Does anticoagulant therapy improve adverse pregnancy outcomes in patients with history of recurrent pregnancy loss?

OBJECTIVES: Recurrent pregnancy loss (RPL) is a serious problem in the reproductive age women. We aimed to study the role of anticoagulant therapy on pregnancy complications and perinatal outcomes in pregnant patients with histories of RPL. MATERIAL AND METHODS: One hundred fifty-three pregnants, with RPL history and thrombophilia positivity, were grouped into two as 89 treated with anticoagulant therapy and 64 non-treated. Treated and untreated groups were compared for pregnancy complications, delivery weeks, abortion rates, fetal birth weights, APGAR scores, live birth rates, and newborn intensive care admission rates. RESULTS: Of the total 153 pregnant patients (63%) 97 developed pregnancy complications; 55 (56.7%) were in the untreated group and 42 (43.3%) were in the treated group, which was statistically significant (p = 0.003). The differences in pregnancy complications were produced by differences in the numbers of IUFDs and anembryonic fetuses among the groups. The average neonatal birth weights of infants whose mothers had taken LMWH + ASA were significantly higher (p=0.011). The prematurely delivered infants were admitted to the neonatal intensive care unit (NICU), and the NICU requirements were not statistically different between the groups (p = 0.446). However, live birth rates were significantly higher in the treated group than in the untreated group (p = 0.001). CONCLUSIONS: Anticoagulant therapy improves pregnancy complications and live birth rates in patients with RPL and hereditary thrombophilia.

The effect of nifedipine tocolysis on Doppler indices of the uterine and umbilical arteries.

PURPOSE: The aim of this study was to evaluate the effect of oral nifedipine on Doppler indices of the uterine artery (UtA) and umbilical artery (UA) before and 24 hours, 48 hours, and 1 week after tocolytic treatment. METHODS: This was a prospective, self-controlled, cohort study of 65 pregnant women undergoing nifedipine tocolysis. Doppler assessment of the UtA and UA was performed before treatment and 24 hours, 48 hours, and 1 week after the initial 4 doses of 10 mg of oral nifedipine, administered at 20-minute intervals. The maintenance dosage was 20 mg of oral nifedipine administered every 6 hours for 48 hours, for a total dose of 80 mg/day. RESULTS: There was a decrease in the 24-hour values of the UA pulsatility index, resistance index (RI), systolic-diastolic (S:D) ratio, right UtA pulsatility index, RI, S:D ratio, and left UtA RI and S:D ratio with nifedipine therapy in comparison with the values recorded prior to nifedipine therapy. However, these differences were not statistically significant. There were no statistically significant differences between the data recorded prior to nifedipine administration and those obtained at 48 hours and 1 week after treatment. CONCLUSIONS: Oral nifedipine is a safe tocolytic agent with no long-term effect on fetomaternal circulation in pregnant women at risk of preterm delivery.

Unilateral ovarian agenesis and clear cell type epithelioid leiomyoma of uterus mimicking ovarian malignancy.

A case of unilateral absent ovary together with clear cell type epithelioid leiomyoma of uterus mimicking ovarian malignancy discovered during laparotomy is presented. Unilateral absence of an ovary is an extremely rare finding. Although the exact pathophysiological mechanism is not known, it could result from a defect in embryological development or asymptomatic torsion of ovary. Clear cell type epithelioid leiomyoma of uterus is also a rare variant, composed of round or polygonal 'clear' cells rather than typical spindle-shaped cells and ultra structurally differs from non-uterine counterparts.

Sexual dysfunction in infertile couples: evaluation and treatment of infertility.

OBJECTIVE: To evaluate the diagnostic and the predictive value of Arizona Sexual Experience Scale among primary infertile couples regarding sexual dysfunction. METHODS: The cross-sectional and prospective pre, post study comprising primary infertile patients was carried out at Bulent Ecevit University Hospital, Zonguldak, Turkey. Fifty consecutive primary infertile couples not treated previously were investigated between 2003 and 2007 for the presence of sexual dysfunction by a psychiatrist. Arizona Sexual Experience Scale scoring was self-administered to determine sexual dysfunction among couples before treatment and also 3 months after the initiation of the treatment. RESULTS: Pretreatment mean values of the index parametres in both women and men were significantly increased after treatment. Statistically significant positive correlation was observed between pre- and post-treatment total scores in both women (r = 0.83; p < .001) and men (r = 0.92; p < .001). Receiver operating characteristic curve analyses revealed optimum cut-offs of pre- and post-treatment scores in women were were > 14 (Sensitivity: 57%; Specificity: 90%) and > 13 (Sensitivity: 83%; Specificity: 93%), respectively. Pre- and post-treatment scores in men were > 10 (Sensitivity: 65%; Specificity: 61%), > 11 (Sensitivity: 83%; Specificity: 62%), respectively. Binary logistic regression analyses revealed women's pre-treatment and post-treatment scores as a significant factor for prediction of sexual dysfunction independent of sociodemographic factors (p = 0.001 and p = 0.001, respectively). CONCLUSION: Evaluation and treatment of infertility is an important risk factor for sexual dyfunction. Pre- and posttreatment Arizona Sexual Experience Scale score could be used as a screening test for sexual dysfunction and might be used to decide pre/post-treatment consultation of couples with a specialist.

Levels of oxidized LDL, estrogens, and progesterone in placenta tissues and serum paraoxonase activity in preeclampsia.

In vitro literature studies have suggested that atherosclerotic oxidized low density lipoprotein (OxLDL) inhibits trophoblast invasion. The objective of this study was to determine the levels of OxLDL and to examine the relationship between antioxidative estradiol, estriol, and prooxidative progestin in normal and preeclamptic placental tissues and measure the serum activity of antioxidative paraoxonase (PON1). The study included 30 preeclamptic and 32 normal pregnant women. OxLDL was determined with ELISA, estradiol, unconjugated estriol, and progesterone that were determined with chemiluminescence method in placental tissues. Serum PON1 activity was determined with spectrophotometric method. Levels of OxLDL (P = 0.027), estriol (P < 0.001), estradiol (P = 0.008), and progesterone (P = 0.009) were lower in the placental tissues of preeclamptic group compared to the normal pregnant women. Serum PON1 activity was higher in preeclamptic group (P = 0.040) and preeclamptic group without intrauterine growth restriction (P = 0.008) compared to normal pregnant women. Tissue estriol of preeclamptic group without/with IUGR (P < 0.001, P = 0.002) was lower than the normal group. Results of our study suggest that the events leading to fetoplacental insufficiency lead to a reduction in the levels of estriol limit deposition of OxLDL in placental tissues. The serum PON1 activity is probably important in the inhibition of OxLDL in preeclampsia.

Placental prostate-specific antigen content in preeclampsia.

Preeclampsia is a multisystem disorder that can manifest clinically with hypertension and proteinuria. Previous studies reported the presence of placental PSA in normal pregnancy but no study has been done in preeclampsia. The aim of this study was to investigate PSA content in preeclampsia. Preeclampsia was diagnosed according to the American College of Obstetricians and Gynecologists criteria. Placentas were obtained from 33 preeclamptic and 34 normotensive women. Placenta samples were homogenized and the supernatants were immediately analyzed. The tissue PSA content was measured by Immulite 2000 PSA assay. The data were analyzed with Student's t-test and Pearson correlation test. There was a significant difference in placental PSA content between preeclamptic and normotensive women. Placental content of PSA was higher in the preeclamptic group with intrauterine growth restriction (IUGR) than in the preeclamptic and normotensive pregnant without IUGR groups. No significant difference was found in this respect between preeclamptic and normotensive women without IUGR. In conclusion, we found that placental PSA content is elevated in preeclampsia and negatively correlated with infant birth weight. Further studies will be necessary to define the roles of PSA more precisely and to examine its effects on the pathophysiology of preeclampsia.

Comparison of the histopathological diagnoses of preoperative dilatation and curettage and hysterectomy specimens.

AIM: A biopsy is often taken as part of the preoperative workup, regardless of the indication for hysterectomy. Some authors believe that dilatation and curettage is a poor diagnostic procedure for intrauterine pathologies, but dilatation and curettage has been the method of choice for obtaining an endometrial sample. The aim of this study was to investigate the concordance between endometrial histopathological diagnoses from preoperative dilatation and curettage and hysterectomy specimens. The differences between premenopausal and postmenopausal women were also investigated. METHODS: Histopathological results for dilatation and curettage specimens from 645 women (401 premenopausal and 244 postmenopausal) who underwent a hysterectomy between 2003 and 2009 were analyzed retrospectively. RESULTS: High sensitivity (87.8%), specificity (100%), positive (100%) and negative (98.7%) predictive values, and accuracy (98.8%) were observed for all malignant endometrial pathologies obtained at dilatation and curettage. In postmenopausal women, eight malignancies were missed when the preoperative diagnosis from the dilatation and curettage sample indicated inadequate tissue or premalignant lesions. For premenopausal women, we found only two missed malignancies. The accuracy was 99.5% and 96.8% for malignant pathologies diagnosed from curettage material for pre- and postmenopausal women, respectively. CONCLUSIONS: Dilatation and curettage remains the 'gold standard' for diagnosing endometrial pathologies, especially malignancies.

Idiopathic ileoileal invagination two days after cesarean section.

Postoperative enteroenteric invagination is rare. The only previously reported case post-cesarean was secondary to colonic adenocarcinoma. A 27-year-old woman with preeclampsia delivered a baby by cesarean section. On the second postoperative day, she had abdominal pain, nausea, vomiting, constipation, and distention. An abdominal x-ray showed air-fluid levels, while free fluid (ascites) was detected by ultrasonography. A computed tomography scan did not show the typical invagination picture. Her condition did not improve after 72 h of conservative treatment, and diagnostic laparotomy was performed. A 10 × 3-cm ileoileal invagination 80 cm proximal to the ileocecal valve was found and manually reduced. The patient was discharged on the fifth postoperative day, and her six-month follow-up was normal.

Management of fetal bronchogenic lung cysts: a case report and short review of literature.

Congenital malformations of the lung (CML) are rare with similar embryological and clinical spectra and could result in mortality if left untreated. Bronchogenic cysts are formed during the budding of the tracheal diverticula and ventral foregut in the embryological period. In this paper we want to present a case of bronchogenic cyst with continuous intrauterine cyst aspiration follow-up. After the baby birth was operated and the postoperative period was uneventful. The pathological examination revealed a bronchogenic cyst.

Herlyn-Werner-Wunderlich syndrome (uterus didelphys, blind hemivagina and ipsilateral renal agenesis) - a case report.

Uterovaginal duplication with obstructed hemivagina and ipsilateral renal agenesis is referred to as the Herlyn-Werner-Wunderlich (HWW) syndrome. A 17 year old woman presented with right pelvic pain and dysmenorrhea, present since menarche at 13 and worsening over the past year. Ultrasound examination revealed a right pelvic mass (5×5 cm), double endometrial echoes, and hematocolpos. A right pelvic mass, agenesis of the right kidney, double uterus, and blind hemivagina with hematocolpos were detected by magnetic resonance imaging and intravenous pyelography. A right tubo-ovarian abscess with dense adhesions and a double uterus were observed on diagnostic laparoscopy. Adhesiolysis was carried out and purulent material irrigated. After a course of antibiotics, a vaginal septum resection was performed and the pyocolpos drained. She remained symptom free after four months of follow-up. Prompt and accurate diagnosis and treatment of this syndrome can significantly improve the lives of sufferers and prevent future complications.

Eikenella corrodens, cause of a vulvar abscess in a diabetic adult.

We report a case of Eikenella corrodens causing vulvar abscess in a diabetic patient. Eikenella corrodens is a slow growing, nonmotile, facultative anaerobic, Gram-negative bacillus which is commensal of the oral cavity, intestinal and genital tracts. The most common clinical sources of this organism are human bite wounds, head and neck infections and respiratory tract infections. In our knowledge, the presented case is the first report of Eikenella corrodens causing vulvar abscess in a diabetic patient.

Comparison of satisfaction and pain relief between patients-controlled analgesia and interval analgesia after laparoscopic ovarian cystectomy.

Preoperative and postoperative psychological factors, postoperative pain, analgesic consumption, treatment satisfaction were compared in patients treated with intravenous patient-controlled analgesia (IV-PCA) or intramuscular analgesics after laparoscopic ovarian cystectomy. Thirty-one women with laparoscopically operated benign ovarian cysts were recruited in Zonguldak Karaelmas University Faculty of Medicine, Department of Obstetrics and Gynecology. Postoperatively sixteen women received morphine delivered by IV-PCA pump system and 15 women were prescribed another opioid (meperidine) intramuscularly. Two weeks before and one day after the surgery, Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI) were self-administered. Afterwards, the operation visual analog scale (VAS) and satisfaction with pain control scale were recorded. Preoperative BDI and BAI scores of both groups were comparable. Postoperative BDI (7.9 +/- 7.2 versus 13.8 +/- 6.9, P = 0.03) and BAI (11.4 +/- 9.1 versus 17.4 +/- 6.2, P = 0.045) scores were significantly lower in the IV-PCA group. Morphine usage with PCA resulted in significantly higher pain scores than equivalent doses of meperidine administered intramuscularly (2.94 +/- 1.0 versus 1.67 +/- 0.7, P = 0.001). Although higher pain scores were obtained from IV-PCA group, self-reported satisfaction rates were higher in this group (8.3 +/- 1.1 versus 7.4 +/- 1.1, P = 0.04). Involvement of patients in their pain management might increase the awareness of pain but their satisfaction about the control of postoperative pain was significantly improved.

Ovarian adenomyoma following gonadotrophin treatment for infertility.

An ovarian adenomyoma developed in a 38-year-old infertile patient following treatment with exogenous gonadotrophins. Laparoscopic excision was performed. Histological examination showed thick muscular bundles resembling myometrium lined with endometrial glands and stroma. Gonadotrophins might be involved in the pathogenesis of extrauterine adenomyoma.

Use of an aromatase inhibitor in patients with polycystic ovary syndrome: a prospective randomized trial.

OBJECTIVE: To compare the use of an aromatase inhibitor (letrozole) with the use of clomiphene citrate (CC). DESIGN: Prospective randomized study. SETTING: An infertility clinic in a university hospital. PATIENT(S): Seventy-four consecutive infertile patients with polycystic ovary syndrome were recruited. Thirty-eight patients were randomized to the letrozole group (99 cycles), and the remaining patients were recruited to the CC group (95 cycles). INTERVENTION(S): The aromatase inhibitor letrozole (2.5 mg/d) and CC (100 mg/d) were administered orally on days 3-7 of menses. MAIN OUTCOME MEASURE(S): Number of follicles, endometrial thickness, E(2) levels on hCG day, and pregnancy rates among both groups. RESULT(S): Ovulation occurred in 65.7% (65/99) of letrozole cycles and in 74.7% (71/95) of CC cycles. The median (minimum-maximum) number of follicles sized >15 mm in diameter on the day of hCG administration were 1 (0-4) and 1 (0-5) in the letrozole and CC groups, respectively. On the day of hCG administration, median serum E(2) concentrations in the letrozole and CC groups were statistically significantly different: 189 pg/mL (18-1,581 pg/mL) and 386 pg/mL (27-6,190 pg/mL), respectively. The median serum E(2) concentrations per follicle sized >15 mm in diameter on the day of hCG also statistically significantly differed between the letrozole and CC groups: 160 pg/mL (18-808 pg/mL) and 281 pg/mL (27-2,615 pg/mL), respectively. The median endometrial thickness on the day of hCG did not significantly differ between the CC and letrozole groups; it was 8 mm. Pregnancy was achieved in nine cycles (9.1%) of the letrozole group and in seven cycles (7.4%) of the CC group, which also was not a statistically significant difference. CONCLUSION(S): The aromatase inhibitor letrozole may be an acceptable alternative to CC as an ovulation-induction drug in patients with PCOS.

Outcome of in vitro fertilization/intracytoplasmic sperm injection after laparoscopic cystectomy for endometriomas.

OBJECTIVE: To assess the impact of prior unilateral or bilateral endometrioma cystectomy on controlled ovarian hyperstimulation (COH) and intracytoplasmic sperm injection (ICSI) outcome. DESIGN: Retrospective case-control study. SETTING: Department of Obstetrics and Gynecology, School of Medicine, Hacettepe University, Ankara, Turkey. PATIENT(S): Fifty-seven consecutive infertile patients were enrolled who had previously undergone unilateral (n = 34) or bilateral (n = 23) laparoscopic cystectomy for endometriomas more than 3 cm in diameter and underwent ICSI. The control group consisted of 99 patients with tubal factor infertility. INTERVENTION(S): Controlled ovarian hyperstimulation and ICSI. MAIN OUTCOME MEASURE(S): Cycle cancellation rate, number of oocytes, fertilization rate, embryo quality, clinical pregnancy rate (PR), and implantation rate. RESULT(S): The mean number of oocytes, metaphase II oocytes, and two-pronucleated oocytes were significantly lower in the bilateral cystectomy group compared to the unilateral cystectomy and control groups. However, all other parameters, including fertilization rate, the mean number of embryos transferred, the mean number of grade 1 embryos transferred, the clinical PR per embryo transfer, and implantation rate, were comparable among the three groups. Within the unilateral cystectomy group, the mean number of oocyte retrieved from the operated site was significantly less than in the contralateral nonoperated site. CONCLUSION(S): Laparoscopic endometrioma cystectomy does reduce the ovarian reserve. However, diminished ovarian reserve does not translate into impaired pregnancy outcome.

Enhancement kinetics of normal ovaries on dynamic contrast-enhanced MR imaging.

OBJECTIVE: The objective was to determine the enhancement kinetics of the normal ovaries in healthy women on dynamic contrast-enhanced magnetic resonance (DCE-MR) imaging. METHOD: Twenty-one women who had normal ovulatory cycles (volunteers; mean age=26.3 years, range=20-35), normal hormone profile, and apparently normal ovaries on ultrasonographic scan underwent DCE-MR imaging on a 1.5-T system (Philips Medical Systems, Gyroscan Intera, Best, The Netherlands) using a phased array pelvic coil. Sequential images with an imaging time of 14.4s per dynamic image were acquired before and after injection of a contrast bolus at 30s and at 1, 2, 3, 4, and 5 min. On postprocessing examination the following measurements were obtained for ovarian and muscle tissue: the signal intensity value per dynamic study, early phase enhancement rate, time to peak enhancement (Tp), and percentage of wash-out at the fifth minute were determined. Data of the ovaries and skeletal muscle were compared using Wilcoxon's rank sum test. RESULTS: Most of the mean values of the postcontrast signal intensity measurements, the mean values of the early phase enhancement rate, and the percentage of wash-out at the fifth minute were found to be significantly higher in ovary than in muscle (p<0.05). The mean values of Tp, on the other hand, were nonsignificantly lower in ovary than in muscle (p>0.05). On the examination of the mean signal intensity-time data graphics the ovary showed a tendency toward greater and quicker enhancement and wash-out. CONCLUSION: In our opinion, DCE-MR imaging, which determines contrast enhancement such as wash-in and wash-out kinetics, can provide knowledge of ovarian vascularization. Thus, by using DCE-MR imaging, determination of these vascularization changes in various ovarian diseases may provide us with additional parameters in the diagnosis of and treatment strategies for ovarian diseases.

Letrozole vs. clomiphene citrate in patients with ovulatory infertility.

OBJECTIVE: To compare the effectiveness of letrozole and clomiphene citrate (CC) in ovulatory patients with borderline male factor infertility, early stage endometriosis, and unexplained infertility. DESIGN: Prospective quasi-randomized trial. SETTING: University infertility clinic. PATIENT(S): Forty-six consecutive patients with ovulatory infertility were recruited. Twenty-five patients (67 cycles) were given CC and 21 patients (52 cycles) were given letrozole. Both drugs were given orally on days 3-7 of menses. INTERVENTION(S): Letrozole, CC, ovulation induction, IUI, timed intercourse. MAIN OUTCOME MEASURE(S): Number of follicles, endometrial thickness, and pregnancy rates. RESULT(S): The median serum E2 concentration on the day of hCG administration in the letrozole and CC groups were 191.5 pmol/L and 476.0 pmol/L, respectively. The median endometrial thickness on the day of hCG were 8 mm in both groups. Ovulation occurred in 81% (42/52) of the letrozole-treated and 85% (57/67) of the CC-treated patients. Pregnancy rate (PR) per cycle was 9% (5/52) in the letrozole group and 12% (8/67) in the CC group. CONCLUSION(S): Letrozole and CC have comparable effectiveness in ovulatory patients with borderline male factor infertility, early stage endometriosis, and unexplained infertility.

Outcome of intracytoplasmic sperm injection in patients with polycystic ovary syndrome or isolated polycystic ovaries.

OBJECTIVE: To determine the intracytoplasmic sperm injection (ICSI) and embryo transfer (ET) performance of patients with polycystic ovary syndrome (PCOS) and isolated polycystic ovarian (PCO) morphology. DESIGN: Case-control study. SETTING: IVF Center, Hacettepe University Faculty of Medicine. PATIENT(S): Ninety-nine consecutive infertile women (n = 109 cycles) with PCOS and 58 patients (n = 58 cycles) with isolated PCO morphology were recruited. The control group consisted of 210 patients (n = 232 cycles) with isolated male factor infertility necessitating ICSI. All three groups were matched for female age and body mass index. INTERVENTION(S): Controlled ovarian hyperstimulation and ICSI. MAIN OUTCOME MEASURE(S): Oocyte number, fertilization rate, embryo quality, clinical pregnancy rate, implantation rate, and ovarian hyperstimulation syndrome (OHSS). RESULT(S): Six (5.5%) cycles in the PCOS group, 6 (10.3%) cycles in the PCO-only group, and 10 cycles (4.3%) in the control group were canceled. Despite a significantly lower total FSH dose used, a significantly higher serum E2 level was attained in both the PCOS and the PCO-only groups compared to the control group. The PCOS and PCO-only groups had significantly higher numbers of retrieved oocyte-cumulus complexes and metaphase II oocytes compared to the control group. The fertilization rates did not differ among the three groups. The mean number of embryos transferred was comparable among the three groups; however, the mean number of grade 1 embryos was significantly higher in the PCOS and PCO-only groups compared to the controls. The clinical pregnancy rates per ET of both the PCOS (66%) and the PCO-only (60%) groups were significantly higher than that of the control group (44%). However, the implantation rates were comparable among the three groups. Four cycles (3.7%) in the PCOS group had OHSS necessitating hospitalization. The respective figures in the PCO-only and the control groups were 1 (1.7%) and 3 (1.3%). CONCLUSION(S): Patients with the full-blown picture of PCOS or isolated PCO-only morphology behave exactly in the same manner during all stages of assisted reproduction. Owing to the availability of more fertilized oocytes and grade 1 embryos, patients with PCOS or PCO-only morphology are associated with higher clinical pregnancy rates per ET compared to patients with isolated male factor infertility.

Polycystic ovary syndrome: dynamic contrast-enhanced ovary MR imaging.

OBJECTIVE: to determine the enhancement behaviour of the ovaries in women with polycystic ovary syndrome (PCOS) by dynamic contrast-enhanced magnetic resonance (DCE-MR) imaging and to compare these data with those of normal ovulating controls. METHOD: 24 women with PCOS and 12 controls underwent DCE-MR imaging. Dynamic images were acquired before and after injection of a contrast bolus at 30 s and the min of 1, 2, 3, 4 and 5. On postprocessing examination: (i) the ovarian volumes; (ii) the signal intensity value of each ovary per dynamic study; (iii) early-phase enhancement rate; (iv) time to peak enhancement (T(p)); and (v) percentage of washout of 5th min were determined. Data of the ovaries of the women with PCOS and controls were compared with Mann-Whitney U-test. RESULTS: the mean values of T(p) were found to be significantly lower in women with PCOS than in controls (p < 0.05). On the other hand, the mean values of ovarian volume, the early-phase enhancement rate, and percentage of washout of 5th min of ovaries were significantly higher in PCOS patients (p < 0.05). Examination of the mean signal intensity-time curve revealed the ovaries in women with PCOS showed a faster and greater enhancement and wash-out. CONCLUSION: the enhancement behaviour of ovaries of women with PCOS may be significantly different from those of control subjects on DCE-MR imaging examination. In our experience, it is a valuable modality to highlight the vascularization changes in ovarian stroma with PCOS. We believe that improved DCE-MR imaging techniques may also provide us additional parameters in the diagnosis and treatment strategies of PCOS.