Turhan Aran

Does dehydroepiandrosterone supplementation really affect IVF-ICSI outcome in women with poor ovarian reserve?

OBJECTIVES It is difficult to choose the correct fertility treatment in women with poor ovarian reserve. Although various methods have been used, the management of controlled ovarian hyperstimulation is not easy in poor responders. The aim of this study was to evaluate the efficacy of dehydroepiandrosterone (DHEA) on in vitro fertilization-intracytoplasmic sperm injection (IVF-ICSI) outcome of poor responders. STUDY DESIGN This was a randomized, prospective controlled trial. Women with serum antimullerian hormone<1 ng/ml or serum follicle-stimulating hormone>15 IU/l and antral follicle count <4 on day 2 of the menstrual cycle were considered to have poor ovarian reserve. All women were treated with a microdose induction protocol. Women in the study group received IVF-ICSI and DHEA 75 mg daily for 12 weeks. Women in the control group received IVF-ICSI without DHEA supplementation. RESULTS In total, 208 women with diminished ovarian reserve was enrolled in the study, 104 in the study group and 104 in the control group. The number of oocytes retrieved and the fertilization rate were slightly higher in the study group, but the pregnancy rate was higher in the control group. The differences were not significant. CONCLUSIONS The results failed to show that DHEA supplementation enhances IVF-ICSI outcome in women with poor ovarian reserve.

Acute increase in plasma D-dimer level in ovarian torsion: an experimental study

BACKGROUND Torsion of the ovary is a rare but serious cause of gynecologic surgical emergency. Specific laboratory markers that support the preoperative diagnosis of ovarian torsion are not currently available in the clinical routine. The aim of this study was to investigate the diagnostic value of plasma D-dimer level as an early indicator of ovarian torsion in an experimental rat ovarian torsion model. METHODS Sixteen female adult Sprague-Dawley rats were used for this controlled experimental study. Eight rats in the sham operation group (Group I) underwent a surgical procedure similar to Group II but the ovary was not occluded. In Group II (eight rats), a torsion model was created by using atraumatic vascular clips just above and below the right ovary for a 2-h period of ischemia. Right ovaries were surgically removed at the end of the procedure in each group. Blood was sampled before and after operation to assess plasma D-dimer levels. The main outcome measure was ovarian histopathologic findings scores and plasma D-dimer levels. RESULTS There was no significant difference in pre-operative plasma D-dimer levels (0.5963 ± 0.2047 mg/l in Group I, 0.6344 ± 0.1348 mg/l in Group II, P = 0.815, Mann-Whitney U-test). However, mean plasma D-dimer value for Group II was significantly higher than that in the control group (1.2267 ± 0.3099 versus 0.6213 ± 0.2346 mg/l, respectively, Mann-Whitney U-test, P < 0.001), following 2 h of ovarian torsion. Ovarian tissue damage scores were also statistically significantly different among groups. CONCLUSIONS If the observations made in a rat model are extended to humans, plasma D-dimer measurement may be a valuable parameter in the early diagnosis of ovarian torsion.

Serum ischemia-modified albumin as a novel marker of ovarian torsion: An experimental study

OBJECTIVE To evaluate the effect of ovarian torsion on serum levels of ischemia-modified albumin (IMA) in an experimental model. STUDY DESIGN Sixteen female adult Sprague-Dawley rats were involved in the study. Rats were allocated randomly to group I or group II on the day of the experiment. Group I (eight rats) comprised the control (sham operated) group. In group II (eight rats), a torsion model was created by using atraumatic vascular clips just above and below the right ovary. At the end of a 3-h period of ischemia, the ovaries were removed. Blood was sampled before and after operation to assess serum IMA levels. Serum IMA levels (absorbance units) and histopathologic damage scores were evaluated. RESULTS Initial serum IMA levels were similar in both groups. After the operation, significant elevation was observed in group II in contrast to group I (0.191+/-0.034 and 0.277+/-0.089 ABSU, p=0.05). Histologic specimens of the ovaries in group II had higher scores of follicular cell degeneration, vascular congestion, hemorrhage and inflammatory cell infiltration than those in group I (p<0.001). CONCLUSIONS The elevated serum IMA levels observed in the ovarian torsion model seem to have a potential role as a serum marker in the early diagnosis of ovarian torsion.

Carbon dioxide pneumoperitoneum induces systemic oxidative stress: a clinical study

OBJECTIVE To investigate the effect of carbon dioxide pneumoperitoneum on systemic oxidative stress by using serum oxidative stress markers (ischemia modified albumin (IMA), malondialdehyde (MDA), total oxidant status (TOS), total antioxidant status (TAS) and oxidative stress index (OSI)) and to compare their effectiveness at clinically accepted safe intra-abdominal pressure levels (<12 mmHg). STUDY DESIGN A total of 33 consecutive patients who had a unilateral ovarian cyst were enrolled for this prospective clinical study. All women underwent a laparoscopic ovarian cystectomy procedure. Venous blood was collected from patients preoperatively, 10 min after induction of anesthesia and 30 min after insufflation. Preoperative, 10(min), and 30(min) serum IMA, MDA, TOS, OSI and TAS levels were compared. RESULTS The mean age was 29.3 ± 6.4 and the range of operation time was 45-80 min. The mean serum IMA levels showed a significant increase 30 min later from CO(2) insufflation (p<0.05). Significant alterations were not observed in serum MDA, TOS, OSI or TAS levels. CONCLUSIONS Laparoscopic surgery causes systemic ischemia and this ischemic effect can be revealed by measuring serum ischemia modified albumin. IMA is more sensitive than MDA, TOS, OSI and TAS in early detection of systemic oxidative stress.

Stage IV C prolapse in pregnancy

⁎ Corresponding author. KTU Tip Fakultesi, Farabi Hastanesi, Kadin Hastaliklari ve Dogum ABD, 61080 Trabzon, Turkey. Tel.: +90 462 3775869; fax: +90 462 3250518. E-mail address: drsuleymanguven@yahoo.com (S. Guven). Prolapse is a common gynecologic condition, yet prolapse during pregnancy is rare, with an estimated incidence of 1 case per 10 000– 15 000 deliveries; the complications of this condition include patient discomfort, urinary tract infection, acute urinary retention, abortion, preterm labor, andmaternal death. Standardmanagement of prolapse in pregnancy is still being debated [1]. In the present paper, 2 cases of uterine prolapse in pregnancy are reported, with review of the related literature. A 21-year-old gravida 4, para 3 was admitted to Sason Government Hospital with complaints of prolapse at 20 weeks of gestation. Her first delivery—at 17 years of age—ended, after a long labor and difficult delivery, with application of uterine fundal pressure. Other deliveries were uneventful at term. The patients medical and surgical histories were unremarkable, and there was no history of pelvic trauma, prolapse, or stress incontinence during or after the previous pregnancies. During the current pregnancy, she noted a feeling of heaviness at 10 weeks of gestation, and examination by local general practitioner revealed cervical descent to the level of the vaginal introitus. During the pregnancy, the cervix prolapsed out of the vaginal vault. Upon admission, clinical examination revealed stage IV prolapse, with point C as the leading edge according to the pelvic organ prolapse quantification (POP-Q) staging system (Fig. 1). The patient was managed conservatively (bed rest in a slight Trendelenburg position and 2 weeks of antibiotic therapy for urinary tract and cervical infection). At 26 weeks of gestation, she delivered an 860-g live male fetus. Shortly after delivery, the neonate died because of prematurity. Stage IV prolapse, with point C as the leading edge according to the POP-Q staging system, was evident at birth and 6 weeks postpartum. Pelvic reconstructive surgery was scheduled. A 36-year-old gravida 3, para 2 was admitted at 16 weeks of gestation following prolapse. Four years earlier, her first delivery was uneventful at term. The prenatal period of her second pregnancy was uncomplicated. The postpartum period immediately after vaginal delivery of her second child was complicated by prolapse. She was discharged from hospital 5 days later in good health and with complete resolution of prolapse. Further examination 6 weeks postpartum showed no evidence of prolapse. During the current pregnancy, 6 months after her second delivery, she was admitted with the same complaint. Upon admission, clinical examination revealed stage IV prolapse, with point C as the leading edge according to the POP-Q staging system (Fig. 1). The patientwas conservatively treatedwith bed rest. Stage IV C prolapsewas not resolved throughout the pregnancy. At 39 weeks of gestation, she delivered a 3300-g live female infant. Stage IV prolapse, with point C as the leading edge according to the POP-Q staging system, was evident at birth and 6 weeks postpartum. Pelvic reconstructive surgery was scheduled. The etiology of prolapse is multifactorial. Factors—including childbirth trauma, congenital weakness in pelvic fascial support, pelvic neuropathies, and large uterine and ovarian tumors—that result in increased intra-abdominal pressure and pelvic trauma can result in pelvic organprolapse.Moreover, thephysiologic changes of pregnancy— in terms of cervical elongation and hypertrophy—and the physiologic increases in cortisol, progesterone, and relaxin, which lead to a concomitant softening and stretching of the pelvic tissues, can also contribute to prolapse [1]. Management options for patientswho experience uterine prolapse in pregnancy have varied little over the years. Conservative management with genital hygiene and bed rest in a slight Trendelenburg position to enable prolapse replacement should be considered the foremost treatment option. These precautions protect the cervix from trauma/desiccation and reduce the incidence of preterm labor. Vaginal pessary application to protect the cervix may be considered beneficial, although displacement is common. Of interest is the recent report of a laparoscopic modified Gilliam suspension during early pregnancy, when other conservative solutions fail or when prolonged bed rest is impossible [2]. In cases of prolapse during pregnancy, normal vaginal delivery can be achieved. Although operative vaginal delivery with forceps or hysterostomatomy is advised, continued stretching of the lower segment to the point of uterine rupture due to cervical dystocia has also been reported [3]. In this situation, cesarean delivery becomes the inevitable choice for women with a thick, edematous, trapped, and irreducible cervix. Cesarean hysterectomy with subsequent suspension of the vaginal cuff might be a therapeutic option for women who have completed their families [4]. Obstetricians should be aware of prolapse during pregnancy and should bear in mind that it may lead to complications such as preterm delivery, prematurity, and urinary tract and cervical infections. However, the optimal current management guidelines for this rare condition are unclear.

Thoracopagus Conjoined Twins: A Case Report

Objective. Conjoined twin is a rarely seen congenital anomaly together with severe mortality and morbidity. The more common types of conjoined twins include the thoracopagus type, where the fusion is anterior, at the chest, and involves the heart. We are reporting one case of conjoined thoracopagus twins diagnosed by ultrasonography at 11 weeks. Case Report. In a multigravid pregnant woman who has been admitted to our clinic with a diagnosis of conjoined twins, thoracopagus, by ultrasonography at an 11-week gestation, termination of the pregnancy was performed. Conclusion. Making an early diagnosis with ultrasonographic examination gives the parents a chance to elect pregnancy termination.

Life-threatening intraabdominal bleeding after oocyte retrieval successfully managed with angiographic embolization

OBJECTIVE To report the first case of massive intraabdominal hemorrhage after transvaginal ultrasonographically guided oocyte retrieval that was successfully managed with angiographic uterine artery embolization. DESIGN Case report. SETTING Assisted reproduction unit of a tertiary university hospital. PATIENT(S) A 40-year-old woman with a history of primary infertility presented 10 days after oocyte retrieval because of severe abdominal pain, vomiting, and vaginal bleeding for 3 days. She had a history of mild factor VIII deficiency for 3 years. INTERVENTION(S) Evaluation of the intraabdominal hemorrhage with ultrasonography and angiography. Management of oocyte pickup complicated with intraabdominal hemorrhage. MAIN OUTCOME MEASURE(S) Treatment of massive life-threatening intraabdominal hemorrhage with bilateral uterine artery embolization. RESULT(S) After transfusion with 2 units of fresh-frozen plasma and packed red blood cell, an interventional radiologist performed percutaneous transcatheter pelvic angiography to detect abnormal vascularization and vascular blush consistent with hemorrhage and then immediate bilateral uterine artery embolization was done. The patient was discharged from the hospital 5 days later without any remarkable complications. CONCLUSION(S) Angiographic uterine artery embolization under fluoroscopic guidance is a successful nonsurgical approach for the treatment of oocyte pickup-induced life-threatening hemorrhage.

Asymptomatic macular tear in a woman with severe preeclampsia

‘silently’ at some point in the second or early third trimester. However, in this case it seems to have happened as an acute event at the time of spontaneous rupture of membranes. The resultant breach of the dividing amnion then permitted what has been termed ‘pseudomonoamniotic twinning’ and cord knotting (Megory et al. 1991). Pseudomonoamniotic twinning occurs when the membrane separating diamniotic twins becomes disrupted. As the three cases demonstrate, this then carries the same potential risk of cord and twin entanglement that typically only affected monoamniotic twin gestations. It has been reported following both amniocentesis and cordocentesis, and as such it is generally recommended that traversing the membrane of a twin sac at these procedures should be avoided whenever possible (Megory et al. 1991). With colour flow Doppler, it is now possible to identify cord entanglement by following the two cords to an area of suspected entanglement, at which point apparent branching of the umbilical vessels may be identified. With pulsed Doppler it may be possible to demonstrate two different heart rates within the entwined area (Belfort et al. 1993). This case adds to the current literature and serves to highlight the need for awareness as to the possibility that a diamniotic twin pregnancy can develop into a pseudomonoamniotic pregnancy either following invasive procedures, silently, or after spontaneous rupture of membranes. These pregnancies can then too be complicated by cord entanglement and or knotting, a complication which becomes particular hazardous during labour and which hitherto has been thought to only occur in monoamniotic twinning.

The effect of chronic pelvic pain scoring on pre-term delivery rate

A total of 57 pregnant women, who were admitted to the outpatient clinic having high visual analogue scale (VAS) and a history of chronic pelvic pain before pregnancy, were evaluated with the international pelvic pain assessment form (IPPAF). Gynaecological disorders, pain at ovulation, dysmenorrhoea, level of cramps with period and suspicion of endometriosis were determined to be higher in the pre-term group (p < 0.05). Regarding urological disorders, pain when the bladder was full, pain with urination, a positive answer to the question, ‘Does your urgency bother you?’ and suspicion of interstitial cystitis were also determined to be higher in the pre-term group (p < 0.05). Thus, the total IPPAF scores were significantly higher in the pre-term group (p < 0.05). The pregnant women with a higher total IPPAF score before pregnancy may thus have a higher probability of pre-term labour.

The Diagnostic Value of β-Human Chorionic Gonadotropin, Progesterone, and Ischemia-Modified Albumin and Their Combined Use in the Prediction of First Trimester Abortions

Objective. To investigate serum levels of free β-HCG, progesterone, and ischemia-modified albumin (IMA) and their combined use in the prediction of first trimester abortions. Methods. A total of 156 pregnant women between 5 and 13 weeks of gestational age were included in this study. At admission, serum levels of free β-HCG, progesterone, and IMA were noted and all cases were divided into two groups; Group I (n = 77) resulted in abortion including missed abortion, incomplete/complete abortion, and inevitable abortion whereas Group II (n = 79) included normal pregnancies. Results. Compared to Group II, the significantly decreased value of free β-HCG progesterone and significantly increased value of IMA were found in Group I (P < 0.01, P < 0.01, P < 0.01, resp.). When combining all three parameters, sensitivity 75%, specificity 99%, PPV 98%, and NPV 76% were obtained. The multivariate logistic regression analysis revealed the free β-HCG, progesterone, and IMA independent factors in the prediction of abortions. Conclusions. The combined use of free β-HCG, progesterone, and IMA levels can be useful in the prediction of first trimester spontaneous abortions.