Munire Erman Akar

Fertility Preservation in Breast Cancer Patients: A Prospective Controlled Comparison of Ovarian Stimulation With Tamoxifen and Letrozole for Embryo Cryopreservation

Purpose To develop safe ovarian stimulation methods to perform in vitro fertilization (IVF) in breast cancer patients who wish to preserve their fertility via embryo cryopreservation before chemotherapy. Patients and Methods Sixty women (age range, 24 to 43 years) with breast cancer were prospectively studied. Twenty-nine patients underwent 33 ovarian stimulation cycles with either tamoxifen 60 mg/d alone (Tam-IVF) or in combination with low-dose follicle-stimulating hormone (TamFSH-IVF) or letrozole 5 mg in combination with FSH (Letrozole-IVF). After IVF, all resultant embryos were cryopreserved to preserve fertility. Recurrence rates were compared with controls (n 31) who elected not to undergo IVF. Results Compared with Tam-IVF, both TamFSH-IVF and Letrozole-IVF patients had greater numbers of follicles (2 0.3 v 6 1 and 7.8 0.9, respectively; P .0001), mature oocytes (1.5 0.3 v 5.1 1.1 and 8.5 1.6, respectively; P .001), and embryos (1.3 0.2 v 3.8 0.8 and 5.3 0.8, respectively; P .001). Peak estradiol (E2) levels were lower with Letrozole-IVF and Tam-IVF compared with TamFSH-IVF. After 554 31 days (range, 153 to 1,441 days) of follow-up, cancer recurrence rate was similar between IVF and control patients (three of 29 v three of 31 patients, respectively; hazard ratio, 1.5; 95% CI, 0.29 to 7.4), and this estimate was not affected by cancer stage. Conclusion The combination of low-dose FSH with tamoxifen (TamFSH-IVF) or letrozole (Letrozole-IVF) results in higher embryo yield compared with Tam-IVF. Recurrence rates do not seem to be increased, but the letrozole protocol may be preferred because it results in lower peak E2 levels.

Preliminary results of the first human uterus transplantation from a multiorgan donor

OBJECTIVE To describe the first-year results of the first human uterus transplantation case from a multiorgan donor. DESIGN Case study. SETTING University hospital. PATIENT(S) A 21-year-old woman with complete müllerian agenesis who had been previously operated on for vaginal reconstruction. INTERVENTION(S) Uterus transplantation procedure consisting of orthotopic replacement and fixation of the retrieved uterus, revascularization, end to site anastomoses of bilateral hypogastric arteries and veins to bilateral external iliac arteries and veins was performed. MAIN OUTCOME MEASURE(S) Resumption of menstrual cycles. RESULT(S) The patient had menarche 20 days after transplant surgery. She has had 12 menstrual cycles since the operation. CONCLUSION(S) We have described the longest-lived transplanted human uterus to date with acquirement of menstrual cycles.

Clinical pregnancy after uterus transplantation

OBJECTIVE To present the first clinical pregnancy after uterus transplantation. DESIGN Case study. SETTING Tertiary center. PATIENT(S) A 23-year-old Mayer-Rokitansky-Kuster-Hauser syndrome patient with previous vaginal reconstruction and uterus transplantation. INTERVENTION(S) Eighteen months after the transplant, the endometrium was prepared for transfer of the thawed embryos. MAIN OUTCOME MEASURE(S) Implantation of embryo in an allografted human uterus. RESULT(S) The first ET cycle with one day 3 thawed embryo resulted in a biochemical pregnancy. The second ET cycle resulted in a clinical pregnancy confirmed with transvaginal ultrasound visualization of an intrauterine gestational sac with decidualization. CONCLUSION(S) We have presented the first clinical pregnancy in a patient with absolute uterine infertility after uterus allotransplantation. Although the real success is the delivery of a healthy near-term baby, this clinical pregnancy is a great step forward and a proof of concept that the implantation phase works.

Reproductive outcome of women with unicornuate uterus

This study was undertaken to examine the reproductive impact of unicornuate uterine abnormalities cases in a group of 571 women with a uterine anomaly. Hospital records of 1784 patients who presented to the infertility outpatient clinic with infertility, recurrent pregnancy loss, pain or acute abdomen during the study period between January 1991 and January 2001, were reviewed retrospectively. The reproductive performance of women with unicornuate uterus was poor, with a live birth rate of only 29.2%, prematurity rate of 44%, miscarriage rate of 29%, and an ectopic pregnancy rate of 4%.

Effect of Pregnancy on Intraobserver and Intertechnique Agreement in Intraocular Pressure Measurements

Aim: To evaluate the effect of pregnancy on intraobserver and intertechnique agreement for intraocular pressure (IOP) measurements. Material and Methods: Right eyes of 88 healthy women who were likely to become pregnant and of 94 healthy age-matched females were included in the study. Complete ocular examinations were performed on each eye. IOP measurements were obtained by Goldmann, Schiötz and non-contact tonometers (NCT) during 3-week exam periods before (within 6 weeks of conception) and during pregnancy (first, second and third trimesters) for pregnant cases, and in similar time intervals for control subjects. In each exam period, three readings with each of three separate tonometers were obtained, at least 1 day apart. Intraobserver and intertechnique agreements for IOP measurements were assessed. Results: The mean visual acuity, keratometry and refractive error of both control and pregnant subjects did not change significantly during the study (all p values >0.01). In late pregnancy, pregnant cases demonstrated significant decreases in IOP measurements obtained with each of the three tonometers, and in intraobserver agreement with Goldmann and Schiötz tonometers (all p values <0.01). Intertechnique agreement of both Goldmann and Schiötz tonometers with NCT decreased significantly in the third trimester. Both intraobserver and intertechnique agreement in IOP measurements of control subjects were not found to change significantly during the study (all p values >0.01). Conclusion: IOP significantly decreased in the third trimester of pregnancy. Perfect intraobserver agreement in IOP readings of pregnant subjects was obtained with NCT. This may suggest that NCT is a viable option for IOP measurements during the follow-up of pregnant patients at risk for glaucoma.

Uterus transplantation from a deceased donor

OBJECTIVE To demonstrate the technique for uterus retrieval and transplantation from a multiorgan donor. DESIGN Video presentation of our case report. The video uses animation to demonstrate the technique. Institutional Review Board (IRB) approval was obtained. SETTING University hospital. PATIENT(S) A 21-year-old woman with complete müllerian agenesis. INTERVENTION(S) Uterus allotransplantation has been performed from a deceased donor. MAIN OUTCOME MEASURE(S) Acquirement of cyclic menstrual function. RESULT(S) This video demonstrates the technique for uterus retrieval, perfusion, and transplantation. The recipient patient has been monitored regularly for vascular flow, immunosuppression, and infection control since the operation. CONCLUSION(S) Uterus transplantation requires extensive evaluation of the recipient and donor by an experienced multidisciplinary transplantation team both pre- and postoperatively. It has major risks related to surgery, immunosuppression, and pregnancy. Uterus transplantation might be considered promising only after the birth of a near-term healthy baby.

Menstrual Cycle-Dependent Changes in Visual Field Analysis of Healthy Women

Purpose: To determine the effect of menstrual cycle phases on the visual field analysis of healthy females. Material and Methods: One randomly selected eye each of 59 healthy normally menstruating women, and of 54 men with no systemic and ocular problems, other than refractive error, were included in the study. Subjects underwent complete ocular examination, and standard achromatic perimetric (SAP) and short-wavelength automated perimetric (SWAP) analysis in both follicular (7th to 10th day of the cycle) and luteal phases (days 3–7 before the menstrual bleeding) of the menstrual cycle. Visual field analysis was performed using a Model 750 Humphrey Field Analyzer II (Humphrey Instruments Inc., San Leandro, Calif., USA) with full-threshold, central 30-2 program. Visual fields were divided into four regions as superior temporal, inferior temporal, superior nasal and inferior nasal, respectively. Results: The mean age of female (n = 59) and the male subjects (n = 54) were 34.6 ± 2.9 and 35.0 ± 2.7 years, respectively (p = 0.49). SWAP tests demonstrated a significantly decreased mean MS value in the luteal phase (p < 0.05). However, it did not change significantly with SAP tests. Regional MS values of both SAP and SWAP tests were not different in both phases of the menstrual cycle (all p values >0.05). Mean perimetric test durations obtained with both SAP and SWAP were not different throughout the menstrual cycle (both p values >0.05). Conclusion: Clinicians should verify menstrual status when evaluating a suspected loss of visual field sensitivity in menstruating women. The findings of the present study suggest that the SWAP test may be more sensitive to determine subtle sex hormone-dependent changes in visual field analysis of healthy women.

Effect of the menstrual cycle on standard achromatic and blue-on-yellow visual field analysis of women with migraine

BACKGROUND It has been postulated that migraine and glaucoma may have common vascular causative factors. Significant sex-based differences in the incidence of many important ocular conditions raise the possibility that estrogens may have direct effects on the eye. We performed a study to determine the effect of the menstrual cycle on standard achromatic automated perimetry (SAP) and short-wavelength automated perimetry (SWAP) (blue-on-yellow perimetry) of women with migraine. METHODS Both eyes of 73 normally menstruating women (31 subjects with migraine and 42 healthy control subjects) were included in the study. Subjects underwent a complete ocular examination including SAP and SWAP in both the follicular phase (12th to 13th day of the cycle) and the luteal phase (1 to 2 days before the onset of bleeding) of two consecutive menstrual cycles.We performed visual field analysis using the Humphrey Field Analyzer II with the full-threshold central 30-2 program. Mean sensitivity was calculated for the superior temporal, inferior temporal, superior nasal and inferior nasal regions separately. RESULTS Thirteen subjects were lost to follow-up (5 in the migraine group and 8 in the control group), leaving 26 subjects and 34 subjects respectively. There was no significant difference in mean age between the two groups (33.9 years [standard deviation (SD) 3.4 years] vs. 35.1 years [SD 3.3 years]). The mean duration of migraine was 7.6 (SD 3.1) years (range 3-14 years). In both groups, serum estradiol levels were significantly lower (p = 0.001) and serum progesterone levels were significantly higher (p < 0.001) in the luteal phase than in the follicular phase. In the control group, the mean sensitivity values with SWAP were significantly lower in the luteal phase than in the follicular phase (p = 0.04). A similar decrease was observed for the subjects with migraine with both SAP and SWAP (p = 0.01). There was no difference in regional mean sensitivity between the two phases with either perimetric test in the control group. For the subjects with migraine, there was no difference in regional mean sensitivity between the two phases with SAP. However, with SWAP, the mean sensitivity for the nasal visual field locations was significantly lower in the luteal phase than in the follicular phase (p = 0.01). INTERPRETATION Our study provides further evidence of an effect of sex hormones on the visual field of women with migraine. In addition to assessment of intraocular pressure, menstrual cycle phases should be considered in women with migraine at risk for glaucomatous optic neuropathy.

Restoration of ovarian endocrine function by ovarian transplantation

Cancer treatment can cause changes in sex hormone production, premature ovarian failure and infertility. As survival rates for young cancer patients improve, protection against iatrogenic infertility caused by chemotherapy or radiotherapy assumes a higher priority.

The use of vascularized jejunum flap for vaginal reconstruction: Clinical experience and results in 22 patients

The ideal reconstructive method for a vagina should provide a durable, stable coverage, a patent tube passage for sexual intercourse, and a natural esthetic contour, while simultaneously minimizing morbidity in both the recipient and donor sites, and should be a single stage procedure obviating the use of stents, obturators, and lubrication. Twenty‐two patients with absence of the vagina underwent vaginal reconstruction using the jejunal segment transfer technique. Two flaps required re‐operation due to venous compromise postoperatively. The flaps were salvaged with venous anastomosis revisions. The overall flap success rate was thus 100%. No urinary tract or gastrointestinal system complication was observed in any case, nor any instance of vaginal introitus. The average follow‐up period was 19 months (between 3 and 48 months). Both the depth and diameter of the neovagina were satisfactory postoperatively. After the immediate postoperative period, the only major and embarrassing problem was hypersecretion of the jejunal segment, but this gradually diminished, especially after the first 3 months. Those patients who engaged in sexual intercourse reported good patency and had no complaints in that regard. In conclusion with its evident advantages, the jejunal segment can serve as a reliable option for vaginal reconstruction. It provides quite satisfactory results from both the cosmetic and functional points of view.