Pinar Ozcan Cenksoy

The importance of the length of uterine cavity, the position of the tip of the inner catheter and the distance between the fundal endometrial surface and the air bubbles as determinants of the pregnancy rate in IVF cycles.

OBJECTIVE To evaluate the relationship between the pregnancy rate (PR) and the positioning of the intrauterine catheter at embryo transfer (ET) under transabdominal ultrasound (US) guidance in in vitro fertilization (IVF) cycles. STUDY DESIGN Prospective data analysis of 281 consecutive US-guided fresh ETs performed by a single physician at Yeditepe University Hospital IVF Center, Istanbul, Turkey, after controlled ovarian hyperstimulation between April 2012 and March 2013. The length of the uterine cavity (A), the distance between the fundal endometrial surface and the tip of inner catheter (B), the distance between the fundal endometrial surface and the air bubbles (C), and the pregnancy rates (PRs) were recorded. RESULTS The mean age of the patients was 33.25±5.5 years. Of all transfers, 115 (40.9%) resulted in a clinical pregnancy. With regard to distance (C), the clinical intrauterine pregnancy rates were 65.2%, 32.2% and 2.6% in the <10mm, 10-20mm, and 20mm distance groups, respectively. The PR was dramatically reduced in cases with >10mm between the fundal endometrial surface and the air bubbles, although this did not reach statistical significance. Between those patients who conceived and those who did not, there was no significant difference in terms of the distance between the fundal endometrial surface and the tip of inner catheter, the ratio of A/B or the ratio of B/C. CONCLUSIONS The final position of the air bubble used as an identifier of the position of the embryo at ET can be determinative for PR, although it cannot be predicted. Clinical pregnancy rates appeared higher in cases with air bubbles closer to the fundus and the optimal position of the air bubble seems to be a distance of <10mm from the fundal endometrial surface. It could be advisable to monitor the final position of air bubble at ET for identifying PR. In addition, the depth of uterine cavity may be considered to indirectly be important factor as it affects ET depth. The optimal distance between the fundal endometrial surface and the tip of inner catheter is 1.5-2cm. Further well-designed randomized controlled trials are required to optimize ET technique in the future.

Which cut-off value of serum anti-Müllerian hormone level can predict poor ovarian reserve, poor ovarian response to stimulation and in vitro fertilization success? A prospective data analysis

Abstract The aim of our study is to demonstrate which cut-off value of serum anti-Müllerian hormone (AMH) level can predict poor ovarian reserve, poor ovarian response to stimulation and IVF outcomes. About 311 of 520 women enrolled IVF treatment cycle that meets inclusion criteria were recruited for this prospective data analysis. Data were collected for: age, duration of infertility, basal FSH and AMH level, total dosage of gonadotropins, maximum estradiol levels, duration of stimulations, total number of oocytes retrieved and clinical PR. Mean AMH was 1.76 ± 1.4 ng/ml and mean age was 33.25 ± 5.5 years. Clinical PR was 39.8% (n = 124). AMH was inversely correlated to total dosage of gonadotropins and age, AMH positively had a significant correlation with maximum estradiol levels, duration of stimulations and total number of oocytes retrieved. The patients in both categories of AMH levels, ≤0.5 and ≤1 ng/ml responded poorly to ovarian stimulation, had significantly higher total dosage of gonadotropins used and FSH levels on cycle day 3, lower maximum E2 levels and clinical PR. AMH could be an acceptable screening test in prediction of ovarian reserve, response to ovarian stimulation and PRs. AMH cut-off value ≤1 ng/ml may predict poor ovarian reserve, poor ovarian response to stimulation and IVF outcomes.

A potential novel treatment strategy: inhibition of angiogenesis and inflammation by resveratrol for regression of endometriosis in an experimental rat model

Abstract The aim of our study was to evaluate the effectiveness of resveratrol in experimentally induced endometrial implants in rats through inhibiting angiogenesis and inflammation. Endometrial implants were surgically induced in 24 female Wistar–Albino rats in the first surgery. After confirmation of endometriotic foci in the second surgery, the rats were divided into resveratrol (seven rats), leuprolide acetate (eight rats), and control (seven rats) groups and medicated for 21 d. In the third surgery, the measurements of mean areas and histopathological analysis of endometriotic lesions, VEGF, and MCP-1 measurements in blood and peritoneal fluid samples, and immunohistochemical staining were evaluated. After treatment, significant reductions in mean areas of implants (p < 0.01) and decreased mean histopathological scores of the implants (p < 0.05), mean VEGF-staining scores of endometriotic implants (p = 0.01), and peritoneal fluid levels of VEGF and MCP-1 (p < 0.01, for VEGF and p < 0.01, for MCP-1) were found in the resveratrol and leuprolide acetate groups. Serum VEGF (p = 0.05) and MCP-1 (p = 0.01) levels after treatment were also significantly lower in the resveratrol and leuprolide acetate groups. Resveratrol appears to be a potential novel therapeutic agent in the treatment of endometriosis through inhibiting angiogenesis and inflammation. Further studies are needed to determine the optimum effective dose in humans and to evaluate other effects on reproductive physiology.

Practice of Embryo Transfer: Recommendations During and After

Many patient and embryo factors influence the outcome of assisted reproductive technology (ART) treatment. The predictors for a successful ART cycle include female age, ovarian reserve, embryo quality, endometrial receptivity, and embryo transfer (ET) technique. ET, the final step of ART, has recently been noted as a crucial step affecting ART success. Variables affecting pregnancy rates following ET include ultrasound guidance, ease of ET transfer, catheter type, transfer and catheter-loading technique, blood or mucus effects, retained embryos, trial transfer, the physicians experience, and catheter tip placement. Despite the lack of consensus regarding the optimal ET technique, it is generally recommended that during ET, the disruption of the endometrium and the induction of uterine contractions should be avoided. The exposure of embryos to the ambient conditions should be minimized, and the embryo(s) should be placed at an optimal position within the fundal region of the uterine cavity.

The comparision of effect of microdose GnRH-a flare-up, GnRH antagonist/aromatase inhibitor letrozole and GnRH antagonist/clomiphene citrate protocols on IVF outcomes in poor responder patients.

Abstract Purpose: To compare the effects of microdose GnRH-a flare-up, GnRH antagonist/aromatase inhibitor letrozole and GnRH antagonist/clomiphene citrate protocols on IVF outcomes in poor responder patients. Methods: Of 225 patients, 83 patients were in microdose flare-up group (Group 1), 70 patients were in GnRH antagonist/letrozole group (Group 2) and 72 patients were in GnRH antagonist/clomiphene citrate group (Group 3). Demographic and endocrine characteristics, the total number of oocytes retrieved, cancellation rate and clinical pregnancy rate were collected Results: Total dosage of gonadotropins (p = 0.002) and serum E2 levels on the day of hCG administration (p = 0.010) were significantly higher and duration of stimulations (p = 0.03) was significantly longer in group 1. The number of oocytes retrieved was significantly greater in group 1 and 2 when compare to those of group 3 (p = 0,000). There was a trend towards increasing cycle cancellation rates with GnRH antagonist/clomiphene citrate and GnRH antagonist/letrozole. Conclusion: Our finding suggest that the results of microdose flare-up protocol are better than other two used treatment protocols, in terms of maximum estradiol levels, number of mature oocytes retrieved, and cancellation rate and it still seems to be superior the ovarian stimulation regime for the poor responder patients.

Parietal peritoneal closure versus non-closure at caesarean section: which technique is feasible to perform?

Abstract Objective: To evaluate short-term effects of closure versus non-closure of the parietal peritoneum at caesarean section. Methods: A randomized controlled study of women undergoing caesarean section was conducted at the obstetrics department of a research and education hospital between October 2010 and May 2011. Patients were randomly assigned to have closure of parietal peritoneal layer (Group I, n = 55), and non-closure of parietal peritoneal layer (Control, Group II, n = 55). Intra-operative and post-operative outcomes were compared between the groups. Results: Groups were similar for baseline characteristics. Although there was statistically significant difference between Group 1 and Group 2 in terms of time to oral intake and mobilization time [12 (8–12) versus 8 (8–10) h; p < 0.001; 12 (8–12) versus 8 (8–10) h; p < 0.001]; the other variables, such as drop in hemoglobin concentration, estimate of blood loss, intra-operative additional sutures, operating time and time to passage of flatus [1.13 ± 0.86 versus 1.41 ± 0.82 g/dL; 487.9 ± 217.01 versus 544.87 ± 237.64 mL; 0 (0–1) versus 0 (0–1); 30.8 ± 7.63 versus 31.6 ± 10.38 h; 18.2 ± 6.04 versus 18.2 ± 4.23 h, p > 0.05] were not statistically different between Group 1 and Group 2. Conclusions: Closure of the parietal peritoneum has no benefit over non-closure of parietal peritoneum and non-closure is associated with rapid post-operative recovery.

Perioperative low-dose ketamine improves postoperative analgesia following Cesarean delivery with general anesthesia

Abstract Objective: In this study, the effect of perioperative uses of low dose ketamine on post-operative wound pain and analgesic consumption in patients undergoing elective Cesarean section was evaluated. Methods: In randomized, double blind clinical trial, 52 women with American Society of Anesthesiologists (ASA) class I-II identification undergoing elective Cesarean section in general anesthesia were enrolled. In the ketamine group (group K), a ketamine bolus of 0.5 mg kg−1 IV was administered at the time of induction of general anesthesia. After induction, a ketamine infusion of 0.25 mg kg−1 h−1 was started and discontinued at the end of surgery. Patients allocated to the control group (group C) were given identical volumes of saline. The cumulative dose of morphine consumption after surgery was measured as the primary outcome of this study. Secondary outcomes were pain control assessed by numeric rating scale (NRS) and need for rescue analgesia and incidence of side effects. Results: The mean 24-h morphine consumption was lower in group K (p = 0,001). At 15 min postoperatively, NRS values were lower in group K than group C (p = 0,001). There was no difference among groups regarding the need for supplemental analgesia (rescue diclofenac doses) (p > 0.05). Conclusions: Perioperative uses of low dose ketamine decreased post-operative opioid requirements, which was observed long after the normal expected duration of ketamine.

The Diagnosis and Management of Asherman's Syndrome Developed after Cesarean Section and Reproductive Outcome

Intrauterine adhesions (IUAs) frequently occur as a result of trauma to the basal layer of endometrium following pregnancy-related curettage such as incomplete abortion (33,3%), postpartum hemorrhage (37,5%), and elective abortion (8,3%). Hysterotomy, myomectomy, Cesarean section, hysteroscopic procedures, such as resection of submucosal leiomyomata or uterine septae, and endometrial ablation are less common etiologic factors resulting in IUA formation. Patients with Ashermans syndrome usually present with menstrual disturbances, infertility, or recurrent pregnancy loss. A successful treatment of infertility could be achieved by restoration of the uterine cavity, prevention of IUA reformation, and promotion of healing process. We presented the diagnosis and management of a case that suffers from menstrual disturbances and secondary infertility resulted from IUA formation developed after Cesarean section.