Recai Pabuccu

Efficiency and pregnancy outcome of serial intrauterine device-guided hysteroscopic adhesiolysis of intrauterine synechiae.

OBJECTIVE To highlight the efficiency of intrauterine device (IUD) guidance during hysteroscopic adhesiolysis for severe intrauterine adhesions. DESIGN A prospective, randomized trial. SETTING Private tertiary and referral infertility clinic. PATIENT(S) Seventy-one subfertile patients who underwent hysteroscopic treatment of intrauterine synechiae or adhesions. INTERVENTION(S) Thirty-six women in group 1 were initially examined by laparoscopy-hysteroscopy at first look, and an IUD was inserted during hysteroscopic adhesiolysis. The adhesions were further lysed by the guidance of IUD during the second-look office hysteroscopy, 1 week later. Patients were prescribed 2 months of estrogen as well as P therapy, and the IUD was removed by the end of this period. The uterine cavity was evaluated, and adhesions were further lysed by a third-look office hysteroscopy, 1 week after the removal of IUD. Thirty-five women in group 2 were similarly examined by first-look office hysteroscopy, and an IUD was inserted during hysteroscopic adhesiolysis. These patients did not undergo early intervention of office hysteroscopy, 1 week after the first procedure. They also used 2 months of estrogen and P therapy. The IUD was removed by the end of this period, and the uterine cavity was evaluated and adhesions were further lysed during a second-look office hysteroscopy. MAIN OUTCOME MEASURE(S) Pregnancy rate and live birth rate. RESULT(S) Spontaneous pregnancy rates after treatment were 17/36 (47.2%) and 11/35 (30%), and live birth rates were 10/36 (28%) and 7/35 (20%) in groups 1 and 2, respectively. These differences between the two groups were not statistically significant. CONCLUSION(S) The method described especially for early intervention may prevent complications during the treatment of severe intrauterine adhesions and may present a secure and effective alternative for constructive clinical outcomes.

Plasma interleukin-18 levels are increased in the polycystic ovary syndrome: relationship of carotid intima-media wall thickness and cardiovascular risk factors

OBJECTIVE To determine serum interleukin (IL)-18 levels and to find out whether IL-18 is associated with carotid intima-media wall thickness (IMT) and various cardiovascular risk factors in women with polycystic ovary syndrome (PCOS). DESIGN A prospective, controlled study. SETTING University hospital. PATIENT(S) Sixty women with PCOS and 60 healthy women were included this study. INTERVENTION(S) Serum levels IL-18, homocysteine (Hcy), C-reactive protein (CRP), IL-6, malonyldialdehyde (MDA), lipid and hormone profiles were measured. Carotid IMT was evaluated for both common carotid arteries. MAIN OUTCOME MEASURE(S) Serum IL-18, carotid IMT, Hcy, CRP, IL-6, MDA, and homeostasis model assessment of insulin resistance. RESULT(S) The evaluation, which was made without the obesity influence taken into consideration, revealed that patients with PCOS have increased serum IL-18 levels than that of the control group (214 +/- 102 vs. 170 +/- 78 pg/mL). The interaction between PCOS and obesity was seen to have statistical significance (F = 67.8). Body mass index (BMI), waist to-hip ratio, Hcy, and homeostasis model assessment of insulin resistance are independent determinants of plasma IL-18 in patients with PCOS. Elevated serum IL-18 levels were positively and significantly correlated with a greater carotid IMT. For Hcy and carotid IMT, the interaction between PCOS and obesity was found in a two-way ANOVA variation analysis (F = 48.5 and F = 81.5, respectively). CONCLUSION(S) Elevated serum IL-18 levels were associated with cardiovascular risk factors and carotid IMT in patients with PCOS.

Serum antimüllerian hormone concentrations on day 3 of the in vitro fertilization stimulation cycle are predictive of the fertilization, implantation, and pregnancy in polycystic ovary syndrome patients undergoing assisted reproduction

OBJECTIVE To determine the possible relationship between serum antimüllerian hormone (AMH) concentrations on day 3 and controlled ovarian stimulation and reproductive outcomes in women with polycystic ovary syndrome. DESIGN Prospective, clinical trial. SETTING University hospital. PATIENT(S) Sixty women with PCOS. INTERVENTION(S) Serum concentrations of AMH measured on cycle day 3. MAIN OUTCOME MEASURE(S) Clinic pregnancy rate (CPR), implantation rate (IR), and fertilization rate (FR). RESULT(S) The CPR, IR, and FR were markedly different among the day-3 serum AMH groups (low, moderate, and high AMH groups). The CPR were 33.3, 46.1, and 60.0, respectively, in the low, moderate, and high serum AMH groups on day 3. The embryo IR were 18.6, 26.7, and 36.3, respectively. The FR were 54, 68, and 79, respectively. An AMH level≥3.01 ng/mL was shown to predict FR with a sensitivity of 86.4% and specificity of 75%. An AMH level≥3.2 ng/mL was shown to predict IR and CPR with sensitivity and specificity of 72.1% and 72.7%, and 75.6% and 77.3%, respectively. CONCLUSION(S) On day 3 of the in vitro fertilization stimulation cycle, serum concentrations of AMH can be used as a marker for ovarian response as well as reproductive outcome in assisted reproductive cycles of PCOS patients.

Testicular versus ejaculated spermatozoa in ICSI cycles of normozoospermic men with high sperm DNA fragmentation and previous ART failures.

As a part of male assessment, conventional sperm parameters including morphologic features have been dedicated as major factors influencing fertilisation and pregnancy rates in assisted reproductive technology (ART). Genomic integrity of spermatozoa has also been found to influence fertility prognosis, and hence, sperm DNA fragmentation index (DFI) has been adopted by many centres to document this entity. Despite several suggested approaches, there is lack of universal consensus on optimising fertility outcomes in males with high sperm DFI. In this context, the results from cycles using testicular spermatozoa (TESA) obtained by aspiration were compared with those of ejaculated spermatozoa (EJ) in normozoospermic subjects with high sperm DFI and previous ART failures. Clinical (41.9% versus 20%) and ongoing pregnancy rates (38.7% versus 15%) were significantly better and miscarriages were lower in TESA group when compared to EJ group. Sperm DFI should be a part of male partners evaluation following unsuccessful ART attempts. When high DFI is detected (>30%), ICSI using testicular spermatozoa obtained by TESA seems an effective option particularly for those with repeated ART failures in terms of clinical, ongoing pregnancies and miscarriages even though conventional sperm parameters are within normal range.

Relationship between interleukin-6 levels and ambulatory blood pressure in women with polycystic ovary syndrome.

OBJECTIVE To determine 24-hour ambulatory blood pressures (ABP) in patients with polycystic ovary syndrome (PCOS) and its relationship with interleukin-6 (IL-6). DESIGN Prospective controlled study. SETTING University hospital. PATIENT(S) Fifty-four PCOS patients. INTERVENTION(S) Ambulatory blood pressure monitoring was conducted. Anthropometric, hormonal, metabolic, and inflammatory parameters, including plasma IL-6, C-reactive protein (CRP), fibrinogen, and nitric oxide (NO), were measured in each subject. MAIN OUTCOME MEASURE(S) Ambulatory blood pressure and plasma IL-6, CRP, fibrinogen, and NO. RESULT(S) Serum IL-6 levels of PCOS women in the highest systolic blood pressure (SBP) quartile were significantly higher than those of women in the lowest SBP quartile. The high serum IL-6 levels (serum IL-6 level>or=5.1 pg/mL) were associated with a higher probability of raised SBP (>/=126 mm Hg), with an odds ratio of 2.2 (95% confidence interval 0.8-7.9). The systolic and diastolic (DBP) blood pressures were significantly related to serum IL-6 levels. The IL-6 levels were positively and significantly correlated with serum CRP levels. Interleukin-6 and CRP were negatively and significantly correlated with serum NO levels. CONLUSION(S): The results suggest that raised plasma IL-6 levels may be related to ambulatory SBP and DBP in PCOS.

Maternal and umbilical cord ischemia-modified albumin levels in nonreassuring fetal heart rate tracings regarding the mode of delivery

Objective: To evaluate umbilical cord blood ischemia-modified albumin (IMA) levels in cases of fetal distress (FD) and to explore fetal blood IMA levels regarding the route of delivery. Methods: Umbilical cord and maternal serum IMA concentrations were assessed in term 40 cases with cesarean section (CS) due to FD, 76 cases with elective repeat CS and 85 cases with noncomplicated vaginal delivery. Results: The maternal and umbilical cord IMA levels were significantly lower in vaginal deliveries when compared with CS cases either in FD or previous CS groups (p = 0.02). Although no statistically significant difference was found in IMA levels of CS groups (previous CS vs. FD), cord blood IMA levels tend to be higher in FD group. Neither demographic characteristics nor fetal outcome parameters were found to have any correlation with maternal IMA levels. However, umbilical cord IMA levels were found to be negatively correlated with 1th min Apgar scores (r = –0.143, p = 0.043). Conclusions: IMA seems to be responsive to hypoxic FD showing the highest levels in cases with severe fetal hypoxia. Higher levels of IMA in cases with elective repeat CS might indicate acute transient hypoxia and possible myocardial ischemia in these cases.

Improved cycle outcomes after laparoscopic ovarian diathermy in hyper-responder patients with previous ART failure.

Abstract Excessive response to ovarian stimulation is common among hyper-responder patients undergoing assisted reproductive technology (ART). Cycle cancellations and severe ovarian hyperstimulation syndrome (OHSS) are all detrimental consequences observed within this cohort and several approaches have been proposed to enhance outcomes. The current study is designed to evaluate whether laparoscopic ovarian diathermy (LOD) improves ART outcomes and pregnancy rates by reducing Anti-mullerian hormone (AMH) levels in a group of patients who had a history of recurrent ART failure and high response. A total of 40 hyper-responder patients with history of previous ART failure were included. Group I consisted of 22 patients that underwent LOD prior to ART. Group II consisted of 18 patients that underwent only ART. Cycle outcomes of groups were compared. Following LOD, significant reduction in AMH levels were detected in group I (4.75 ng/mL to 2.25 ng/mL). Clinical pregnancies were similar among groups (40% versus 27.8% p = 0.65). There was no cycle cancellation in Group I, whereas there were three cycle cancellations observed due to OHSS in Group II. Our results indicate that LOD might offer enhanced fertility outcomes and may reduce the likelihood of cycle cancellations in hyper-responders with previous ART failures. Chinese abstract 高反应患者在辅助生殖过程(ART)中对卵巢刺激呈现过度反应是很常见的。在这些人群中，周期的终止和卵巢过度刺激综合征（OHSS）都属于已观察到的过度反应可导致的有害结果。为改善ART的结局已提出了一些方法。本研究被设计用于评估腹腔镜下卵巢打孔术（LOD）是否能通过降低抗苗勒氏管激素（AMH）而改善有ART反复失败史和高反应患者ART的结局和妊娠率。总计有40名高反应和ART失败史的患者被纳入了此项研究。一组包括22名患者，在ART前行LOD，二组包括18名患者，只进行了ART。两组的周期结局被拿来比较。在LOD后，一组观察到了AMH值的明显降低(4.75 ng/mL 到2.25 ng/mL)。两组临床妊娠率相似(40% versus 27.8% p=0.65)。一组无周期终止，而二组有三名患者由于OHSS而终止了周期。我们的研究表明LOD或可改善妊娠结局，减少有ART失败史的高反应患者终止周期的可能性。

Evaluation of serum boron levels and lipid profile in pregnancies with or without gestational diabetes

Abstract Aims: Animal research has demonstrated that boron has effects on triglycerides and glucose and may act as a metabolic regulator in several enzymatic systems. Gestational diabetes mellitus (GDM) is a prevalent obstetrical complication and the lack of data on maternal status of boron in normal/diabetic pregnancies, prompted us to undertake this study. Methods: Maternal blood samples were collected during screening and diagnosis of GDM at 24–28 weeks. Serum lipids (total cholesterol, high-density cholesterol, low density cholesterol, triglycerides, lipoprotein-a, apolipoprotein-A-I and apolipoprotein-B) and boron levels were determined. Fifteen non-GDM and 19 GDM women constituted the study population. Results: The mean age was 30.1±5 years. The median boron levels were 15.2 μg/L (0.0152 ppm; range, 8.4–25.4 μg/L). When GDM and non-GDM cases were compared for age, gravidity, parity, lipid profiles and serum boron levels, no significant differences were found (P>0.05). No correlation was found between lipids and boron levels. Conclusion: This preliminary study contributes to the limited information about the metabolic aspects of boron. Considering the evidence that boron acts as a regulator of energy substrate utilization, the effect of dietary boron on glucose metabolism deserves further research.

Uncommon but devastating event: total fertilisation failure following intracytoplasmic sperm injection

Fertilisation with intracytoplasmic sperm injection (ICSI) is a consequence of complex molecular interactions between spermatozoon and oocyte. Disruption of the process obviously prompts a frustrating event called total fertilisation failure (TFF). Up to 3% of ICSI cycles may result in TFF, and brief counselling for subsequent cycle management is indispensable. Within this perspective, ICSI cycles of a centre over a 10‐year period were analysed to document TFF cases. Initial TFF after ICSI and subsequent ICSI cycle of the same cases were documented to clarify predictive factors of successful outcomes after initial TFF. In subsequent cycles, assisted oocyte activation (AOA) with calcium ionophore and Hypo‐osmotic swelling test (HOST)/pentoxifilline for sperm selection was used. In the current analysis, successful fertilisation was achieved in 85% of the cases with previous TFF. The significant contributing factors for successful fertilisation in the latter cycle were: improved oocyte quantity and better sperm morphology. In conclusion, sporadic TFF event in the first and only cycle is usually a technically modifiable condition, but repeated TFF could indicate possible gamete defects, which might not be overcomed in the next modified ICSI cycle.

Different gonadotropin releasing hormone agonist doses for the final oocyte maturation in high-responder patients undergoing in vitro fertilization/intra-cytoplasmic sperm injection

Context: Efficacy of gonadotropin releasing hormone agonists (GnRH-a) for ovulation in high-responders. Aims: The aim of the current study is to compare the impact of different GnRH-a doses for the final oocyte maturation on cycle outcomes and ovarian hyperstimulation syndrome (OHSS) rates in high-responder patients undergoing ovarian stimulation. Settings And Designs: Electronic medical records of a private in vitro fertilization center, a retrospective analysis. Subjects and Methods: A total of 77 high-responder cases were detected receiving GnRH-a. Group I consisted of 38 patients who received 1 mg of agonist and Group II consisted of 39 patients who received 2 mg of agonist. Statistical Analysis: In order to compare groups, Student′s t-test, Mann-Whitney U-test, Pearson′s Chi-square test or Fisher′s exact test were used where appropriate. A P < 0.05 was considered as statistically significant. Result: Number of retrieved oocytes (17.5 vs. 15.0, P = 0.510), implantation rates (46% vs. 55.1%, P = 0.419) and clinical pregnancy rates (42.1% vs. 38.5%, P = 0.744) were similar among groups. There were no mild or severe OHSS cases detected in Group I. Only 1 mild OHSS case was detected in Group II. Conclusion: A volume of 1 or 2 mg leuprolide acetate yields similar outcomes when used for the final oocyte maturation in high-responder patients.