The effects of conservative and surgical approaches in tubal ectopic pregnancy on fertility.

BACKGROUND: Medical treatment, expectant approaches, and surgical treatment options are available in the treatment of ectopic pregnancy. Regardless of the treatment, in addition to its effectiveness, the main concern is to limit the risk of relapse and preserve fertility. OBJECTIVES: Determine the impact of medical or surgical treatment for ectopic pregnancy on future fertility. DESIGN: Retrospective. SETTING: Department of obstrtrics and gynecolgy at Ankara Etlik Zübeyde Hanim Women's Health Training and Research Hospital, Ankara, Turkey. PATIENTS AND METHODS: Patients who were treated for ectopic pregnancy between June 2016 and November 2019 were allocated into two groups. Expectant approach or medical treatment by methotrexate constituted the conservative treatment group while salpingectomy by laparoscopy indicated the surgical treatment group. MAIN OUTCOME MEASURES: Fertility rates within two years following treatment were evaluated according to treatment options. SAMPLE SIZE: 202 patients. RESULTS: Of the 202 patients, 128 had medical treatment and 74 patients had surgical treatment for ectopic pregnancy. Of 272 diagnosed with ectopic pregnancy, 70 were excluded for various reasons. Parity and unemployment rate was significantly higher in the surgical treatment (P=.006 and P=.12, respectively). Moreover, ectopic mass size and serum ß-hCG levels were significantly higher in the surgical treatment group (P<.001 and P<.001, respectively). There were no significant differences between the conservative and surgical treatment groups in time to pregnancy (17.0 months vs 19.0 months, P=.255). Similarly, there was no significant difference between the conservative and surgical treatment groups with respect to history of infertility (P=.12). There were no significant differences between the conservative and surgical treatment groups in terms of live birth (51.6% vs 44.6%) and ectopic pregnancy (2.3% vs 1.4%) (P=.72 for both). There was no significant difference between the conservative and surgical treatment groups with respect to infertility rate (35.9% vs 41.9%, P=.72) and admittance to the IVF program (3.9% vs 6.8%, P=.39) following ectopic pregnancy treatment. CONCLUSIONS: Reproductive outcomes did not differ significantly in women undergoing expectant management, medical treatment, and surgery for ectopic pregnancy. This finding suggests that clinicians should not hesitate to act in favor of surgical treatment for ectopic pregnancy even if there were concerns for future fertility. LIMITATIONS: Retrospective study.

Gonadotropin releasing hormone antagonist use in controlled ovarian stimulation and intrauterine insemination cycles in women with polycystic ovary syndrome.

OBJECTIVE: To evaluate the effect of the GnRH antagonist on gonadotropin ovulation induction in women with PCOS. MATERIALS AND METHODS: A total of 175 intrauterine insemination (IUI) cycles in women with polycystic ovary syndrome (PCOS) were included in the study. Women in the control group (n = 87) underwent controlled ovarian stimulation (COS) with recombinant follicle stimulating hormone (r-FSH) only, while women in the study group (n = 88) were administered r-FSH plus cetrorelix. RESULTS: As expected, the mean value of luteinizing hormone and progesterone, on the day of human chorionic gonadotropin administration were statistically significantly lower in patients receiving GnRH antagonist than the control group (p = 0.002). Premature luteinization occurred in only one of the patients in the GnRH antagonist group (1.1%) and in 15 of the 88 cycles in the control group (17.2%), showing a significant difference between the two groups (P = 0.001). The clinical pregnancy rate per cycle was higher in GnRH-antagonist group compared to the control group but the difference did not reach to a statistical significance (25% vs 14.9%, P = 0.096). CONCLUSIONS: Adding GnRH-antagonist in COS/IUI cycles in women with PCOS resulted in a lower incidence of premature luteinization but did not improve pregnancy rates. However, owing to some benefits, antagonist therapy could be considered as a reasonable alternative to IVF in order to reduce PCOS patients'emotional distress.

The incidence of metabolic syndrome in adolescents with different phenotypes of PCOS.

OBJECTIVES: To evaluate the incidence of metabolic syndrome in Turkish adolescents with different phenotypes of polycystic ovary syndrome (PCOS). MATERIAL AND METHODS: This cross-sectional study was performed on the Youth Center clinic of a tertiary referral hospital in Turkey. Adolescents with PCOS (n = 144) were classified into four phenotype groups according to the presence of oligo/anovulation (O), hyperandrogenism (H), and polycystic ovarian morphology (P) as follows: Phenotype A (O + H + P), Phenotype B (H + O), Phenotype C (H + P), Phenotype D (O + P). The adolescents gave early follicular phase blood samples for endocrine and metabolic tests. The incidence and the presence of parameters of metabolic syndrome were assessed among the four groups. RESULTS: In total, 54.9% of the adolescents with PCOS were overweight and 25.7% had metabolic syndrome. The incidence of metabolic syndrome in Phenotypes A-D were as follows: 39.5%, 20.5%, 26.5%, and 15.2%, respectively. Although body mass index was higher in the Phenotype A group, insulin resistance was similar in all of the phenotype groups. The most common dyslipidemia was low HDL-C levels and this was present in more than half of the adolescents with PCOS. Both body mass index and total testosterone levels were significantly higher in adolescents with metabolic syndrome in comparison to those without metabolic syndrome. CONCLUSIONS: Although low HDL-C levels and insulin resistance are common PCOS findings in adolescents, the metabolic profile seems to be worse in Phenotype A than the other phenotypes. Therefore, screening programs should evaluate patients based on the known risk factors and phenotypes for adolescents with PCOS.

Uterine and Ovarian Carcinosarcomas: Do They Behave Similarly?

OBJECTIVE: We aimed to compare the clinicopathologic characteristics, recurrence patterns, and survival of patients with ovarian carcinosarcomas (OCs) and uterine carcinosarcomas (UCs). METHODS: Patients who were diagnosed with UCs or OCs on the basis of final pathology reports and who underwent surgery between January 1993 and January 2015 were included in the study. Data of patients were obtained from Gynecological Oncology Clinic electronic database and patient files. RESULTS: The study included 101 and 21 patients who underwent surgery for UCs and OCs, respectively. Forty percent and 67% of patients who had UCs and OCs, respectively, experienced lymph node metastasis (P = 0.051). Median follow-up time was 12 months (range, 1-158 months) for patients with UCs and 24 months (range 1-154 months) for patients with OCs. Recurrence developed outside the abdomen in 58% of patients with UCs and in 10% of patients with OCs (P = 0.005). Median time to recurrence was 9 months (range 3-58 months) in patients with UCs, whereas it was 18 months (range 11-72 months) in patients with OCs (P = 0.002). Five-year disease-free survival was 34% and 19% for patients with UCs and OCs, respectively (P = 0.90). Five-year overall survival was 56% for patients with UCs and 54% for patients with OCs (P = 0.51). CONCLUSION: We found that UCs recurred earlier and extra-abdominally. Recurrence pattern should be kept in mind during the planning of adjuvant therapies for these patients.

The impact of prenatal psychologic and obstetric parameters on postpartum depression in late-term pregnancies: A preliminary study.

OBJECTIVE: To determine the prenatal psychologic (anxiety and depression) and perinatal obstetric (pregnancy and labor complications) predictors of postpartum depression (PPD) in late-term pregnancies. MATERIALS AND METHODS: A total of 149 women with late-term gestation who were hospitalized for antenatal fetal surveillance were included. All participants were asked to complete Hospital Anxiety and Depression Scale immediately after hospitalization and Edinburgh Postnatal Depression Scale in the postpartum period. Demographic, psychologic, and obstetric variables were tested as predictors of PPD by regression analysis. RESULTS: High scores for prenatal anxiety, depression, and PPD were detected in 17.4%, 12.8%, and 23.5% of the participants, respectively. The mode of delivery was not associated with PPD for late-term pregnancies. Women having urgent cesarean, planned cesarean, and vaginal delivery had similar rates of PPD (28.1%, 23.8%, and 21.9%, respectively). In the multivariant analysis, prenatal depression [odds ratio (OR), 9.85; 95% confidence interval (CI), 2.72-35.65], prenatal anxiety (OR, 4.95; 95% CI, 1.59-15.39) and suspicion of fetal distress (OR, 4.44; 95% CI, 1.13-13.64) were found to be independent predictors of PPD. CONCLUSION: For late-term pregnancies, women with prenatal anxiety or depression and had cesarean delivery due to the suspicion of fetal distress were at risk for PPD.

Maximum surgical effort is warranted for recurrent adult granulosa cell tumors of ovary.

PURPOSE: Adult granulosa cell tumor (AGCT) of ovary is a rare tumor and usually has a benign course. Due to its indolent nature, recurrences are observed in a wide period and data on management of recurrences in AGCT are relatively sparse. We aimed to evaluate the clinical features, management, and survival of patients with recurrent AGCT. METHODS: The data of 144 patients with AGCT treated in Etlik Zubeyde Hanim Teaching and Research Hospital between 1990 and 2013 were retrospectively evaluated. Patients with radiologic or pathologic recurrences were included in the analysis. RESULTS: A total of 18 patients (12.5%) with recurrent AGCT were included. Median follow-up was 97.5 months (range 6-255 months). A total of 16 patients underwent salvage surgery and maximal debulking was achieved in 13 patients. Ten patients had unifocal and 8 had multifocal tumors. Maximal debulking could be achieved in all patients with unifocal recurrence. On the other hand, maximal debulking could only be obtained in 3 patients (37%) with multifocal recurrence (p = 0.031). Multifocality of recurrent disease and the presence of residual tumor after surgery were associated with diminished progression-free survival and overall survival (31 vs 207 months, p = 0.031; and 22 vs 220 months, p = 0.005, respectively). CONCLUSIONS: Multifocal recurrence and suboptimal surgery were related with poor survival outcomes in patients with AGCT recurrence. Surgical treatment of recurrent AGCT should aim to achieve no visible disease.

Metabolic syndrome and metabolic risk profile according to polycystic ovary syndrome phenotype.

AIM: It is unknown which phenotype of polycystic ovary syndrome (PCOS) has a greater metabolic risk and how to detect this risk. The aim of this study was therefore to compare the incidence of metabolic syndrome (MetS) and metabolic risk profile (MRP) for different phenotypes. METHODS: A total of 100 consecutive newly diagnosed PCOS women in a tertiary referral hospital were recruited. Patients were classified into four phenotypes according to the Rotterdam criteria, on the presence of at least two of the three criteria hyperandrogenism (H), oligo/anovulation (O) and PCO appearance (P): phenotype A, H + O + P; phenotype B, H + O; phenotype C, H + P; phenotype D, O + P. Prevalence of MetS and MRP were compared among the four groups. RESULTS: Based on Natural Cholesterol Education Program Adult Treatment Panel III diagnostic criteria, MetS prevalence was higher in phenotypes A and B (29.6% and 34.5%) compared with the other phenotypes (10.0% and 8.3%; P < 0.001). Although the prevalence of obesity was similar, the number of patients with homeostatic model assessment insulin resistance index (HOMA-IR) >3.8 was significantly higher in androgenic PCOS phenotypes. After logistic regression analysis, visceral adiposity index (VAI) was the only independent predictor of MetS in PCOS (P = 0.002). VAI was also significantly higher in phenotype B, when compared with the others (P < 0.01). CONCLUSION: Phenotypes A and B had the highest risk of MetS among the four phenotypes, and VAI may be a predictor of metabolic risk in PCOS women.

Short-Term Impact of Laparoscopic Cystectomy on Ovarian Reserve Tests in Bilateral and Unilateral Endometriotic and Nonendometriotic Cysts.

STUDY OBJECTIVE: To evaluate the short-term changes in ovarian reserve markers after laparoscopic cystectomy performed for endometriotic and nonendometriotic cysts. DESIGN: Prospective case-control study (Canadian Task Force classification II-2). SETTING: The Reproductive Endocrinology Clinic of a training and research hospital. PATIENTS: Thirty-four women with endometrioma ≥ 4 mm (group 1) and 33 women with nonendometriotic cysts of matched size (group 2) who underwent surgery during the same period. INTERVENTIONS: The follicular phase follicle-stimulating hormone (FSH), estradiol (E2), and antimüllerian hormone (AMH) levels and the antral follicle count (AFC) of both groups were analyzed preoperatively and 2 months after laparoscopic cystectomy. The pre- and postoperative values were compared within the same group and between the 2 groups. MEASUREMENT AND MAIN RESULTS: Preoperative FSH and E2 levels were similar in both groups. However, preoperative AMH levels and AFC were significantly lower in group 1 (endometrioma) compared with group 2 (nonendometrioma; p = .004 and p = .025, respectively). In both groups there was a significant decrease in the AMH levels after surgery (3.1 ± 1.9 ng/mL to 2.5 ± 1.6 ng/mL, p < .001, and 5.7 ± 3.7 ng/mL to 4.8 ± 3.3 ng/mL, p = .04). AMH levels exhibited a significant decrease in the unilateral and bilateral endometrioma groups after cystectomy (p < .001 and p = .025, respectively). However, preoperative and postoperative changes in AMH and AFC were similar in groups 1 and 2 for both unilateral and bilateral cysts (p = .586 and p = .267). CONCLUSION: Preoperative AMH and AFC levels are lower in both unilateral and bilateral endometriomas compared with nonendometriotic cysts. The AMH levels decreased after cystectomy in both endometriotic and nonendometriotic cysts. However, in the short-term period the amount of change in ovarian reserve tests in both unilateral and bilateral cysts was similar for both endometrioma and nonendometriotic cysts.

Success rates of single-dose methotrexate and additional dose requirements among women with first and previous ectopic pregnancies.

OBJECTIVE: To compare the success of the single-dose methotrexate regimen and the requirement for a second or third dose of methotrexate between women with their first ectopic pregnancy (EP) and those with previous EP. METHODS: In a retrospective cohort study, data were analyzed from women treated for EP by single-dose methotrexate at a Turkish tertiary referral center between January 2010 and December 2013. Data were compared between women with at least one previous EP and those with their first EP. RESULTS: The success rate of the protocol in the first and previous EP groups was similar: 93.0% (320/344) and 87.3% (48/55), respectively. History of previous EP was not a predictor of treatment failure. However, the requirement for additional methotrexate doses was significantly higher in the previous EP group (16/48 [33.4%]) than in the first EP group (55/320 [17.2%]; P=0.03). Multivariate analysis showed that history of tubal surgery (P=0.006) and initial levels of the ß-subunit of human chorionic gonadotropin (P=0.001) were significant predictors of treatment failure. CONCLUSION: Although the single-dose regimen had similar success rates in the previous EP and first EP groups, additional doses of methotrexate were more frequently required in the previous EP group.

Is late adolescence a real risk factor for an adverse outcome of pregnancy?

OBJECTIVE: To compare the obstetrical and neonatal outcomes of late adolescent (LA) and adult pregnancies. METHODS: Between January 2012 and December 2012, a total of 313 late adolescent pregnant aged between 16 and 19 years and 418 adult pregnant women aged between 20 and 35 years having given birth in our maternity service were enrolled into this case-control study. The demographic and clinical data were reviewed from hospital database and patients' medical records. RESULTS: The incidence of preterm birth (PB) in the LA group was significantly higher than in the adult group (p = 0.001), while the incidence of gestational diabetes mellitus was significantly lower (p = 0.001). The mean birth weight and the rate of delivered macrosomic fetuses in the study group were lower than in the control group (p = 0.03). The LA group had significantly higher rate of vaginal delivery when compared to the adult group (p = 0.001). Both the rate of pregnancy induced hypertensive disorders and postpartum hemorrhage were not statistically different between the two groups (p = 0.31; p = 0.38, respectively). The LA group had lower rate of stillbirth when compared to the adult group; however, the difference was statistically insignificant (0.3% versus 1.2%) (p = 0.24). CONCLUSIONS: The LA pregnancy should be closely followed up during their antenatal care period due to the significantly higher rate of PB.

Early and Late Complications after Inguinofemoral Lymphadenectomy for Vulvar Cancer.

BACKGROUND: We aimed to determine the frequency of early and late complications following groin surgery for vulvar cancer and analyze possible risk factors. MATERIALS AND METHODS: This retrospective cohort study included 99 women who underwent for vulvar cancer. The early (≤1 month) complications were wound infection, breakdown and lymphocyst and late (>1 month) complications were lower limb lymphedema, incontinence and erysipelas. The risk factors for developing each of the complications were analyzed with regression analysis. RESULTS: In the entire cohort, 29 (29.3%) women experienced early and 12 (12.1%) had late complications. Wound complications including infection and breakdown were the leading early complications (23.2%). In the multivariate analysis, both obesity (body mass index≥30 kg/m2) and advanced age (≥65 years) were found as independent predictive factors for early complications. Obese women of advanced age had 6.32 times more risk of experiencing any of the early complications, when compared to non-obese and young women (55.6% vs 8.7%). The most common late complication was lower limb lymphedema (10.1%) that was more frequently seen in young women. However, neither age nor lymph node count were significantly associated with the occurrence of lower limb lymphedema. CONCLUSIONS: More than 40% of the women suffered from postoperative complications after inguinofemoral lymphadenectomy in the current study. While advanced age and obesity were the significant predictors for any of the early complications, there was no identified risk factor for lower limb lymphedema.

Early prediction for the requirement of second or third dose methotrexate in women with ectopic pregnancy, treated with single-dose regimen.

PURPOSE: To investigate the predictive factors for the requirement of additional doses of methotrexate in women with ectopic pregnancy treated with single-dose methotrexate regimen. METHODS: This retrospective cohort study was conducted on women treated with single-dose methotrexate regimen for ectopic pregnancy at a tertiary referral center. Control group included the patients who were treated only with a single dose of methotrexate (n = 131) and study group included the patients who need a second dose or third dose methotrexate (n = 76). The sonographic variables such as size of the ectopic mass, the endometrial thickness and biochemical variables were analyzed via Chi square and student t test. Logistic regression analysis used to determine independent predictors of the additional dose requirement. RESULTS: The size of the ectopic mass and the endometrial thickness were similar in both groups. However, all human chorionic gonadotropin values on day 1, 4 and 7 were significantly higher in study group than the control group (p = 0.0001). Logistic regression analysis revealed that the human chorionic gonadotropin changes between day 1 and 4 is a predictive factor for requirement of additional doses of methotrexate (area under curve: 0.763, p < 0.001) and the cutoff value for human chorionic gonadotropin change was calculated as 22%. The probability of the requirement for an additional dose of methotrexate is 6.45 times more in patients who had less than 22% reduction in human chorionic gonadotropin levels from day 1 to 4 compared to those who had >22% reduction from day 1 to 4. CONCLUSION: Less than 22% reduction in human chorionic gonadotropin levels from day 1 to 4 can be used as a predictive factor for the requirement of an additional dose of methotrexate in single-dose regimen. This cutoff value can be used for patients to inform about the probable longer resolution time and refer to alternative treatment modalities such as two-dose, multiple-dose regimens or surgery.

Frozen section in borderline ovarian tumors: is it reliable?

OBJECTIVE: We reported the concordance of frozen/section (FS) diagnosis of borderline ovarian tumor (BOT) and identified the factors associated with the concordance. STUDY DESIGN: FS results of the patients with a final diagnosis of BOT operated between 1990 and 2012 were analyzed. The FS results were reported as benign, rule out borderline tumor, borderline tumor, at least borderline tumor and malign tumor intraoperatively. The concordance of FS diagnosis was determined by comparing the FS result with the final pathological diagnosis. We accepted the FS concordant with the final pathology when the FS result was borderline tumor or at least borderline tumor, since we managed these patients in a similar way intraoperatively. Data regarding histological subtype, tumor size, age of the patients, menopausal status, presence of bilateral disease, preoperative Ca-125 level and the final diagnosis were evaluated. RESULTS: FS results of 145 patients were analyzed. The concordance of FS analysis for the total group, for the ones with serous and mucinous BOT were 79%, 92% and 62%, respectively. Totally, 29 patients (20%) weren't staged intraoperatively due to inaccurate FS result. Mucinous histology and larger tumor size were associated with lower concordance of FS. Concordance wasn't associated with type of surgery (conservative vs radical), menopausal status, laterality of the tumor, age of the patients and Ca-125 level of the patients. CONCLUSION: The high discrepancy rate of FS, especially in mucinous and larger tumors should be kept in mind during intraoperative decision-making based on FS analysis for BOT.

What do we know about metabolic syndrome in adolescents with PCOS?

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy of reproductive-aged women that manifests itself with a variety of features. For this reason, three different diagnostic criteria have been introduced. For adults, the National Institutes of Health Conference (NIH) criteria, which consists of hyperandrogenism and oligo-anovulation, is the most widely used. Symptoms of PCOS usually start with puberty and may overlap with normal pubertal development. Hormonal fluctuations during this period make the diagnosis of PCOS more difficult. Until now, there is no validated diagnostic criteria for PCOS in adolescents. Although menstrual disorders and cosmetic problems are the most common complaints of adolescents with PCOS, patients should also be evaluated for the potential risk for insulin resistance, obesity, subclinical atherosclerosis, diabetes, metabolic syndrome and cardiovascular disease. Obesity is the most prominent predictor of metabolic syndrome. As the incidence of obesity is increasing both in childhood and adolescence, governments will be faced with a social and economic burden in the future. Adolescents with PCOS are more obese than normal adolescents and have an increased risk of metabolic syndrome. It is suggested that abdominal adiposity increases the risk of metabolic syndrome by inducing various cytokine secretions. Although there is no consensus on metabolic syndrome criteria in the adolescent period, International Diabetes Federation (IDF) criteria may be used for children older than 10 years. Various clinical and metabolic markers are investigated for the prediction of metabolic syndrome in the literature. Waist circumference, serum triglycerides and androgens are the suspected predictors of metabolic syndrome. The prevention of abdominal adiposity and the early diagnosis of PCOS in adolescence should be the main target for the prevention of metabolic syndrome. Clinicians should investigate adolescents with PCOS for metabolic and cardiovascular risks and take preventive action. A Mediterranean diet, low in fat and high in fruits and vegetables, along with moderate-intensity exercise and smoking cessation are the recommended interventions for especially obese adolescents with PCOS. Metformin may be the treatment of choice when lifestyle modifications are ineffective.

Study of uterine and fetal hemodynamics in response to labor induction with dinoprostone in prolonged pregnancies with normal amniotic fluid and oligohydramnios.

OBJECTIVE: We investigated the effects of labor induction with Dinoprostone on uteroplacental and fetal circulations with Doppler velocimetry in prolonged pregnancies with and without oligohydramnios. METHODS: We performed Doppler evaluations of Uterine A, Umbilical A and Middle Cerebral A. (MCA) in 117 patients (27 associated with oligohydramnios) just before and 6 h after the administration of Dinoprostone. We compared two groups with Mann Whitney U Test and Independent Sample T Test. RESULTS: Uterine Artery Doppler indices of both groups obtained before the medication were compared. All indices were within normal range; however Umbilical A. S/D and PI were higher in oligohydramnios group, approaching statistical significance (p=0.07 for S/D and p=0.03 for PI). All of the Uterine A. Doppler indices significantly increased after the administration of Dinoprostone ovule in normal amniotic fluid index (AFI) group (p=0.00). Doppler indices of the other arteries in this group did not change significantly. Similarly, none of the Doppler indices of all investigated arteries in oligohydramnios group changed significantly. Changes in all measured Doppler indices were minor and similar in both groups. CONCLUSIONS: Labor induction with Dinoprostone in prolonged pregnancies complicated with oligohydramnios is as safe and effective as it is in prolonged pregnancies with normal AFI.

Sentinel lymph node detection and accuracy in vulvar cancer: Experience of a tertiary center in Turkey.

OBJECTIVE: To explore the accuracy of sentinel lymph node (SLN) dissection in predicting regional lymph node status by using either only Technetium-99m-labelled (Tc-99m) or in combination with a blue dye in patients with squamous cell cancer of vulva. MATERIAL AND METHODS: Twenty-one patients who had T1 (≤2 cm) or T2 (>2cm) tumors that did not encroach into the urethra, vagina or anus were included in the study. For the first twelve patients, Tc-99m was used for SLN identification, and the combined technique was used in subsequent patients. Preoperatively, Tc-99m and a blue dye was injected intradermally around the tumor. Following SLN dissection, complete inguinofemoral lymphadenectomy was performed. RESULTS: We could detect SLN in all 21 patients (100%) by either Tc-99m or the combined method. SLN was found to be histopathologically negative in 13 groins via Tc-99m and 10 groins via the combined method. Twenty-one of these 23 (91.3%) groin non-SLN were also negative, but in two groins, we detected metastatic non-SLN. CONCLUSION: Although SLN dissection appears promising in vulvar cancer, false negative cases are reported in the literature. Sentinel lymph node dissection without complete lymphadenectomy does not seem appropriate for routine clinical use, since it is known that groin metastasis is fatal.