Sebiha Özkan

Endometriosis and Infertility : Epidemiology and Evidence-based Treatments

Endometriosis is an estrogen‐dependent disorder defined as the presence of endometrial tissue outside of the uterine cavity. A leading cause of infertility, endometriosis has a prevalence of 0.5–5% in fertile and 25–40% in infertile women. The optimal choice of management for endometriosis‐associated infertility remains obscure. Removal or suppression of endometrial deposits by medical or surgical means constitutes the basis of endometriosis management. Current evidence indicates that suppressive medical treatment of endometriosis does not benefit fertility and should not be used for this indication alone. Surgery is probably efficacious for all stages of the disease. Controlled ovarian hyperstimulation with intrauterine insemination is recommended in early‐stage and surgically corrected endometriosis when pelvic anatomy is normal. In advanced cases, in vitro fertilization is a treatment of choice, and its success may be augmented with prolonged gonadotropin‐releasing hormone analog treatment. Further randomized clinical trials focusing on diverse etiopathogenic mechanisms and therapeutic innovation are necessary to find more conclusive, evidence‐based answers regarding this enigmatic disease.

Replete vitamin D stores predict reproductive success following in vitro fertilization

OBJECTIVE To determine whether 25OH-D levels in the follicular fluid (FF) of infertile women undergoing IVF demonstrate a relationship with IVF cycle parameters and outcome, hypothesizing that levels of 25OH-D in body fluids are reflective of vitamin repletion status. DESIGN Prospective cohort study. SETTING Academic tertiary care center. PATIENT(S) Eighty-four infertile women undergoing IVF. INTERVENTION(S) Follicular fluid from follicles>or=14 mm; serum (n = 10) and FF levels of 25OH-D. MAIN OUTCOME MEASURE(S) Clinical pregnancy (CP), defined as evidence of intrauterine gestation sac on ultrasound, following IVF; IVF cycle parameters. RESULT(S) Serum and FF levels of 25OH-D were highly correlated (r=0.94). In a predominantly Caucasian population (66%), significantly lower FF 25OH-D levels were noted in Black versus non-Black patients. Significant inverse correlations were seen between FF 25OH-D levels and body mass index (r=-0.25). Significantly higher CP and implantation rates were observed across tertiles of FF25OH-D; patients achieving CP following IVF (n=26) exhibited significantly higher FF levels of 25OH-D. Multivariable logistic regression analysis confirmed FF 25OH-D levels as an independent predictor to success of an IVF cycle; adjusting for age, body mass index, ethnicity, and number of embryos transferred, each ng/mL increase in FF 25OH-D increased the likelihood for achieving CP by 6%. CONCLUSION(S) Our findings that women with higher vitamin D level in their serum and FF are significantly more likely to achieve CP following IVF-embryo transfer are novel. A potential for benefit of vitamin D supplementation on treatment success in infertile patients undergoing IVF is suggested and merits further investigation.

Advances in Treatment Options of Endometriosis

Endometriosis, defined as the presence of endometrial tissue outside the uterus, is a challenging condition associated with substantial morbidity. Management of endometriosis must be individualized according to the desired treatment outcome, whether it is relief of pain, improvement of fertility, or the prevention of recurrence. For alleviation of endometriosis-associated pain, medical treatment is generally successful, with no medical agent being more efficacious than another in spite of significantly differing side-effect profiles. Surgical therapy has also been demonstrated to reduce pain scores in comparison with expectant management, although conservative surgery has been frequently associated with recurrence. The efficacy of combination therapies still remains to be clarified. For treatment of endometriosis-associated infertility, suppressive medical treatment has been proven to be detrimental to fertility and should be discouraged, while surgery is probably efficacious for all stages. Controlled ovarian hyperstimulation with intrauterine insemination is recommended in early-stage and surgically corrected endometriosis. Combined surgery with GnRH analog treatment has been proposed to be first-line therapy, followed by IVF as second-line therapy in advanced cases. More rigorously designed randomized clinical trials focusing on the endocrinological, immunological, and genetic aspects of endometriosis are necessary to refine conclusions regarding the etiopathogenesis and therapeutic innovations of this perplexing disease.

A right sliding indirect inguinal hernia containing paraovarian cyst, fallopian tube, and ovary: a case report

Albeit very uncommon, the hernia sac may contain unusual structures such as vermiform appendix, acute appendicitis, ovary, fallopian tube and, urinary bladder. Most of the cases of hernia containing ovary and fallopian tubes were reported to be found in children and, often accompanied with other congenital anomalies of genital tract. We present the first case of sliding inguinal hernia containing right ovary and fallopian tube and a right paraovarian cyst in 80-year-old, multiparous patient without any associated genital anomaly. The hernia was repaired with plication darn, while the paraovarian cyst was excised and adnexa were preserved. It is of utmost importance to keep in mind that the hernia sac may contain almost any abdominal organ, and surgical dissection should be carried out accordingly. Pathophysiologically, the ovary might be simply pulled along with a sliding paraovarian cyst or the paraovarian cyst might be accompanying the maldescended ovary. There seems to be a need for clinical and experimental studies to further explain the mechanisms that apply to the pathogenesis of sliding inguinal hernias.

Review of a challenging clinical issue: Intrahepatic cholestasis of pregnancy

Intrahepatic cholestasis of pregnancy (ICP) is a reversible pregnancy-specific cholestatic condition characterized by pruritus, elevated liver enzymes, and increased serum bile acids. It commences usually in the late second or third trimester, and quickly resolves after delivery. The incidence is higher in South American and Scandinavian countries (9.2%-15.6% and 1.5%, respectively) than in Europe (0.1%-0.2%). The etiology is multifactorial where genetic, endocrine, and environmental factors interact. Maternal outcome is usually benign, whereas fetal complications such as preterm labor, meconium staining, fetal distress, and sudden intrauterine fetal demise not infrequently lead to considerable perinatal morbidity and mortality. Ursodeoxycholic acid is shown to be the most efficient therapeutic agent with proven safety and efficacy. Management of ICP consists of careful monitoring of maternal hepatic function tests and serum bile acid levels in addition to the assessment of fetal well-being and timely delivery after completion of fetal pulmonary maturity. This review focuses on the current concepts about ICP based on recent literature data and presents an update regarding the diagnosis and management of this challenging issue.

Pure nongestational choriocarcinoma of ovary

IntroductionPrimary ovarian choriocarcinoma arising presumably from a germ cell is extremely rare. Besides arising gestationally or nongestationally, it may be pure or mixed with other germ cell tumors like immature teratoma, dysgerminoma, polyembryoma.Case report and discussionWe present a case of a 22-year-old woman diagnosed with pure nongestational choriocarcinoma of the ovary with a review of the literature and discussion of its origin.

Magnetic resonance imaging and angiography for the prerupture diagnosis of rudimentary uterine horn pregnancy.

Magnetic resonance (MR) imaging and MR angiography were used for the differential diagnosis and preoperative planning of a 17 weeks of age rudimentary horn pregnancy. A 26-year-old primigravida was referred to our hospital with a preliminary diagnosis of abdominal pregnancy. After an inconclusive ultrasound evaluation we were able to identify a rudimentary horn pregnancy, extent of the placental invasion, and the vascular supply via MR imaging and time of flight sequence MR angiography. The obtained data were also used for preoperative planning, which resulted in an uncomplicated, prerupture laparotomy for pregnancy termination and a healthy female.

Three-dimensional ultrasonographic diagnosis and hysteroscopic management of a viable cesarean scar ectopic pregnancy.

Implantation of conception material within a cesarean section scar is an extremely rare form of ectopic pregnancy with devastating complications, such as uterine rupture and intractable bleeding. Both 2‐D and 3‐D transvaginal ultrasonographic devices are used adequately for precise diagnosis, but there is still a lack of consensus concerning management strategies. No therapeutic modality is suggested to be entirely efficacious and safe for preserving uterine integrity. We present here a 29‐year‐old woman with vaginal bleeding and a gestational sac with a viable embryo of 6 weeks of age that was implanted in a cesarean section scar. Serum β‐hCG levels were 16 792 mIU/mL. Following an unsuccessful treatment course of systemic methotrexate, the patient underwent operative hysteroscopy. Minimally invasive hysteroscopic resection of the ectopic gestational mass without major complication appears to be an alternative therapeutic approach with minimal morbidity and preservation of future fertility.

Is prostate-specific antigen a potential new marker of androgen excess in polycystic ovary syndrome?

Aim:  To determine whether serum prostate‐specific antigen (PSA) levels are increased in polycystic ovary syndrome (PCOS) and the possibility of PSA to be used as a diagnostic marker of hyperandrogenism in females.

Unsuccessful management of acardiac fetus with intrafetal alcohol injection.

Twin reversed arterial perfusion (TRAP) sequence is an extreme form of twin-to-twin transfusion in which the normal ‘pump’ twin perfuses its acardiac cotwin. The pump twin has a 50% mortality rate due to congestive heart failure, and polyhydramnios and preterm delivery are further obstetric complications. The risk of an adverse pregnancy outcome is increased when the ratio of acardiac twin : pump twin weight exceeds 70%. Management of TRAP sequence includes elective termination, observation and follow-up using ultrasound or cardiotocography, digoxin therapy for cardiac failure of the pump twin and interventions that target the blood supply of the acardiac fetus. Coagulation of the vascular anastomosis under sonoendoscopic control and percutaneous umbilical cord ligation are invasive therapeutic options. Percutaneous intrafetal alcohol injection has also been reported as a simple and less invasive procedure1,2. We report here our unsuccessful management using intrafetal alcohol injection of an acardiac acephalic twin pregnancy in a 16-year-old woman, gravida 1 para 0, at 12 weeks of gestation. On admission, ultrasound evaluation demonstrated a monochorionic twin pregnancy in which one of the fetuses had no head and upper extremities but normal mobile lower extremities (Figure 1) and significant edema around the trunk. Despite the absence of the heart, blood flow in the