Murat Api

Is ovarian reserve diminished after laparoscopic ovarian drilling

Background. Surgical therapy with laparoscopic ovarian ‘drilling’ (LOD) may avoid or reduce the need for gonadotrophins or may facilitate their use. However, the procedure, though effective, can be traumatic on the ovaries, which may cause postoperative adhesions and/or diminished ovarian reserve (DOR). Objective. To review the available literature, whether the LOD is harmful on the ovarian reserve markers. Search strategy. A literature search was conducted using the keywords LOD, laparoscopic ovarian diathermy, PCOS, ovarian reserve, premature ovarian failure (POF). The MEDLINE and EMBASE databases and the Cochrane Database of Systematic Reviews were searched. Selection criteria. All trials, case reports and letters to the editor in the PubMed database were included. Data collection and analysis. Along with the long-term clinical follow-up research articles, four that were specifically identifying the ovarian reserve tests were included in this review. Among these, three of them compared before and after LOD values, and one of them compared ovarian reserve markers among different groups of subjects; those with LOD, those with PCOS without LOD and those with normal ovulatory controls. Results. There were statistically significant differences between Day 3 FSH, inhibin B levels, ovarian volume and antral follicle count before and after LOD in some of the reports. Although the after LOD values were found to be lower than the before LOD values by means of ovarian reserve markers, the after values stayed higher than normal when compared with normal women without PCOS. Conclusion. Although the available data in the literature is limited, there was no concrete evidence of a DOR or POF associated with LOD in women with PCOS. Most of the changes in the ovarian reserve markers observed after LOD could be interpreted as normalisation of ovarian function rather than a reduction of ovarian reserve. LOD, if applied properly, normalises the exaggerated ovarian morphologic and endocrinologic properties.

Comment on: The effect of uterine fundal pressure on the duration of the second stage of labor: A randomized controlled trial

Objective. To determine the effect of uterine fundal pressure on shortening the second stage of labor and on the fetal outcome. Design. Randomized controlled trial. Setting. Teaching and research hospital. Sample. One hundred ninety‐seven women between 37 and 42 gestational weeks with singleton cephalic presentation admitted to the delivery unit. Methods. Random allocation into groups with or without manual fundal pressure during the second stage of labor. Main outcome measures. The primary outcome measure was the duration of the second stage of labor. Secondary outcome measures were umbilical artery pH, HCO3−, base excess, pO2, pCO2 values and the rate of instrumental delivery, severe maternal morbidity/mortality, neonatal trauma, admission to neonatal intensive care unit, and neonatal death. Results. There were no significant differences in the mean duration of the second stage of labor and secondary outcome measures except for mean pO2 which was lower and mean pCO2 which was higher in the fundal pressure group. Nevertheless, the values still remained within normal ranges and there were no neonates with an Apgar score <7 in either of the groups. Conclusion. Application of fundal pressure on a delivering woman was ineffective in shortening the second stage of labor.

Modified myocardial performance index for evaluation of fetal cardiac function in pre-eclampsia.

To assess cardiac function by means of the modified myocardial performance index (Mod‐MPI) in fetuses of pre‐eclamptic mothers without intrauterine growth restriction and to compare this with values from normal controls.

Comparison of oral nonsteroidal analgesic and intrauterine local anesthetic for pain relief in uterine fractional curettage: a randomized, double-blind, placebo-controlled trial

OBJECTIVE We sought to investigate the analgesic efficacy of oral dexketoprofen trometamol and intrauterine lidocaine in patients undergoing fractional curettage. STUDY DESIGN A randomized, double-blind, placebo-controlled trial was conducted on 111 women. Subjects were randomly assigned into 4 groups to receive either 25 mg of dexketoprofen or similar-appearing placebo tablets and either 5 mL intrauterine 2% lidocaine or saline. The main outcome measure was the intensity of pain measured by a 10-cm visual analog scale. Pain scoring was performed prior to, during, and 30 minutes after the procedure. RESULTS No statistically significant difference was found among the mean pain scores of women during the procedure in the dexketoprofen and saline, placebo and lidocaine, and dexketoprofen and lidocaine groups. The mean pain scores in all 3 groups revealed significant reduction when compared with placebo and saline combination (P = .001). CONCLUSION Administration of intrauterine lidocaine or oral dexketoprofen appears to be effective in relieving fractional curettage associated pain. However, a combination of them does not work better in further reduction of pain.

The correlation of the antral follicle count and Serum anti-mullerian hormone.

OBJECTIVE To compare the value of the basal serum anti-Müllerian hormone (AMH) level with most of the established ovarian reserve tests. MATERIAL AND METHODS A total of 141 infertile women was studied prospectively. On cycle day 3, serum levels of AMH, inhibin B, estradiol (E), FSH and LH levels were measured, and the number of early antral follicles (2-6 mm in diameter) estimated at ultrasound scanning to compare the strengths of hormonal-follicular correlations. RESULTS The mean age of the participants was 29.18±5.54. The mean AMH and total AFC on day 3 were 2.23±1.90 ng/ml and 8.35±2.83, respectively. Serum AMH levels were more tightly correlated (p<0.001) with number of the early antral follicle count (r=0.467, p<0.0001) than age and serum levels of FSH (r=-0.400, p<0.001; r=-0.299, p<0.001 respectively). No correlation was detected between serum levels of inhibin B, E2, and LH (r=0.154, p=0.06; p=0.31; r=-0.085 and r=0.067, p=0.42) and AFC. CONCLUSION Serum AMH levels showed a strong correlation with AFC, and also this correlation is stronger than the other ovarian reserve parameters.

Laparoscopic cornuotomy in the management of an advanced interstitial ectopic pregnancy: a case report

OBJECTIVE To report the successful treatment of an advanced interstitial ectopic pregnancy via laparoscopic cornuotomy following treatment failure with methotrexate (MTX). CASE A 28-year-old, gravida 3, para 0 woman with a history of successfully treated tubal pregnancy with medical therapy 2 years ago, presented with spotting bleeding and lower abdominal pain. Her initial beta-hCG level was 11706 mIU/ml and the transvaginal ultrasound examination showed an empty uterine cavity with a gestational sac 8 x 10 x 9 mm in diameter having no fetal pole or yolk sac, located just adjacent to the left uterine cornual region. She was introduced 50 mg of systemic MTX with the presumed diagnosis of interstitial pregnancy. Because the serum beta-hCG level raised to 18654 mIU/ml and a fetal pole with cardiac activity emerged on the ultrasound on the fourth day after MTX injection, laparoscopy was planned. The interstitial pregnancy was successfully treated via laparoscopic cornuotomy with the preservation of the uterus. CONCLUSION In advanced interstitial pregnancies with high hCG levels, systemic MTX therapy is expected to be ineffective. Laparoscopic cornuotomy is a minimally invasive and effective method of treatment with the advantage of preserving future fertility.

Anxiety scores before and after genetic sonogram

ObjectiveThe value of genetic sonogram is controversial in low-risk population. The aim of our study was to compare the anxiety levels among women with high risk and low risk for fetal chromosomal/structural defects.Materials and methodsA total of 115 consecutive pregnant women were included. The anxiety levels were assessed by the use of Turkish version of the standardized state-trait-anxiety-inventory. Before and after genetic sonogram, state and trait-anxiety was measured.ResultsThe mean state anxiety score before genetic sonogram was statistically, significantly higher than the mean score after the examination. Before genetic sonogram, the mean state-anxiety score of the women with high risk for fetal chromosomal/structural defects was significantly higher than the mean score of women with low risk. Following genetic sonogram, although the anxiety scores decreased, the scores of women with high risk still remained significantly higher than the scores of women with low risk and the anxiety scores significantly further increased among women with a positive minor or major ultrasound finding.ConclusionGenetic sonogram presents an anxiety-inducing situation for the parents-to-be. The level of experienced anxiety was found to be proportional to the level of the perceived risk. Women with low risk for chromosomal/structural defects experienced lower anxiety than women with high risk. Following the examination, women with a negative result were found to have a significant reduction of anxiety and emotional relief whereas a positive test result led to a further increase in anxiety scores.

Uterine fundal pressure and duration of the second stage of labor: A randomized controlled trial

We appreciate Drs. Hoogsteder and Pijnenborg’s interest in our article. However, we would like to clarify a few of their concerns regarding our study and interpretations that may derive thereof. Although the parity distribution was heterogeneous, our study was not conducted to evaluate the effect of fundal pressure on the duration of the second stage in separate groups of nulliparous or multiparous women; yet the subgroup analysis according to parity revealed no statistically significant difference between the study and control groups. Nevertheless, our study was not powered enough to assess that effect. Finally, our randomized controlled trial pointed out that fundal pressure seems to be ineffective in shortening the second stage of labor (1). We disagree with Drs. Hoogsteder and Pijnenborg’s comment related to the primary outcome of the trial. According to them, fundal pressure is mainly used to terminate the second stage, in order to prevent instrumental delivery in cases of fetal distress. It would be inappropriate to compare the effect of instrumental delivery which is recommended by many respectful authorities in prolonged second stage or suspected fetal compromise with the effect of fundal pressure in fetal distress where the specified role is understudied and still remains controversial (1–4). Until the efficacy of the fundal pressure is proven to shorten the second stage of labor, it is irrational and unethical to design such a comparative study evaluating the efficacy of instrumental delivery and uterine fundal pressure in cases of fetal distress. Since fetal distress is a serious condition, the currently indicated methods, namely cesarean section or instrumental delivery, must be applied; otherwise the consequences could be catastrophic. Although we appreciate the authors’ concern about the lack of standardization of the force used during fundal pressure in our study, the techniques described by other authors were also not fully standardized (5,6). It is very difficult to describe a standard technique because the application of such a method has a lot of variation by its nature. Neither interposed cuff nor measurement of intrauterine pressure are validated methods for standardization of fundal pressure. Due to confounders, such as fetal position, amniotic fluid volume, soft tissue, and bony structure of the pelvis and birth canal, vector of the applied pressure, abdominal location of the applicant’s hand, maternal body mass, abdominal girth, the degree of lumbar lordosis, maternal concomitant pushing-down efforts – the applied force during the fundal pressure maneuver cannot be controlled or homogenized. On the other hand, we found no differences in the rate of secondary outcomes which were severe maternal morbidity, neonatal trauma, admission to neonatal care unit, neonatal death between the study and control groups. The total number of adverse outcomes in our study was only one (admission to neonatal care unit). Furthermore, since we did not have any patient with severe perineal lacerations, we did not report the number in our article. However, we reported the rate of episiotomy (mediolateral) in our control and study groups which were 51% and 56%, respectively, with no statistically significant difference. Although Matsuo et al. described a higher incidence of severe perineal laceration in the group of fundal pressure and the risk of severe perineal laceration was synergistically increased with the concurrent use of uterine fundal pressure maneuver with vacuum extraction and episiotomy, these authors did not define if they used midline or mediolateral episiotomy in their retrospective case–control study (7). This issue is important because it is well-known that the use of midline episisotomy is much more commonly associated with severe perineal lacerations including sphincter tears (8). Additionally, we agree with the Drs. Hoogsteder and Pijnenborg’s comment that the higher incidence of severe perineal laceration in the group of fundal pressure could be a reflection of an abnormal labor instead of the use of fundal pressure itself.

Fetal retroperitoneal lipoblastoma: Ultrasonographic appearance of a rare embryonal soft tissue tumor

Lipoblastomas are rare lesions that occur almost exclusively in infants and young children [1,2]. They are primarily located in the extremities and the trunk. The other rare sites of occurance include the neck, face and abdomen. Most of the abdominal lipoblastomas are known to arise from the retroperitoneum [3]. Although there have been numerous sporadic case reports and small series of lipoblastoma in the pediatric literature, there has been no case of a prenatally diagnosed lipoblastoma or the follow-up of a fetal cystic mass confirmed postnatally as a lipoblastoma. Because of their rare occurance, nothing is known related to the antenatal sonographic features of fetal lipoblastomas. Therefore, presenting the antenatal characteristics of a lipoblastoma may raise awareness of the diagnosis and help illustrating the ultrasonographic features. Our case describes the sonographic characteristics of a lipoblastoma that was recognized as a retroperitoneal cystic mass prenatally and the definitive diagnosis was made postnatally. A 24-year-old gravida 1 woman was referred to our fetal medicine unit for second-trimester screening for fetal malformation at 20 weeks’ gestation. Her obstetric history had been uneventful so far. Her maternal serum triple screening test revealed a combined risk of 1/5659 with the values of 3.74 ng/ ml (1.63 MoM) for unconjugated estriol, 13,392 mIU/ml (0.62 MoM) for human chorionic gonadotropin (hCG), 34.9 IU/ml (0.77 MoM) for alphafeto protein (AFP). Detailed ultrasound examination (Accuson Antares with 3 and 5 MHz transducers; Siemens, Issaquah, WA) revealed a 38 mm6 32 mm, anechogenic, cystic mass having multiple septae and irregular borders occupying the right retroperitoneum and extending from the edge of the lower pole of the right kidney almost to the bladder (Figure 1). Blood flow in the tumor was unremarkable, and there was no polyhydramnios. There was no evidence of hydrops as demonstrated by the absence of ascites, pleural or pericardial effusions and placentomegaly. The growth of the fetus was normal for the gestational age and no other abnormalities were detected. The primary differential diagnosis for the retroperitoneal cystic mass included teratoma, urinoma, hemangioma and lymphangioma. Although the most probable differential was thought to be a lymphangioma based on the sonographic characteristics, we were unable to confirm the diagnosis prenatally. Amniocentesis was performed upon patient’s request and it revealed a normal female karyotype. Serial ultrasound scans performed every 4 weeks showed that the cyst size gradually enlarged to 50 mm6 42 mm at the time of delivery. During the follow-up, the fluid echogenicity did not change remarkably, it did not spread to involve any other body parts of the fetus and no hydropic changes were seen. We could not perform fetal magnetic resonance imaging (MRI) because of unavailability. The patient was scheduled for cesarean section at 38 weeks. Ultrasound examination performed on the first neonatal day confirmed the presence of the prenatally detected retroperitoneal anechoic, thin-walled,

The effects of pregnancy on the sexual life of Turkish women

Aim: To investigate the effects of pregnancy on the sexual life of Turkish women Materials and Methods: One thousand twenty six pregnant women were included in the study. The Libido Scoring System, which is a questionnaire consisting of four questions about the frequency of intercourse, the partner initiating the intercourse, orgasm and masturbation status of the pregnant women, was completed by all patients. Both prepregnancy and pregnancy sexuality was evaluated independently using this scale. Results: The frequency of sexual intercourse during pregnancy significantly decreased from 3.07/week to 2.40/week (p<0.05). The masturbation rate during pregnancy was significantly lower than the pre-pregnancy period (3.6% vs 4.9 %, p<0.001). The percentage of pregnant women who never had an orgasm was significantly higher compared to the pre-pregnant period (21.7 % vs 10.8 %, p<0.01). The rates of initiation of sexual intercourse in the pre-pregnancy period by men and by women were 94.5% (970/1026) and 5.3% (54/1026) respectively. In pregnancy period the rates of initiation of sexual intercourse by man and woman were 93.4% (904/968) and 6.6% (64/968) respectively (p=0.0001). The mean libido scores during pregnancy were statistically lower than the prepregnancy period (6.38±0.04 vs 7.31±0.04, p<0.001). Conclusion: Pregnancy has a negative effect on the sexual life of women, but more prospective studies are required to clarify the