E Turkgeldi

Short and long term outcomes of children conceived with assisted reproductive technology

Despite their wide and global use, possible short and long-term effects of fertility treatments on children is not well-established. In this review, birth defects and perinatal complications and their relationship with assisted reproductive technology (ART), along with long-term effects of ART on cardiovascular system, metabolism, behavior, cognitive skills, and childhood cancers are discussed. Children conceived through ART are at increased risk for birth defects and perinatal complications such as preterm delivery, low birth weight and small for gestational age. Parental characteristics, underlying infertility etiology and ART procedures themselves may contribute to this. The long-term effects of ART are difficult to establish. Studies so far report that ART children have normal social, emotional, cognitive, and motor functions. Likewise, despite some minor inconsistencies in some studies, they do not seem to be at increased risk for childhood cancers. However, there are a number of studies that imply vascular system may be adversely affected by ART and its possible consequences should be further investigated with follow up studies. Large scale studies with long-term follow up periods are required to determine the effects of ART on conceived children.

Do endometriomas grow during ovarian stimulation for assisted reproduction? A three-dimensional volume analysis before and after ovarian stimulation

Whether endometriomas grow because of supraphysiological oestradiol levels attained during ovarian stimulation for assisted reproduction techniques is a concern. In this prospective study, 25 women with 28 endometriomas underwent three-dimensional ultrasound using sono-automated volume calculation software. Endometrioma volume was measured on the first day of gonadotrophin injection (V1) and the day of ovulation trigger (V2). Nine (36%) women were stimulated in a gonadotrophin releasing hormone antagonist protocol (GnRH), 13 (52%) in a long, and three (12%) in an ultra-long GnRH agonist protocol. Mean duration of stimulation was 10.3 days with median total gonadotrophin dose of 4500 IU/day. Median number of cumulus oocyte complexes was five, and metaphase-two oocytes was four. None of the endometriomas were punctured during oocyte retrieval. Median V1 was 22.2 ml (12-30 ml) and median V2 was 24.99 ml (11.2-37.4 ml) with P = 0.001. Twenty-three out of 28 endometriomas (82%) grew to some extent during ovarian stimulation. Endometrioma growth was positively correlated with prestimulation cyst volume (Correlation coefficient 0.664; P < 0.01). Although the 3-ml average growth was statistically significant, it could be regarded as clinically insignificant.

Use of a gelatin-thrombin hemostatic matrix in obstetrics and gynecological surgery

Gelatin-thrombin matrix (GTM) is a hemostatic sealant consisting of bovine-derived gelatin matrix and human-derived thrombin, combining both mechanical and active mechanisms to achieve hemostasis. It was approved by the Food and Drug Administration in 1999. GTM has been used by several surgical specialties; however, it is a possibly an under-used tool in obstetrics and gynecology. A limited number of studies have been performed on its use during laparoscopic endometrioma excision and myomectomy. It may prove useful in endometrioma excision in reproductive aged women because it is likely to harm ovarian reserve less than electrocautery; however, this conclusion needs to be validated. The only study on GTM use in myomectomy included 50 women randomized into GTM and control groups, and showed decreased blood loss and shorter hospital stays in the GTM group. In gynecologic oncology, it was successfully used to reduce lymphocele cases in a cohort study. GTM has been used successfully in obstetrics in a handful of cases of uncontrolled bleeding from caesarean scar, placental site, ectopic pregnancy, rectovaginal hematoma, and venous plexus over the vaginal vault after emergency postpartum hysterectomy. Risk of viral transmission is a major concern about GTM, yet there are no reports on disease transmission with GTM use to date. Rare but serious adverse effects and complications have been reported such as fatal or near-fatal thromboembolism and small bowel obstruction. Although GTM is mostly a safe product, it is still not free of complications and risks. In conclusion, although routine use of GTM cannot be recommended due to concerns about its safety, cost, and availability, it may prove useful when conventional hemostatic methods such as suturing and electrocauterization fail or are not appropriate.

Ultrasound Monitoring of Ovarian Stimulation

Ovarian stimulation (OS) is an umbrella term covering (i) induction of monofollicular growth in anovulatory women, i.e., ovulation induction (OI), and (ii) induction of multifollicular growth for intrauterine insemination, sometimes referred to as superovulation, or for in vitro fertilization (IVF), i.e., controlled ovarian stimulation (COS). OI and COS differ in the desired number of growing follicles. While the goal of OI is to grow up to three dominant follicles, conventional COS aims to enable the collection of 10–15 mature oocytes for IVF.

Gonadotropin-releasing hormone agonist triggering of oocyte maturation in assisted reproductive technology cycles

Gonadotropin-releasing hormone agonists (GnRHa) have gained increasing attention in the last decade as an alternative trigger for oocyte maturation in patients at high risk for ovarian hyperstimulation syndrome (OHSS). They provide a short luteinizing hormone (LH) peak that limits the production of vascular endothelial growth factor, which is the key mediator leading to increased vascular permeability, the hallmark of OHSS. Initial studies showed similar oocyte yield and embryo quality compared with conventional human chorionic gonadotropin (hCG) triggering; however, lower pregnancy rates and higher miscarriage rates were alarming in GnRHa triggered groups. Therefore, two approaches have been implemented to rescue the luteal phase in fresh transfers. Intensive luteal phase support (iLPS) involves administiration of high doses of progesterone and estrogen and active patient monitoring. iLPS has been shown to provide satisfactory fertilization and clinical pregnancy rates, and to be especially useful in patients with high endogenous LH levels, such as in polycystic ovary syndrome. The other method for luteal phase rescue is low-dose hCG administiration 35 hours after GnRHa trigger. Likewise, this method results in statistically similar ongoing pregnancy rates (although slightly lower than) to those of hCG triggered cycles. GnRHa triggering decreased OHSS rates dramatically, however, none of the rescue methods prevent OHSS totally. Cases were reported even in patients who underwent cryopreservation and did not receive hCG. GnRH triggering induces a follicle stimulating hormone (FSH) surge, similar to natural cycles. Its possible benefits have been investigated and dual triggering, GnRHa trigger accompanied by a simultaneous low-dose hCG injection, has produced promising results that urge further exploration. Last of all, GnRHa triggering is useful in fertility preservation cycles in patients with hormone sensitive tumors. In conclusion, GnRHa triggering accompanied by appropriate luteal phase rescue protocols is a relatively safe option for patients at high risk for OHSS.

Laparoscopic Removal of Bladder From the Uterine Niche With Retrograde Dissection

Videolaparoscopy citorreduction with debulking limphadenectomy in a Fallopian tube cancer patient. We present the case of a fifity-seven years old woman who underwent to non-oncologic hysterectomy with bilateral salpingoophoretomy, in another medical service, with the diagnosis of Fallopian tube serous adenocarcinoma. Postoperative TC showed a conglomerate retroperitoneal lymph node mass of 4.3 by 3.6 cm. So, we performed a videolaparoscopy cytorreduction wich included omentectomy and debulking limphadenectomy. The video shows the debulking time which was laboured and demanded extremely delicate movements. We change the laparoscopic instruments and energy several times to achieve the best way to overcome challenges safety. The total procedure time was 7 hours and blood loss was 200cc. About the patological report, 6 of 31 retroperitoneal nodes was positive for adenocarcinoma. At he present time, patient is on chemotherapy, on the third cycle of carboplatin and paclitaxel.