Does obesity have detrimental effects on IVF treatment outcomes?

BACKGROUND: The aim of this study was to investigate the influence of body mass index (BMI) on the in vitro fertilization (IVF) treatment outcomes in a cohort of women undergoing their first IVF, using an intracytoplasmic sperm injection (ICSI). METHODS: This retrospective cohort study included 298 cycles from women younger than 38 years old undergoing IVF-ICSI at a university infertility clinic. The treatment cycles were divided into three groups according to the BMI of the women involved: normal weight (18.5 ≤ BMI < 25 kg/m(2), 164 cycles), overweight (25 ≤ BMI < 30 kg/m(2), 70 cycles), and obese (BMI ≥ 30 kg/m(2), 64 cycles). The underweight women (BMI < 18.5 kg/m(2)) were not included in the analysis due to small sample size (n = 22). The patient characteristics and IVF-ICSI treatment outcomes were compared between the BMI groups. RESULTS: The total gonadotropin dose (p <0.001) and duration of stimulation (p = 0.008) were significantly higher in the obese group when compared to the normal BMI group. There were no significant differences across the BMI categories for the other IVF-ICSI cycle outcomes measured, including the number of retrieved oocytes, mature oocytes, embryos suitable for transfer, proportion of oocytes fertilized, and cycle cancellation rates (p >0.05 for each). Additionally, clinical pregnancy, spontaneous abortion, and the ongoing pregnancy rates per transfer were found to be comparable between the normal weight, overweight, and obese women (p >0.05 for each). CONCLUSION: Obese women might require a significantly higher dose of gonadotropins and longer stimulation durations, without greatly affecting the pregnancy outcomes.

A Flexible Multidose GnRH Antagonist versus a Microdose Flare-Up GnRH Agonist Combined with a Flexible Multidose GnRH Antagonist Protocol in Poor Responders to IVF.

OBJECTIVE: To compare the effectiveness of a flexible multidose gonadotropin-releasing hormone (GnRH) antagonist against the effectiveness of a microdose flare-up GnRH agonist combined with a flexible multidose GnRH antagonist protocol in poor responders to in vitro fertilization (IVF). STUDY DESIGN: A retrospective study in Akdeniz University, Faculty of Medicine, Department of Obstetrics and Gynecology, IVF Center, for 131 poor responders in the intracytoplasmic sperm injection-embryo transfer (ICSI-ET) program between January 2006 and November 2012. The groups were compared to the patients' characteristics, controlled ovarian stimulation (COH) results, and laboratory results. RESULTS: Combination protocol was applied to 46 patients (group 1), and a single protocol was applied to 85 patients (group 2). In group 1, the duration of the treatment was longer and the dose of FSH was higher. The cycle cancellation rate was significantly higher in group 2 (26.1% versus 38.8%). A significant difference was not observed with respect to the number and quality of oocytes and embryos or to the number of embryos transferred. There were no statistically significant differences in the hCG positivity (9.5% versus 9.4%) or the clinical pregnancy rates (7.1% versus 10.6%). CONCLUSION: The combination protocol does not provide additional efficacy.

Might uterus transplantation be an option for uterine factor infertility?

Current data on uterus allotransplantation research has been reviewed and summarized. Over the past 15 years, progress in uterus transplantation research has increased dramatically. As a consequence, the first pregnancy and delivery following uterus allotransplantation in rats have been reported. The technique has been better defined. Although clinical pregnancy and delivery following uterus allotransplantation has been reported in humans, there are still many questions to be answered before clinical application. Gestational surrogacy still remains an important option for being a genetic parent in selected cases with uterine factor infertility.

Fatal Disseminated Tuberculous Peritonitis following Spontaneous Abortion: A Case Report.

We describe a rare case of fatal disseminated tuberculous peritonitis in a young woman with rapid progressive clinical course following spontaneous abortion of 20-week gestation. Clinical and laboratory findings were initially unremarkable. She underwent diagnostic laparoscopy which revealed numerous tiny implants on the peritoneum and viscera. Histopathology showed chronic caseating granulomas, and the tissue culture grew Mycobacterium tuberculosis. At fifth day of the antituberculous treatment multiorgan failure occurred in terms of pulmonary, hepatic, and renal insufficiency. She developed refractory metabolic acidosis with coagulopathy and pancytopenia, and she died of acute respiratory distress syndrome and septic shock on her twelfth day of hospitalization.

Uterus transplantation from a deceased donor.

OBJECTIVE: To demonstrate the technique for uterus retrieval and transplantation from a multiorgan donor. DESIGN: Video presentation of our case report. The video uses animation to demonstrate the technique. Institutional Review Board (IRB) approval was obtained. SETTING: University hospital. PATIENT(S): A 21-year-old woman with complete müllerian agenesis. INTERVENTION(S): Uterus allotransplantation has been performed from a deceased donor. MAIN OUTCOME MEASURE(S): Acquirement of cyclic menstrual function. RESULT(S): This video demonstrates the technique for uterus retrieval, perfusion, and transplantation. The recipient patient has been monitored regularly for vascular flow, immunosuppression, and infection control since the operation. CONCLUSION(S): Uterus transplantation requires extensive evaluation of the recipient and donor by an experienced multidisciplinary transplantation team both pre- and postoperatively. It has major risks related to surgery, immunosuppression, and pregnancy. Uterus transplantation might be considered promising only after the birth of a near-term healthy baby.

Preliminary results of the first human uterus transplantation from a multiorgan donor.

OBJECTIVE: To describe the first-year results of the first human uterus transplantation case from a multiorgan donor. DESIGN: Case study. SETTING: University hospital. PATIENT(S): A 21-year-old woman with complete müllerian agenesis who had been previously operated on for vaginal reconstruction. INTERVENTION(S): Uterus transplantation procedure consisting of orthotopic replacement and fixation of the retrieved uterus, revascularization, end to site anastomoses of bilateral hypogastric arteries and veins to bilateral external iliac arteries and veins was performed. MAIN OUTCOME MEASURE(S): Resumption of menstrual cycles. RESULT(S): The patient had menarche 20 days after transplant surgery. She has had 12 menstrual cycles since the operation. CONCLUSION(S): We have described the longest-lived transplanted human uterus to date with acquirement of menstrual cycles.

Robotic-assisted laparoscopic repair of symptomatic cesarean scar defect: a report of two cases.

BACKGROUND: Symptomatic cesarean scar defect is one of the commonly reported long-term complications of cesarean section. CASES: We present two cases of symptomatic cesarean scar defect treated conservatively by robotic-assisted laparoscopy at our institution. Both patients presented with hematocele, pelvic discomfort and secondary infertility. Transvaginal ultrasound revealed hematocele measuring 3.7 x 1.9 x 3.8 cm and 3.0 x 2.0 x 1.6 cm in the lower uterine segments, respectively. After surgery normal menses resumed in both patients, and their childbearing potential was preserved. The patients conceived 3 and 11 months after surgery, respectively. CONCLUSION: Recognition of cesarean scar defect is important in the explanation of certain menstrual disorders since surgical intervention can result in improvement of symptoms and prevent the related secondary obstetric and gynecologic complications. Robotic-assisted laparoscopic approach is a good minimally invasive alternative for the repair of cesarean scar defect.

Successful conservative management of cervical ectopic pregnancy: a case series.

OBJECTIVE: To report our experience of conservative treatment in four patients with cervical ectopic pregnancy. DESIGN: Case series. SETTING: Academic medical center. PATIENTS: Four women diagnosed with cervical ectopic pregnancy managed conservatively. INTERVENTION(S): Systemic methotrexate alone or combined with subsequent uterine artery embolization (UAE). MAIN OUTCOME MEASURES: Conservative management with decreased rate of serious complications. RESULTS: No hysterectomies were needed. One patient required subsequent intervention, UAE. CONCLUSION: Conservative treatment of cervical pregnancy might be successful with careful follow up and subsequent conservative interventions.

Robotic-assisted laparoscopic ovarian tissue transplantation.

OBJECTIVE: To describe a technique for frozen-banked ovarian tissue transplantation using robotic-assisted laparoscopy. DESIGN: Case study. SETTING: Academic tertiary care center. PATIENT(S): A 38-year-old patient in remission for non-Hodgkin lymphoma, whose ovarian tissue had been frozen for 3 years. INTERVENTION(S): Robotic-assisted laparoscopic transplantation of thawed ovarian cortical tissue to the remaining ovary and peritoneum. MAIN OUTCOME MEASURE(S): Resumption of spontaneous menses, follicular development, and ovulation as demonstrated by ultrasound, and serum E(2) and P levels. RESULT(S): The patient experienced cyclic spontaneous menstruation 6 months after the transplantation. Ovulation was confirmed by ultrasound and serum E(2) and P levels at month 11 after surgery. CONCLUSION(S): Robotic-assisted laparoscopic surgery may be a good, minimally invasive alternative for the ovarian tissue transplantation procedure to restore ovarian function.

Culdocentesis followed by saline solution-enhanced ultrasonography: technique for evaluation of suspected ectopic pregnancy.

STUDY OBJECTIVE: To evaluate the use of a technique consisting of culdocentesis followed by saline solution-enhanced pelvic ultrasonography in cases suspect for ectopic pregnancy in which an accurate diagnosis could not be made using routine transvaginal ultrasound. DESIGN: Retrospective clinical study (Canadian Task Force classification III). SETTING: Academic medical center. PATIENTS: Twenty patients with an initial diagnosis of pregnancy of unknown location. INTERVENTIONS: In 20 patients with symptoms of early pregnancy and serum quantitative human chorionic gonadotropin concentration, ectopic pregnancy could not be confirmed or ruled out. Transvaginal ultrasound-guided culdocentesis was performed, and 300 to 400 mL of normal saline solution was injected into the posterior cul-de-sac and pelvis. Transvaginal ultrasound was repeated with particular attention to the floating fallopian tubes MEASUREMENTS AND MAIN RESULTS: Using this technique, a tubal pregnancy was visualized in 15 of 20 patients, and ectopic pregnancy was ruled out in 5 patients. In all patients, appropriate management was provided according to the final diagnosis, and consisted of either methotrexate, laparoscopic salpingostomy or salpingectomy, or expectant management in patients with abnormal intrauterine pregnancies. CONCLUSION: Ultrasound-guided culdocentesis followed by saline solution-enhanced pelvic ultrasound can be considered as a diagnostic tool in patients with suspected ectopic pregnancy in whom other methods fail to demonstrate this diagnosis.

The use of vascularized jejunum flap for vaginal reconstruction: clinical experience and results in 22 patients.

The ideal reconstructive method for a vagina should provide a durable, stable coverage, a patent tube passage for sexual intercourse, and a natural esthetic contour, while simultaneously minimizing morbidity in both the recipient and donor sites, and should be a single stage procedure obviating the use of stents, obturators, and lubrication. Twenty-two patients with absence of the vagina underwent vaginal reconstruction using the jejunal segment transfer technique. Two flaps required re-operation due to venous compromise postoperatively. The flaps were salvaged with venous anastomosis revisions. The overall flap success rate was thus 100%. No urinary tract or gastrointestinal system complication was observed in any case, nor any instance of vaginal introitus. The average follow-up period was 19 months (between 3 and 48 months). Both the depth and diameter of the neovagina were satisfactory postoperatively. After the immediate postoperative period, the only major and embarrassing problem was hypersecretion of the jejunal segment, but this gradually diminished, especially after the first 3 months. Those patients who engaged in sexual intercourse reported good patency and had no complaints in that regard. In conclusion with its evident advantages, the jejunal segment can serve as a reliable option for vaginal reconstruction. It provides quite satisfactory results from both the cosmetic and functional points of view.

Microvascular augmented pedicled jejunum transfer for vaginal reconstruction using a laparoscopy-assisted technique.

Although there is no distinct, absolute, and ideal method for vaginal reconstruction, intestinal transfers are preferable to the other described techniques in the main clinics. In this report, we describe the transfer of a jejunal segment for vaginal reconstruction in a 20-year-old female patient, harvesting the flap based on its vascular pedicle by means of a laparoscopic technique that obviates the use of midline laparotomy. To prevent any vascular compromise, two different vascular supply sources were provided for the flap performing additional arterial and venous microvascular anastomosis. The results have confirmed the feasibility of the technique. The functional, structural, and esthetic advantages of the jejunal flap and the lower donor site morbidity of the laparoscopy-assisted technique that were rather encouraging are described and discussed.

Long-term fluctuation of retinal sensitivity during pregnancy.

BACKGROUND: We investigated the effect of pregnancy on the long-term fluctuation of retinal sensitivity in healthy women. METHODS: Candidates for the study were healthy women who were likely to become pregnant. A complete ocular examination of both eyes was performed in 41 women, and 1 eye each was chosen at random for the study. This initial examination included 2 sets of visual field measurements consisting of 5 individual measures done at least a day apart. After pregnancy, ocular examinations were repeated once between 10 and 15 weeks of gestation and once between 29 and 34 weeks. The mean threshold sensitivity (MS) of the visual field and the coefficient of variation of MS measurements for upper temporal, upper nasal, lower temporal, and lower nasal quadrants were calculated in each series. RESULTS: The visual field MS of the subjects increased significantly in the third trimester (p < 0.01). The coefficient of variation of the visual field MS measurements did not change significantly in the nasal quadrants. However, it decreased significantly in both upper and lower temporal quadrants. INTERPRETATION: Visual field MS and the reproducibility of MS measurements for temporal visual field increased significantly in the third trimester of the pregnancy. Further studies on the role of pregnancy-related ocular hemodynamic changes may provide insight into the etiopathogenesis of hormone-related processes.

Menstrual cycle-dependent differences between right and left visual hemifields in perimetry.

PURPOSE: To evaluate the effect of the menstrual cycle and gender on right and left visual hemifields in healthy subjects. METHODS: One randomly selected eye from each of 42 healthy normally menstruating women and of 37 men with no systemic and ocular problems, other than refractive error, were included in the study. Subjects underwent complete ocular examination and standard acromatic perimetric (SAP) and short-wavelength automated perimetric (SWAP) analysis in both follicular (7th to 10th day of the cycle) and luteal phases (days 3 to 7 before the menstrual bleeding) of the menstrual cycle. Visual field analysis was performed using Model 750 Humphrey Field Analyzer II (Carl Zeiss Meditec, Dublin, CA, USA) with full-threshold, central 30-2 program. RESULTS: The mean age of female (n = 42) and the male subjects (n = 37) were 35.2 +/- 3.1 years and 34.8 +/- 2.9 years, respectively (p = 0.58). Neither females nor males showed any statistically significant differences in the right and left hemifield tests with SAP (both p values > 0.05). However, using SWAP, in luteal phase of female subjects, left hemifield sensitivity was significantly less than (with a mean of 0.47 dB) right hemifield. In follicular phase, there was no significant interhemifield difference (p > 0.05). Male subjects did not show any significant differences between the sensitivity of the two hemifields with SWAP tests. CONCLUSIONS: There has been a significant difference between the mean SWAP sensitivity of right and left visual hemifields in luteal phase of the menstrual cycle. In case of a suspected hemifield difference, SAP rather than SWAP may be used to confirm suspected neurological defects as SAP is not affected by the menstrual cycle.

Effect of the menstrual cycle on the optic nerve head in diabetes: analysis by confocal scanning laser ophthalmoscopy.

BACKGROUND: The purpose of this study was to examine and compare menstrual-cycle-dependent topographic changes in the optic nerve head of normally menstruating women with different grades of type 2 diabetes mellitus. METHODS: We studied the right eyes of 123 normally menstruating women (36 with severe nonproliferative diabetic retinopathy [NPDR], 42 with mild NPDR and 45 healthy subjects). All subjects underwent a complete ocular examination at baseline. At 4 hormonally distinct phases of the menstrual cycle (early follicular, late follicular, mid-luteal and late luteal), we analysed the topography of the optic nerve head, using a confocal scanning laser ophthalmoscope, and measured the serum levels of estradiol, progesterone and luteinizing hormone. RESULTS: We excluded from analysis the data for 8 patients with severe NPDR, 10 patients with mild NPDR and 15 control subjects who were lost to follow-up examinations during the menstrual cycle. The mean age and optic disc area did not differ significantly among the 3 groups. The duration of diabetes was significantly longer in the patients with severe NPDR than in those with mild NPDR (p < 0.05). The women with severe NPDR had a significantly increased neuroretinal rim area and a significantly decreased cup-shape measure, linear cup/disc ratio, cup/disc area ratio and cup area in the late luteal phase compared with the other phases of the menstrual cycle (p < 0.05). Those with mild NPDR or a normal retina had no significant topographic changes in the optic nerve head during the menstrual cycle. INTERPRETATION: Severe NPDR is associated with significant topographic changes in the rim and cup of the optic nerve head during the menstrual cycle. This must be considered in the evaluation of women with both diabetes and glaucoma. The normal fluctuations in serum sex hormone levels during the menstrual cycle of diabetic women seem to affect the optic nerve head more when the disease is advanced.