Tayfun Cok

Single versus double intrauterine insemination in multi-follicular ovarian hyperstimulation cycles: a randomized trial

BACKGROUND The rationale for double insemination is to create the opportunity for a longer fertilization period as follicle rupture may occur over a wide interval (approximately 22-47 h) after hCG administration in ovarian hyperstimulation (OH) with intrauterine insemination (IUI) cycles. This randomized study evaluates the effectiveness of single versus double IUI in only OH cycles with multi-follicular development. METHODS We conducted a single center trial, 228 eligible patients were randomized for this study on the day of hCG. Only cycles with multi-follicular development without premature luteinization (progesterone levels >1 ng/ml on the day of hCG), were included in the study. Multi-follicular development has been defined as at least two dominant follicles reaching minimum > or = 15 mm diameter in which one of them is >17 mm. OH cycles with more than five dominant follicles (>15 mm in diameter) were excluded from the study. In the single IUI group (Group 1 = 112 patients) IUI was applied 36 h after the hCG injection and in the double IUI group (Group 2 = 114 patients) the first IUI was performed 18 h after hCG administration and the second IUI was performed 40 h after hCG administration. The primary end-point is to compare live birth rates (LBRs) between single and double IUI arms. RESULTS LBRs were 10.7% (12/112 patients) in the single IUI group and 12.3% (14/114) in the double IUI group and the difference was not statistically significant (P = 0.835, OR = 1.16, 95% CI: 0.51-2.64). In the unexplained infertility group the LBR was 11.1% (5/45 patients) with single IUI and 18.4% (9/49) with double IUI (P = 0.393). In the mild male factor group this rate was 10.4% (7/67) and 7.7% (5/65) in the single and double IUI groups, respectively (P = 0.764). CONCLUSION Our study did not find any difference in LBRs between single and double IUI groups in OH cycles with multi-follicular development. To the best of our knowledge this is the first report with this kind of study design. The study was registered at clinicaltrials.gov: NCT 00993902.

Transvaginal ultrasound-guided local methotrexate administration as the first-line treatment for cesarean scar pregnancy: Follow-up of 18 cases

Cesarean scar pregnancy (CSP) is a rare type of ectopic pregnancy, which occurs in previous cesarean section scar tissue, with an incidence of 1 in 1800–3000 pregnancies. Transvaginal ultrasound‐guided local methotrexate (MTX) administration presents as a non‐systemic option with possible better penetration to the pregnancy site. We present the management of 18 patients with CSP solely by transvaginal ultrasound‐guided local MTX administration. All patients were treated with local MTX with a dose of 50 mg/m2. Eleven (61.1%) of the patients did not need any further intervention. Four patients (22.2%) were treated with additional single‐dose systemic MTX due to inadequate alteration in blood β‐human chorionic gonadotrophin levels. Three patients (16.7%) required hysteroscopy and/or laparotomy. We suggest that transvaginal ultrasound‐guided local MTX treatment may be considered as a first‐line treatment for CSP.

Polycystic ovary syndrome and increased polyp numbers as risk factors for malignant transformation of endometrial polyps in premenopausal women

To determine the pre‐malignant and malignant potential of endometrial polyps and to assess whether different clinical parameters are associated with malignancy in the polyps of premenopausal women.

Abnormal Uterine Bleeding: Is It an Under‐Reported Side Effect after Epidural Steroid Injection for the Management of Low Back Pain?

To the Editor, We read Dr. Gitkinds report with great interest [1]. Since epidural steroid injection (ESI) is a rational treatment approach for radicular pain due to herniated nucleus pulposus and lumbar stenosis [2], its popularity is rising. It is reported to decrease surgical rates and self-reported pain and disability [3]. Corticosteroids contribute to pain treatment with their ability to decrease inflammation by inhibiting production of prostaglandins and excitation of c-fibers, which is mainly responsible for pain generation. However, ESI is not an option free of side effect due to intervention itself and the drugs used [4]. Here, we describe two patients with abnormal uterine …

In vitro fertilization-intracytoplasmic sperm injection outcomes in single- versus double-lumen oocyte retrieval needles in normally responding patients: a randomized trial.

We compared the retrieval efficiency of single- (direct follicular aspiration) and double-lumen-needle (attained with follicular flushing) procedures in normal-responder IVF-intracytoplasmic sperm injection cycles. This prospective randomized study did not demonstrate a beneficial effect of double-lumen needle retrieval compared with single-needle retrieval in normal-responder IVF-intracytoplasmic sperm injection cycles in terms of retrieved oocytes, clinical pregnancy rates, and live birth rates.

Isolated abnormal value during the 3-hour glucose tolerance test: which value is associated with macrosomia?

Objective. The aim of this retrospective review was to evaluate obstetric outcomes in patients with an isolated abnormal value on the oral glucose tolerance test (OGTT) at 0, 1, 2, and 3 h. Methods. From January 2003 through June 2009, all consecutive pregnant women who presented to Baskent University were screened for gestational diabetes mellitus (GDM). Patients with one abnormal value based on findings of the OGTT were grouped according to increased levels of glucose at 0, 1, 2, and 3 h (Group 1 > 95 mg/dl for fasting glucose concentration, Group 2 > 180 mg/dl for the serum glucose concentration in the first hour, Group 3 > 155 mg/dl for the serum glucose concentration in the second hour, Group 4 > 140 mg/dl for serum glucose concentration in the third hour). The four groups were compared for classic GDM risk factors. The primary outcome measures were large for gestational age (LGA) (birthweight >95th percentile for gestational age using population birth weight centile charts) and macrosomia. Results. The incidence of LGA baby (Group 1, 10%; Group 2, 3.8%; Group 3 20.3%; Group 4, 13.2%; p = 0.008) was significantly highest in Group 3 and macrosomia (Group 1, 30%; Group 2, 5.1%; Group 3, 18.6%; Group 4, 15.8%; p = 0.039) was significantly higher in Groups 1 and 3. Conclusions. Our results suggest that even with relatively mild degrees of glucose intolerance at 2 h, no treatment is associated with LGA babies.

Effect of cervical mucus aspiration before intrauterine insemination.

To determine whether cervical mucus aspiration before intrauterine insemination (IUI) has any effect on clinical pregnancy rates.

Can calcium ionophore “use” in patients with diminished ovarian reserve increase fertilization and pregnancy rates? A randomized, controlled study

OBJECTIVE To determine whether calcium ionophore solution can improve the fertilization rate in patients with diminished ovarian reserve whose partners have normal sperm parameters. DESIGN Between January 2014 and August 2014, patients with diminished ovarian reserve were randomized to make artificial oocyte activation with calcium ionophore solution. SETTING University hospital. PATIENT(S) A total of 296 patients who had diminished ovarian reserve and partners with normal sperm parameters were included in the study. INTERVENTION(S) Metaphase 2 oocytes were treated with calcium ionophore solution (GM508 Cult-Active) for 15 minutes just after intracytoplasmic sperm injection. MAIN OUTCOME MEASURE(S) Fertilization rate, implantation rate, clinical pregnancy rate, ongoing pregnancy rate. RESULT(S) Fertilization, implantation, pregnancy, and ongoing pregnancy rates for the calcium ionophore and control groups were 60.7% and 55.4%, 12.8% and 10.7%, 21% and 12.8%, and 10.9% and 6.1%, respectively. CONCLUSION(S) This is the first prospective, randomized, controlled study to analyze the effect of calcium ionophore solution on fertilization rate in patients with diminished ovarian reserve. We did not observe any differences in fertilization, clinical pregnancy, or ongoing pregnancy rates between the groups. We propose that fertilization ratios could not be increased by artificial oocyte activation via application of calcium ionophore solution in patients with diminished ovarian reserve. CLINICAL TRIAL REGISTRATION NUMBER NCT02045914.

Transsacral S2-S4 Nerve Block For Vaginal Pain Due To Pudendal Neuralgia

Pudendal neuralgia is a type of neuropathic pain experienced predominantly while sitting, and causes a substantial decrease in quality of life in affected patients. Pudendal nerve block is a diagnostic and therapeutic option for pudendal neuralgia. Transsacral block at S2 through S4 results in pudendal nerve block, which is an option for successful relief of pain due to pudendal nerve injury. Herein is reported blockade of S2 through S4 using lidocaine and methylprednisolone for successful treatment of pudendal neuralgia in 2 patients with severe chronic vaginal pain. The patients, aged 44 and 58 years, respectively, were referred from the Gynecology Department to the pain clinic because of burning, stabbing, electric shock-like, unilateral pain localized to the left portion of the vagina and extending to the perineum. Their initial pain scores were 9 and 10, respectively, on a numeric rating scale. Both patients refused pudendal nerve block using classical techniques. Therefore, diagnostic transsacral S2-S4 nerve block was performed using lidocaine 1%, and was repeated using lidocaine 1% and methylprednisolone 80 mg after confirming block efficiency as demonstrated by an immediate decrease in pain scores. After 1 month, pain scores were 1 and 0, respectively, and both patients were free of pain at 6-month follow up. It is suggested that blockade of S2 through S4 using lidocaine and methylprednisolone is an effective treatment option in patients with chronic pudendal neuralgia when traditional pudendal nerve block is not applicable.

Addition of gonadotropin releasing hormone agonist for luteal phase support in in-vitro fertilization: an analysis of 2739 cycles.

OBJECTIVE Luteal phase is defective in in vitro fertilization (IVF) cycles, and many regimens were tried for the very best luteal phase support (LPS). Gonadotropin releasing hormone (GnRH) agonist use, which was administered as an adjunct to the luteal phase support in IVF cycles, was suggested to improve pregnancy outcome measures in certain randomized studies. We analyzed the effects of addition of GnRH agonist to standard progesterone luteal support on pregnancy outcome measures, particularly the live birth rates. MATERIAL AND METHODS This is a retrospective cohort study, including 2739 IVF cycles. Long GnRH agonist and antagonist stimulation IVF cycles with cleavage-stage embryo transfer were included. Cycles were divided into two groups: Group A included cycles with single-dose GnRH agonist plus progesterone LPS and Group B included progesterone only LPS. Live birth rates were the primary outcome measures of the analysis. Miscarriage rates and multiple pregnancy rates were the secondary outcome measures. RESULTS Live birth rates were not statistically different in GnRH agonist plus progesterone (Group A) and progesterone only (Group B) groups in both the long agonist and antagonist stimulation arms (40.8%/41.2% and 32.8%/34.4%, p<0.05 respectively). Moreover, pregnancy rates, implantation rates, and miscarriage rates were found to be similar between groups. Multiple pregnancy rates in antagonist cycles were significantly higher in Group A than those in Group B (12.0% and 6.9%, respectively). CONCLUSION A beneficial effect of a single dose of GnRH agonist administration as a luteal phase supporting agent is yet to be determined because of the wide heterogeneity of data present in literature. Well-designed randomized clinical studies are required to clarify any effect of luteal GnRH agonist addition on pregnancy outcome measures with different doses, timing, and administration routes of GnRH agonists.