(s), DMPA was initiated with the intent of preventing recurrent bleeding events by means of ovulation suppression. Follow-up included close monitoring of anticoagulation intensity, lipid profile, measurement of systolic and diastolic blood pressures and weight, and a general physical and gynecological examination. Results Of the participating 13 patients, one stopped DMPA after the third injection because she wanted to have a child. Among the remaining 12 women, over a mean follow-up of 39.9 months all patients were well and no hemorrhagic corpus luteum was observed. During the follow-up, anticoagulation intensity, assessed by the international normalized ratio (INR), was in the optimum therapeutic ranges at all times (range 2.5–3.5), except for values of 4.6, 5.8 and 5.9 in three patients at 9, 12 and 24 months, respectively. With regard to lipid profile, we observed a significant decrease in high-density lipoprotein cholesterol levels at 12 months, and significant increases in total cholesterol and triglyceride levels after 30 months compared to baseline serum levels. No significant changes were observed in serum low-density lipoprotein cholesterol levels. Mean body weight was higher at months 12 and 30, compared with baseline values (p > 0.05). Conclusion DMPA, which is an effective contraceptive agent, can be used to prevent bleeding from the corpus luteum by means of ovulation suppression in anticoagulated patients with prosthetic heart valves. However, meticulous surveillance should be provided during the follow-up, including close monitoring of anticoagulation intensity and lipid profile.

Comparison of hysterosalpingography and hysteroscopy in the evaluation of the uterine cavity in patients undergoing assisted reproductive techniques

OBJECTIVE To investigate the diagnostic value of hysterosalpingography (HSG) for intracavitary and structural uterine pathologies in comparison with hysteroscopy (HS) in patients undergoing intracytoplasmic sperm injection-embryo transfer and also to specify the patients who should be subjected to HS in the early stages of an infertility work-up. DESIGN Retrospective analysis. SETTING IVF unit of a university hospital. PATIENT(S) Three hundred fifty-nine consecutive women who underwent both HSG and HS for infertility investigation. INTERVENTION(S) HS and HSG. MAIN OUTCOME MEASURE(S) HS findings. RESULT(S) HSG shows a sensitivity of 21.56%, specificity of 83.76%, positive predictive value of 55.26%, and negative predictive value of 70.75%. Its false-negative rate is 78.43%, and its false-positive rate is 16.23%. Overall agreement between the two procedures is 68.9%. The risk of abnormal HS increases with advancing patient age and duration of infertility. Risk increments associated with patient age over 35 years and increasing number of previous assisted reproductive techniques (ART) persist even in the presence of a normal HSG. As expected, we encounter significantly less abnormal HS in the male factor infertility group. CONCLUSION(S) HS should be performed especially in patients older than 35 years of age and/or with a history of two or more previous ART trials even in the presence of a normal HSG. HSG shows unconvincing diagnostic value for intracavitary and structural uterine pathologies in infertility evaluation.

OVARIAN ECTOPIC PREGNANCY AFTER INTRACYTOPLASMIC SPERM INJECTION

A ruptured primary ovarian pregnancy occurred following ovulation induction, intracytoplasmic sperm injection (ICSI) and embryo transfer (ET). The exact mechanism of ovarian pregnancy after intracytoplasmic sperm injection is unclear, but, it is possible that there may be an association between blastocyst transfer and ovarian pregnancy in infertile patients who underwent ICSI, prolonged in vitro culture and fifth day embryo transfer at blastocyst stage.

Hysteroscopic management of vaginal septum in a virginal patient with uterus didelphys and obstructed hemivagina

OBJECTIVE To report the hysteroscopic management, preserving hymen integrity, of a vaginal septum in a virginal patient with uterus didelphys and obstructed hemivagina as a short and safe alternative to the conventional method. DESIGN Case report. SETTING University hospital. PATIENT(S) A 13 year-old girl with uterus didelphys and obstructed hemivagina. INTERVENTION(S) Hysteroscopic septum resection. MAIN OUTCOME MEASURE(S) Hysteroscopic resection, preserving hymen integrity, of a vaginal septum in uterus didelphys and obstructed hemivagina in an adolescent patient. RESULT(S) The vaginal septum was resected safely in the patient, and hymen integrity was preserved. The cyclic dysmenorrhea and hematometra disappeared, and the patient was free of dysmenorrhea after 1 year of follow-up. CONCLUSION(S) Hysteroscopy, preserving hymen integrity, provides excellent visualization in adolescents and is an easy, quick, convenient, and effective tool in the management of obstructed hemivagina.

Surgical treatment in polycystic ovary syndrome

Purpose of review The purpose of this review is to provide a critical summary of current knowledge on the role and effectiveness of ovarian surgery in the treatment of polycystic ovary syndrome. Recent findings Clomiphene citrate is used as a first-line treatment for ovulation induction in infertile anovulatory patients with polycystic ovary syndrome. In clomiphene citrate-resistant women, other treatment modalities such as laparoscopic electrocautery or ovulation induction with gonadotropins have been proposed as alternative therapies. Although gonadotropin treatment and laparoscopic ovarian drilling have demonstrated similar reproductive outcomes, laparoscopic ovarian drilling has some advantages over gonadotropin treatment such as lower cost per pregnancy, improvement in menstrual regularity, and better long-term reproductive performance. On the other hand, knowledge about the pathogenesis of polycystic ovary syndrome has been growing and insulin-sensitizing drugs have gained popularity as a new treatment option. Summary According to current data, metformin has gained popularity as first-line management in clomiphene citrate-resistant women with polycystic ovary syndrome. If ovulation does not occur within several months after treatment with metformin, after the evaluation of all pros and cons related to each treatment, laparoscopic ovarian drilling or gonadotropins may be considered as an effective option according to patient choice.

Tissue Trauma in Abdominal and Laparoscopic-Assisted Vaginal Hysterectomy

STUDY OBJECTIVE To compare the degree of tissue damage between abdominal and laparoscopic-assisted hysterectomy. DESIGN Prospective, randomized, controlled study (Canadian Task Force classification I). SETTING University hospital. PATIENTS Forty-six women. INTERVENTION Laparoscopic-assisted and abdominal hysterectomy. MEASUREMENTS AND MAIN RESULTS The degree of tissue injury caused by surgical trauma was assessed by measuring plasma levels of creatine phosphokinase (CPK), C-reactive protein (CRP), lactic dehydrogenase (LDH), and CA 125 in patients undergoing laparoscopic-assisted (n = 23) and abdominal hysterectomy (n = 23). Plasma levels of CPK-MB isoenzyme were measured in order to exclude the possibility of myocardial injury. Blood samples were taken preoperatively, and on the first and second postoperative days. There was no difference in demographic characteristics between the groups. One patient in the laparotomy group and two patients in the laparoscopy group were excluded from analysis due to bladder injury, postoperative thrombophlebitis, and conversion to laparotomy because of severe adhesions. The mean operation time was longer (105.5 +/- 23.1 minutes vs 77.3 +/- 18.7 minutes, p < .001), but the duration of hospital stay was shorter (2.7 +/- 0.8 days vs 4.3 +/- 1.4 days, p < .001) and analgesic requirement was lower in the laparoscopy group compared with the abdominal group. We observed significant postoperative increases in CRP and CPK in both groups on postoperative days 1 and 2, whereas the increase in LDH was significant only in the laparotomy group on postoperative day 2. There were no significant changes in CPK-MB and CA 125. Moreover, mean plasma levels of CRP and CPK were significantly higher in the laparotomy group on postoperative days 1 and 2 than in the laparoscopy group (p < .05). CONCLUSION Surgery is a significant cause of tissue injury that can be assessed by specific enzymes and proteins. We suggest that laparoscopic surgery causes less tissue damage as assessed by lower postoperative CRP and CPK values, and that less tissue trauma related with laparoscopic surgery may account for early mobilization and reduced analgesic requirement in these patients.

Serum levels of adenosine deaminase and pregnancy-related hormones in hyperemesis gravidarum.

Abstract Objectives: We investigated the correlation between pregnancy-related hormones and serum adenosine deaminase (indicator of cellular immunity) level in women with hyperemesis gravidarum. Materials and methods: Twenty patients with hyperemesis gravidarum and 20 normal pregnancies were included in this prospective, case-control study. Serum adenosine deaminase levels, hematological parameters (white blood cells, neutrophil, monocyte and lymphocyte counts) and hormone levels (prolactin, progesterone, thyroid stimulating hormone, human chorionic gonadotropin β subunit, estradiol (E2)) were measured in all women. Interrelations of blood cell counts and hormone levels with serum adenosine deaminase levels were also investigated. Results: Serum adenosine deaminase, human chorionic gonadotropin β subunit, thyroid stimulating hormone, E2, progesterone and prolactin levels, and lymphocyte and monocyte counts in women with hyperemesis gravidarum were significantly higher than in controls but white blood cells, neutrophil, T3 and T4 levels were not different. Serum adenosine deaminase level correlated with E2, progesterone, lymphocyte, and monocyte levels for all patients. Conclusion: Elevated serum adenosine deaminase in patients with hyperemesis gravidarum may relate to high levels of E2 and progesterone.