Rifat Gursoy

Comparison of Basal and Clomiphene Citrate Induced FSH and Inhibin B, Ovarian Volume and Antral Follicle Counts as Ovarian Reserve Tests and Predictors of Poor Ovarian Response in IVF

AbstractPurpose: To compare basal and clomiphene citrate (CC) induced follicle-stimulating hormone (FSH), estradiol (E2), and inhibin B levels with ultrasound indices of ovarian reserve in infertile women and to test the prognostic value of these tests on response to ovarian stimulation in in vitro fertilization (IVF). Methods: Fifty-six patients had basal and CC induced serum hormone levels and ultrasound measured mean ovarian volume (MOV) and mean antral follicle counts (MFC). Thirty-two patients were then appropriately selected to have a total of 41 cycles of IVF/ICSI treatment. Results: Women with diminished ovarian reserve had lower MOV, MFC, day 3 and day 10 inhibin B levels (p< 0.001). Only basal and CC induced FSH and inhibin B correlated with MOV and MFC. Poor responders in IVF/ICSI had higher basal FSH (p< 0.05), lower basal and induced inhibin B levels (p< 0.05), and lower MOV and MFC (p< 0.01) than normal responders. Ovarian volume alone was better than age and basal hormones in predicting poor ovarian response, while abnormal CC test was the only independent significant factor in predicting ovarian response. However, age was the only independent predictor of pregnancy in IVF as compared to hormonal and ultrasound indices of ovarian reserve. Conclusion: CC test and ovarian volume are better than other hormonal and sonographic tests in predicting the response to ovarian stimulation in IVF cycles.

The incidence of congenital malformations in a Turkish population

Objective: To determine the incidence and types of congenital anomalies in a Turkish population. Method: The total number of neonates (9160) born in the Department of Obstetrics and Gynecology, Gazi University Faculty of Medicine during 1988–1995 were studied retrospectively. Newborns with congenital anomaly were identified from their birth registries. The total incidence, types and combined anomalies were determined. Also, the relationship between congenital anomalies and maternal age and/or gender were investigated. For statistical evaluation, Chi‐square test, Yates correction and Fishers exact tests were used where appropriate. Results: The overall congenital anomaly incidence was 1.11% and the NTD incidence was 0.27% in our population. Anencephaly was the second most common NTDs with the ratio of 40%, following the spina bifida cases. There was a significant difference between female and male newborns with ancephalocele (P < 0.05). Urogenital system anomalies were found to be the second most common type of malformation with an incidence of 0.21%. Facial and musculoskeletal system abnormalities were the third and fourth most common malformations. Omphalocele incidence in our population was 5 in 9160 births and gastrochisis was 1 in 9160 births. Conclusion: The overall congenital anomaly incidence in newborns in our population is 1.11%. The most common malformations were CNS and urogenital abnormalities. NTDs incidence was 0.27% in a Turkish population.

Comparison of the clinical value of CA 19-9 versus CA 125 for the diagnosis of endometriosis

Preoperative blood samples and intraoperative tissue specimens were obtained from 101 patients with endometriosis and 78 patients without endometriosis referred for benign gynecologic operations to investigate the clinical value of serum and tissue CA 19-9 levels in the diagnostic evaluation of endometriosis as compared to CA 125. Our prospective cohort study showed that serum CA 19-9 is a valuable marker in the diagnosis of endometriosis, and it may be used to predict the patients with severe endometriosis when used with CA 125.

Transvaginal color Doppler ultrasonography for prediction of pre-cancerous endometrial lesions

Objective: To determine whether measurements of blood flow in endometrial and uterine vessels by transvaginal color Doppler ultrasonography was valuable in the diagnosis of a neoplastic endometrial pathology (hyperplasia and carcinoma) in women with abnormal bleeding. Methods: This is a prospective study and included 105 post‐menopausal women and 33 pre‐menopausal women with abnormal uterine bleeding. All subjects underwent transvaginal color Doppler ultrasonography. We investigated whether obtained results were correlated with histopathological findings. Results: There was no significant difference in the mean±S.D. RI of the left and the right uterine arteries, intramyometrial arteries and endometrial arteries between patients with neoplastic and non‐neoplastic endometrium on histopathological examination. Dopplers velocity waveforms of small endometrial blood vessels could be detected in 9% of the women with non‐neoplastic endometrium and in 42% of the women with neoplastic endometrium (P<0.05). The mean±S.D. of the endometrial thickness was significantly higher in the women with neoplastic endometrium than that of the women with non‐neoplastic endometrium (16.6±6.1 mm vs. 9.5±4.7 mm, P<0.05). Conclusion: Dopplers velocity waveforms of uterine vessels coupled with transvaginal ultrasonography are not valuable enough to replace histopathological examination in the diagnosis of a neoplastic endometrial pathology. However, it may be helpful in cases in which invasive techniques are difficult to perform and in the differentiation of a certain group of patients at little risk of endometrial carcinoma.

Prevalence of hepatitis B surface antigen among pregnant women in a low-risk population

OBJECTIVES: To estimate the prevalence of chronic hepatitis B carriers among our lowrisk obstetric population and to determine the need for routine screening. METHODS: A group of 1224 pregnant women, admitted to Gazi University Medical Center, were screened for HBsAg using an enzyme‐immunoassay technique, and the obstetrical care records were reviewed. RESULTS: Fifty‐three patients were seropositive with a prevalence of 4.33% for HBV chronic carrier status in our obstetric population. CONCLUSIONS: Routine HBsAg screening is advisable in our antenatal population.

A potential novel strategy, inhibition of vasopressin-induced VEGF secretion by relcovaptan, for decreasing the incidence of ovarian hyperstimulation syndrome in the hyperstimulated rat model

OBJECTIVE To investigate the effects of V1A receptor antagonist through inhibition of vasopressin-induced VEGF secretion in an experimental model. STUDY DESIGN Thirty rats were randomly divided into five groups. Four groups were given 10IU pregnant mare serum gonadotropin/day (sc) at 8:00-8:30am on days 22-25 of life. They were administered 30IU hCG at 8:00-8:30am on day 26 of life. On days 26 and 27 of life at 8:00am and 4:00pm, (ip) per animal, 50μg/kg/day GnRH antagonist in the GnRH antagonist group, 0.3mg relcovaptan in the high dose relcovaptan group, and 0.15mg relcovaptan in the low dose relcovaptan group were administered. The control group was given the same dosage of 0.9% saline solution (ip) on days 22-26 day of life. The main outcomes were weight gain, ovarian weights, peritoneal fluid VEGF values, corpus luteum count, and atretic follicle count. RESULTS Weight gain was highest in the OHSS group; it was almost twice as much in the OHSS group than it was in the control group. Ovarian weights were significantly lower in all treatment groups (p=0.03). There was no statistically significant difference in ovarian weights between the GnRH antagonist and relcovaptan groups (p=0.176). The evaluation of peritoneal fluid VEGF-A levels revealed statistically significant differences between levels in the treatment groups and in the OHSS group (p=0.005). Atretic follicle count in the OHSS group was significantly lower (p=0.048). In all treatment groups, CL counts were prominently lower than they were in the OHSS group (p=0.002). CONCLUSION Relcovaptan may be a novel strategy for decreasing risk of OHSS by inhibition of vasopressin-induced VEGF secretion through V1A receptor antagonist.

Incidental tubo-ovarian abscess at abdominal delivery: a case report

Tubo-ovarian abscess in the third trimester of pregnancy is extremely rare. In this report, an unusual case with asymptomatic tubo-ovarian abscess, diagnosed incidentally during Cesarean section performed for an obstetric indication, is presented. Unlike other reported cases, no signs or symptoms attributable to pelvic abscess throughout the pregnancy were observed in our patient. To our knowledge, this is the first report of such a case in the literature.

Influence of exogenous estrogen administration on serum CA-125 originating from the endometrium

Objectives: The purpose of the study is to assess the endometrial contribution of serum CA‐125 using exogenous estrogen administration by ruling out ovarian activity. A randomized, controlled, prospective study was designed to assess the endometrial contribution of serum CA‐125 and its influence from estrogen administration in menopausal women. Methods: Twenty menopausal women with intact uterus and ovaries (study group) and 10 cases with previous total hysterectomy with intact ovaries (control group) were included in the study. The mean age of subjects in the study and control groups were similar at 53±1.9 (S.D.) and 51±2.7 years. The length of menopause in the study and control groups were also similar at 61.0±18 and 52.6±26.5 months, respectively. Group 1 consisted of 10 randomly selected cases and five controls who received 15 days of 50 μg/day transdermal 17β‐estradiol (TE). Group 2 consisted of the next randomly selected 10 cases and five controls who had 15 days of transdermal 100 μg/day 17β‐estradiol (Estraderm‐Ciba) administration. Serum CA‐125 and estradiol were measured at day 0, 15 by radioimmunoassay (RIA). Results: Serum mean CA‐125 levels increased significantly in endometrium intact menopausal women from day 0 to 15 of TE administration in group 2 and 1, 70% and 6%, respectively (P=0.03 and P=0.05, respectively). Interestingly, the increase in serum estradiol levels accompanied this change only in group 2. Conclusions: These results suggest that endometrial CA‐125 secretion to serum is dependent on the dose of administered exogenous estrogen.

The effects of 3-day clomiphene citrate treatment on endocrine and ovulatory responses

A prospective cohort, paired clinical trial was carried out to test a shorter clomiphene citrate regimen of 3 days, measuring the endocrine outcomes and ovulatory responses. The trial took place at Gazi University Medical School Department of Obstetrics and Gynecology. The 28 infertile patients were newly accepted to the clinic with hypothalamopituitary disorder according to WHO classification Group II. They were treated with 50 mg/day clomiphene citrate (CC) for 3 days in 63 cycles. The control group of 28 paired patients were treated with 50 mg/day CC for 5 days in 40 cycles. The main outcome measures were: serum estradiol levels on day 11 (E-11), 14 (E-14) and postovulatory day 7 (E+ 7); serum progesterone levels on postovulatory day 7 (P+ 7); endometrial thickness on day 14 of the cycle; mean follicular phase length; and ovulation rates. The mean ages, gravidas, paritas, menstrual histories, E-11, P+ 7 levels, mean follicular phase length and luteal phase length were similar in both groups. E-14 (229.76 +/- 156.05 pg/ml vs. 338.25 +/- 350.60 pg/ml) and E+ 7 (217.30 +/- 114.95 pg/ml vs. 310.6 +/- 11.05 pg/ml) were significantly lower, whereas mean endometrial thickness on day 14 (10.30 +/- 1.39 mm vs. 9.52 +/- 1.96 mm) were significantly higher in the study group compared to controls (p < 0.05). Ovulation occurred in 82.53% of cycles in the study group and 95% in controls. In the study group, pregnancy was achieved in 17.3% of the ovulatory cycles; this rate was 10.5% in the control group. To decrease the peripheral antiestrogenic effects of CC, a regimen of 50 mg/day for 3 days may be used as a starting dose instead of the standard 5-day regimen.

Prenatal ultrasonographic appearance of isolated cutis verticis gyrata

Cutis verticis gyrata (CVG) is a rare disorder of the scalp characterized by the presence of ridges and furrows that resemble the surface of the brain and that are usually associated with a syndrome such as Beare–Stevenson cutis gyrata or Turner syndrome. It has an estimated prevalence of 1 in 100 000 of the male population and 0.026 in 100 000 of the female population1–4. Primary CVG is commonly associated with neuropsychiatric problems such as schizophrenia, mental retardation, and epilepsy. Although Hsu et al.5 have previously reported the prenatal sonographic appearance of Beare–Stevenson cutis gyrata syndrome, there was no sonographic image of the CVG. We present here the prenatal appearance of isolated CVG. A 36-year-old Turkish woman, gravida 2, para 1, with no risk factors other than advanced maternal age, attended for antenatal care of her second pregnancy at our unit. Her first ultrasound examination, using a Logiq 9 (General Electric, Milwaukee, USA), was performed at 9 weeks of gestation for confirmation of intrauterine pregnancy. Ultrasound evaluation at 16 weeks of gestation prior to amniocentesis, revealed a fluid collection 18 mm in length and 13 mm in depth beneath the scalp in the frontal region (Figure 1). There was no brain tissue within the lesion. We were unable to clearly identify bone tissue between the intracranial structures and the lesion, raising the suspicion of the presence of a bone defect in the skull. On ultrasound examination at 20 weeks of gestation the fluid collection beneath the scalp had disappeared. Examination of the cranium showed that the skull in this region was intact. Detailed ultrasound examination of all organ systems revealed no abnormal findings, and the karyotype was normal female. At 38 weeks of gestation spontaneous delivery of a 3350-g (50 cm in length) female occurred. Physical examination of the newborn was normal except for CVG measuring 3 × 2 cm in the frontal region (Figure 2). The lesion’s skin fold depth was approximately 7 mm. Follow-up at 2 years of age revealed that the infant was mentally and physically normal apart from the clinically non-significant finding of a 5-mm discrepancy in the size of her feet, the right foot being larger than the left. Since we did not perform a late first-trimester ultrasound examination, we could not ascertain when the lesion first appeared. The lesion was characterized by a focal fluid collection between the cranial bone and the scalp, which disappeared around 20 weeks of pregnancy. It is likely that when the fluid that had collected beneath the skin was absorbed, the skin folds were not large enough to be demonstrable by ultrasonography. Our initial differential diagnosis included cephalocele or Figure 1 Prenatal ultrasonographic appearance of the cutis verticis gyrata.