Kemal Özerkan

Prospective assessment of the impact of endometriomas and their removal on ovarian reserve and determinants of the rate of decline in ovarian reserve

STUDY QUESTION Do the presence of endometriomas and their laparoscopic excision lead to a decrease in ovarian reserve as assessed by serum anti-Müllerian hormone (AMH) levels? SUMMARY ANSWER Both the presence and excision of endometriomas cause a significant decrease in serum AMH levels, which is sustained 6 months after surgery. WHAT IS KNOWN ALREADY No previous comparison of serum AMH levels between women with and without endometrioma has been reported. However, studies have suggested a decline in serum AMH levels 1-3 months after endometrioma excision but long-term data are needed. STUDY DESIGN, SIZE, DURATION A prospective cohort study including 30 women with endometrioma >2 cm were age matched with 30 healthy women without ovarian cysts. PARTICIPANTS/MATERIALS, SETTING, METHODS Women with endometrioma underwent laparoscopic excision with the stripping technique. Serum AMH level and antral follicle count (AFC) were determined preoperatively, 1 and 6 months after surgery. Correlation analyses were undertaken in order to identify determinants of surgery-related change in ovarian reserve. MAIN RESULTS AND THE ROLE OF CHANCE Compared with controls at baseline, women with endometrioma had lower AMH levels (4.2 ± 2.3 versus 2.8 ± 2.2 ng/ml, respectively, P = 0.02) and AFC (14.7 ± 4.1 versus 9.7 ± 4.8, respectively, P < 0.01). Serum AMH levels were further decreased 6 months after surgery (2.8 ± 2.2 versus 1.8 ± 1.3 ng/ml, P = 0.02), while AFC remained unchanged (9.7 ± 4.8 versus 10.4 ± 4.2, P = 0.63). The rate of decline in AMH was not correlated with age, laterality of endometrioma, cyst diameter or the number of primordial follicles on the surgical specimens. The preoperative serum AMH level was positively correlated with the rate of decline in serum AMH after surgery (r = 0.47, P = 0.02). LIMITATIONS, REASONS FOR CAUTION The absence of a non-treated group of women with endometriomas as a further control prevents comment on the presence of a progressive decline in ovarian reserve related to endometrioma per se. The sample size may be too small for detection of factors correlated with the extent of ovarian damage. WIDER IMPLICATIONS OF THE FINDINGS While the findings are mostly in agreement with previous studies, the present study is the first to show that the presence of endometrioma per se is associated with a decrease in ovarian reserve. The extent of surgery-related decline in ovarian reserve is not predictable using preoperative or perioperative factors. It may be prudent to measure AMH levels preoperatively and delay/avoid surgical excision as far as is possible if subsequent fertility is a concern. Additional studies are required to further investigate whether the endometrioma-related decline in ovarian reserve per se is progressive in nature and whether it exceeds the surgery-related decline. STUDY FUNDING/COMPETING INTEREST(S) This study was funded by the Research Fund of the Uludag University School of Medicine. The authors have no conflict of interest associated with this study.

GST (GSTM1, GSTT1, and GSTP1) polymorphisms in the genetic susceptibility of Turkish patients to cervical cancer

OBJECTIVE This work investigates the role of glutathione S-transferase M1 (GSTM1), glutathione S-transferase T1 (GSTT1), and glutathione S-transferase P1 (GSTP1) enzymes and polymorphisms, which are found in phase II detoxification reactions in the development of cervical cancer. METHODS This study was conducted with 46 patients diagnosed with cervical cancer and 52 people with no cancer history. Multiplex PCR methods were used to evaluate the GSTM1 and GSTT1 gene polymorphism. However, the GSTP1 (Ile105Val) gene polymorphism was studied using a PCR-RFLP method. The patient and control groups were compared using a chi-square test with p<0.05. RESULTS In the patient group, statistical significance was determined for gravidity (p=0.03), parity (p=0.01), and the number of living children (p=0.01) compared to the control group. The gene frequency of GSTM1, GSTT1, and GSTP1 polymorphisms was evaluated. We observed that GSTM1 and GSTT1 null genotype frequencies were 54.3% and 32.6% respectively, while GSTP1 (Ile/Val), (Ile/Ile), (Val/Val) genotype frequencies were 52%, 44%, and 4%, respectively, in the cervical cancer patients. No statistical variation was determined between the control and patient groups in terms of GSTM1, GSTT1, and GSTP1 polymorphisms (p>0.05). CONCLUSION Our results demonstrate that GSTT1, GSTM1, and GSTP1 polymorphisms are not associated with cervical cancer in Turkish patients.

Effect of tamoxifen on ovarian reserve: A randomized controlled assessor-blind trial in a mouse model.

OBJECTIVE To determine whether tamoxifen (TMX) exposure causes a permanent decrease in ovarian reserve. MATERIAL AND METHODS A randomized controlled assessor-blind trial including 30 adult female inbred BALB/C mice. Fifteen mice in the TMX group were given a single 0.1-mg dose of TMX intraperitoneally. Fifteen mice in the control group were given a single dose of the vehicle at the same volume intraperitoneally. Two cycles later, blood samples were collected for determination of anti-Müllerian hormone (AMH) levels, and the mice were sacrificed. After gonadectomy, ovarian size was measured, and follicles were counted under light microscopy. RESULTS Median serum AMH levels were 6.53 and 6.14 ng/ml in the control and TMX groups, respectively (p=0.03). Ovarian size was significantly decreased in the TMX group. While the number of primordial (9 vs 8), primary (6 vs 3), and secondary (4.5 vs 5) follicles were similar, there were significantly fewer preantral (11.5 vs 6, p<0.01) and antral (2 vs 1, p: 0.03) follicles, as well as corpora lutea (6 vs 3, p: 0.04), in the TMX group than in the control group. The number of atretic (2.5 vs 5, p: 0.048) follicles was increased in the TMX group. CONCLUSION Tamoxifen administration leads to arrested growth of gonadotropin-sensitive follicles, while insensitive follicles can remain unaffected. TMX is merely an endocrine disruptor, and it does not cause a decrease in primordial follicle pool.

Mannose-binding lectin levels in endometriosis

The serum concentrations of mannose-binding lectin in patients with or without endometriosis do not differ. Mannose-binding lectin could be involved in the modulation of inflammatory responses, but it does not seem to take part in endometriosis pathogenesis.

Change in the ovarian environment after hysterectomy with bilateral salpingectomy: is it the technique or surgery itself?

OBJECTIVE To compare the effects of total laparoscopic hysterectomy with bilateral salpingectomy (TLH-BS) and total abdominal hysterectomy with bilateral salpingectomy (TAH-BS) on ovarian function among women of reproductive age. STUDY DESIGN One hundred and three patients with a diagnosis of benign uterine disorder were divided into two groups in this prospective longitudinal study. Patients who had never had sexual intercourse and patients with uterovaginal disproportion underwent TAH-BS (n=57), and the remaining patients (n=46) underwent TLH-BS. Ovarian function was assessed before and 6 months after surgery; ovarian volume was assessed by gray-scale ultrasonography, and levels of serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), oestradiol (E2), anti-Mullerian hormone (AMH) and inhibin B were measured. RESULTS Postoperative serum FSH, LH and inhibin B decreased significantly in both groups. Postoperative serum E2 did not change significantly. Postoperative serum AMH and ovarian volume decreased significantly in the TAH-BS group (p=0.016 and p<0.001, respectively), but not in the TLH-BS group. Significant differences were observed between the TLH-BS and TAH-BS groups with respect to change in FSH (p=0.012) and ovarian volume (p=0.001); between-group differences were not significant for changes in AMH and inhibin B. CONCLUSIONS Although serum AMH did not change significantly in patients who underwent TLH-BS, ovarian aging commenced following both surgical procedures.

Laparoscopic Evacuation of an Early Pregnancy

STUDY OBJECTIVE Minimally invasive surgical procedures have shown significant improvement over the last 20 years. Today, nearly half of the surgeries, including oncology, are performed with minimally invasive methods. In obstetrics and gynecology surgery practice, laparoscopy can now be used in almost all operations. In this video, we performed a laparoscopic evacuation of a 12-week missed abortion case like a cesarean section at the time of bilateral salpingectomy. DESIGN A case report (Canadian Task Force classification III). SETTING A tertiary referral center in Bursa, Turkey. PATIENT A 38-year-old patient. INTERVENTION Laparoscopic evacuation of the pregnancy product (like a cesarean section) and bilateral salpingectomy. The local institutional review board approved the video. MEASUREMENTS AND MAIN RESULTS Gravida: 4, parity: 3. The patient was in the 12th week of her gestation when we diagnosed a missed abortion. In situs of the operation, there was a 12-week pregnancy filling the pouch of Douglas. We clipped the uterine arteries bilaterally and retracted the bladder flap to create a safe surgical incision in the low anterior segment of the uterus. We used the monopolar cautery to incise the uterus from superior to inferior similar to the low vertical classic uterine incision in the cesarean section. The abortus material was removed with the laparoscopic endobag, and bilateral salpingectomy was performed. CONCLUSION Developments in minimally invasive surgery are progressing day by day. As advances in laparoscopic and robotic surgery progress, complicated surgical procedures would be done efficiently.

Anatomic and Functional Outcomes of Paramesonephric Remnant-Supported Laparoscopic Double-Layer Peritoneal Pull-Down Vaginoplasty Technique in Patients with Mayer-Rokitansky-Küster-Hauser Syndrome: Uncu Modification

OBJECTIVE To describe modifications to the double-layer peritoneal pull-down laparoscopic vaginoplasty technique (Davydov operation) and evaluate anatomic and functional outcomes of the new technique, known as the Uncu modification. DESIGN Case series (Canadian Task Force classification III). SETTING Tertiary care university hospital. PATIENTS Women with Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) who underwent surgery between 2010 and 2016. INTERVENTIONS Laparoscopic double-layer peritoneal pull-down vaginoplasty with paramesonephric remnant support to the neovagina. MEASUREMENTS AND MAIN RESULTS Long-term anatomic and functional satisfaction results. Twenty-seven women with MRKHS underwent surgery with the Uncu-modified Davydov procedure. At 1 year after surgery, the mean vaginal length in these patients was 7.91 ± 1.4 cm. Among the 23 patients who had regular vaginal intercourse, the mean functional satisfaction score was 8.65 ± 1.2. One patient had a perioperative bladder injury, and another patient had a rectovaginal fistula at 3 months after the operation. One woman who did not comply with the prescribed postoperative mold exercises had complete closure of the introitus. CONCLUSION The Uncu modified laparoscopic double-layer peritoneal pull-down technique appears to be an effective and safe surgical management option that is easy to learn and perform by gynecologic surgeons.

Wilson Hastalığı Olan Gebelerin Obstetrik Sonuçları

Amac: Wilson Hastaligi bulunan annelerin gebeligine ait obstetrik sonuclari sunmak. Gerec ve Yontemler: Klinigimizde takip edilmis olan 4 gebe kadinin gecirmis oldugu toplam 6 gebelige ait kayitlar retrospektif olarak tarandi. Bu gebelerin ozellikleri, gebeliklerinin klinik seyirleri, gebeliklerinde uygulanan tedavi yontemleri ve fetal-maternal sonuclar literatur esliginde degerlendirildi. Bulgular: Gebelerin medyan yasi ve dogum anindaki medyan gebelik haftasi sirasiyla 33,5 yil (25-37) ve 19 hafta (10-38) olarak saptandi. Uc gebelik 1. trimesterde, bir gebelik 2. trimesterde ve iki gebelik de 3. trimesterde sonlandirildi. Sonlandirilma sebepleri ablasyo plasenta, akut fetal distres, missed abortus ve terapotik abortus olarak gozlendi. Tartisma ve Sonuc : Wilson hastaligi biliyer bakir atilim bozuklugu sonucu ozellikle karaciger, beyin, bobrek ve korneada toksik miktarda bakir birikmesi ile karakterize otozomal resesif genetik bir hastaliktir. Infertilite ve dusuklere neden olmaktadir. Wilson hastaligi gebelikte komplikasyonlarla seyredebilen bir hastaliktir. Maternal ve fetal komplikasyonlari en aza indirmek icin hastalar tedavi ve takipleri acisindan yakin gozlem altinda bulundurulmalidir.