Incidence of unexpected leiomyosarcoma in a Turkish province: a retrospective multi-centre study in a low income setting.

The aim of the current study was to estimate the incidence of unexpected leiomyosarcoma (LMS) in patients who underwent surgery due to leiomyomas in Konya province, and to contribute to the literature discussing comparisons with similar studies. The digital archives of eight high-volume hospitals were studied for surgeries performed due to leiomyomas between January 2012 and January 2019, and leiomyosarcoma incidence was calculated based on the data obtained. Twenty-one patients in 3703 cases were found to have unexpected leiomyosarcoma, which means we can expect one leiomyosarcoma in 176 (0.56%) surgeries. Six more malignant tumours were detected among the remaining cases. Thus, our study estimated the incidence of unexpected leiomyosarcoma as 1/176 (0.56%), which is higher than most of the studies in the literature justifying the debate started by the FDA in 2014. As the tumour biology is not yet clear, and the incidence of unexpected leiomyosarcoma tends to be so high, the key focus must be to try to detect uterine leiomyosarcomas preoperatively for robust patient care.IMPACT STATEMENTWhat is already known on this subject? The incidence of unexpected leiomyosarcoma varies widely from 1/498 to 1/8300 depending on the study method and the type of procedure, and there is still controversy, even after the FDA statement that led to a major restriction in laparoscopic surgeries due to concerns about inadvertent morcellation of leiomyosarcomas.What do the results of this study add? To the best of our knowledge, the current study found the highest incidence of unexpected leiomyosarcoma, and consequently a serious evaluation of all patients undergoing surgery due to leiomyomas preoperatively considering a leiomyosarcoma candidate is recommended.What are the implications of these findings for clinical practice and/or further research? Studies on tumour biology and novel markers must be supported for accurate preoperative diagnosis of leiomyosarcoma.

Management of Adnexal Torsion: A 13-Year Experience in Single Tertiary Center.

PURPOSE: Adnexal torsion constitutes 2.7% of gynecological emergencies, it is more frequently seen in reproductive age. Delay in diagnosis and treatment may lead to loss of the ovary. In this study, we aimed to assess patients who had adnexal torsion and compare laparoscopy with laparotomy in the treatment of these patients and point the most appropriate surgery according to age groups of the patients and comparison of patient characteristics and management between adnexal torsion in postmenopausal and premenopausal patients. MATERIALS AND METHODS: This study was carried out in Necmettin Erbakan University, Meram Medicine Faculty, Department of Obstetrics and Gynecology. The study retrospectively analyzed 380 patients presented to our clinic with abdominal pain between January 2005 and December 2017 and had surgery for adnexal torsion. RESULTS: The study included 380 patients who had surgery for adnexal torsion. A total of 220 patients had laparoscopy and 160 patients had laparotomy. Laparoscopy group consisted of young patients with low parity, whereas laparotomy group consisted of 160 patients of which 92 (57.5%) were in menopause. Teratomas were the most common pathological finding followed by follicular cysts. Fourteen ovarian malignancies and 11 borderline tumors had been reported. Eleven ovarian malignancies had been reported in postmenopausal patients and three in premenopausal patients. CONCLUSION: Laparoscopic surgery is preferred for young patients who want to preserve their fertility, but postmenopausal ovarian masses presenting with torsion should be analyzed with frozen section whenever possible, if not possible or not conclusive, staging surgery is more appropriate especially if there is suspicion of malignancy.

Conservative management of placental invasion anomalies with an intracavitary suture technique.

OBJECTIVE: To assess the efficacy and safety of a new surgical suture technique for uterine preservation among patients with placental invasion anomalies. METHODS: The present prospective case series included women diagnosed with placental invasion anomalies undergoing cesarean deliveries who desired future fertility at the obstetrics department of a Turkish university hospital between January 10, 2013, and April 20, 2017. Patients were diagnosed with ultrasonography and Doppler ultrasonography; the type of placental invasion anomaly (placenta accreta, increta, or percreta) was confirmed intraoperatively. Surgical management involved an intracavitary suture technique after the proximal branch of the uterine artery was clamped and utero-ovarian anastomoses had been blocked. Outcomes included units of blood transfused, intraoperative and postoperative adverse events, duration of hospital admission, and hysterectomy rate. RESULTS: There were 62 patients included. The mean operative blood loss was 1350 ± 750 mL (range 600-5000 mL). Blood transfusion required a mean of four units (range 2-15). Bleeding was controlled with the intracavitary sutures in 58 (94%) patients. Three patients experienced postoperative wound infections and two patients developed endometritis that required therapy with broad-spectrum antibiotics. The mean length of hospital stay was 3.6 ± 1.6 days (range 2-11). None of the patients required reoperation after the initial surgery. CONCLUSION: The novel uterus-sparing suture technique was highly effective among patients with placental invasion anomalies.

Comparison of embryo morphokinetics following intracytoplasmic sperm injection in smoker and non-smoker couples: Are the results different?

OBJECTIVE: To assess early embryo development via time-lapse in smokers and non-smokers. METHODS: The retrospective study was conducted at Novafertil IVF centers in Konya, Turkey and comprised oocytes of both smoker and non-smoker couples subjected to in vitro fertilisation / introcytoplasmic sperm injection from 2012 to 2015. Age, basal follicle-stimulating hormone, number of stimulation days, amount of gonadotropin used, number of metaphase II oocytes, number of embryos transferred and pregnancy, abortus and clinical pregnancy rates were noted. The embryos were observed for 72 hours in the time-lapse monitoring system. SPSS 22 was used for data analysis. RESULTS: Of the 257 couples, 132(51.4%) were non-smokers and 125(48.6%) were smokers. A total of 1,414 oocytes were collected from non-smokers and 1,280 oocytes from smokers. There was no significant difference in the age of patients and number of stimulation days between the smoker and non-smoker groups (p>0.05). The number of oocytes, fertilised oocytes, transferred embryos and metaphase II oocytes was significantly less in the smoker group (p<0.05). The rate of pregnancy and ongoing pregnancy was also lower in the smoker group (p<0.05). A difference was observed in time of pronuclei appearance, t8, t9+ cleavage times in time-lapse in the smoker and non-smoker groups (p<0.05). A prolongation was observed in time to pronuclear fading and t2 cleavage times in time-lapse in the non-smoker group (p<0.05). Some chromosomal number and structural defects were identified in pre-implantation genetic in some embryos with prolongation in time-lapse cleavage time in the smoker and non-smoker groups. CONCLUSIONS: The negative impacts of smoking were not observed at each cleavage phase of embryo development in time-lapse.

The evaluation of recombinant LH supplementation in patients with suboptimal response to recombinant FSH undergoing IVF treatment with GnRH agonist down-regulation.

We aimed to evaluate the clinical efficacy of r-LH supplementation to r-FSH in patients with suboptimal response to ovarian stimulation undergoing assisted reproduction with GnRH-a downregulation and stimulation with r-FSH. One-hundred thirty-seven patients were included in the study; among them 52 showed normal ovarian response to stimulation and composed the control group (Group 1), and 85 showed suboptimal response to stimulation and were divided into two groups. For Group 2 (n = 50), 75 IU/L r-LH was added to the treatment, for Group 3 (n = 35) r-FSH dose was increased by 75 IU/L. IVF results were compared between the groups. Implantation rates were 34.8% in control group, and 36.1% and 15% in LH supplementation group and increased-dose r-FSH group, respectively. Implantation rates were statistically significantly higher in Groups 1 and 2 compared to Group 3 (p < 0.02). Pregnancy rate was noticed in 64.7% of Group 1, 57.8% of Group 2 and at 32.4% of Group 3. Pregnancy rate was significantly higher in Group 2 than Group 3 (p < 0.05). r-LH supplementation is an option for improving IVF outcome in patients with suboptimal ovarian response to ovulation induction with r-FSH during GnRH agonist down-regulation. Particularly, r-LH is recommended as it may have a beneficial action on implantation in selected group.

Bilateral adnexal torsion due to postmenopausal hydatidiform mole.

Occurrence of gestational trophoblastic neoplasia (GTN) and adnexal torsion is rare in postmenopause. We report a 58-year-old postmenopausal woman with adnexal torsion caused by hydatidiform mole. The patient was admitted to our clinic complaining of acute abdominal pain, nausea and vomiting lasting one day. Ultrasonography showed an enlarged uterus including hypo/hyperechogenous cystic areas in the endometrial cavity and bilateral adnexal masses. ß-HCG level was investigated and determined as 157.000 IU/l, because of the suspicion of GTN in ultrasonography. Doppler sonography revealed enlarged left adnexa with absence of vascular flow. The patient underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy. ß-HCG decreased to normal ranges in the fourth postoperative week. The resected uterus contained an endometrial, cystic, grapelike tumor. The ovaries were enlarged bilaterally with necrotic appearance. Histopathology revealed complete hydatidiform mole and theca lutein cysts. To our knowledge, the present case is the first hydatidiform mole associated with bilateral adnexal torsion caused by theca lutein cysts in postmenopausal period.

Improvement in embryo quality and pregnancy rates by using autologous cumulus body during icsi cycles.

OBJECTIVE: To determine whether the addition of intact cumulus cell mass (ICM) to both embryo culture (EC) and embryo transfer (ET) improves embryo quality and pregnancy rates. MATERIAL AND METHODS: A total of 133 infertile couples were included, of which 67 received ICM (study group) and 66 did not (control group). The ICM was obtained from a simple cutting of the cumulus corona oocyte complex (CCOC). A case control study design was used. RESULTS: The clinical characteristics of the two groups before the embryo culturing step were similar with respect to age, estradiol level on the day of hCG and endometrial thickness on the day of embryo transfer (p>0.05). On the other hand study group with ICM had higher number of high quality embryos (3.1±1.4 vs 2.4±1.1, p=0.03), higher implantation rate (53.7% vs 34.8%, p=0.02) and higher ultrasound confirmation of gestational sac and fetal heart beat as ongoing pregnancy rates (44.7% vs 27.2%, p=0.04) compared to the control group without ICM. CONCLUSION: Addition of ICM improves embryo quality and pregnancy rates. This is a cost-and time-effective simple procedure that shows great promise for the improvement of infertility treatment.

Specific dermatologic features of the polycystic ovary syndrome and its association with biochemical markers of the metabolic syndrome and hyperandrogenism.

OBJECTIVE: To investigate biochemical and metabolic abnormalities in relation with cutaneous features of polycystic ovary syndrome (PCOS). DESIGN: Prospective descriptive analysis. SETTING: University-based tertiary care. SAMPLE: One-hundred and fifteen untreated consecutive women diagnosed as having PCOS. METHODS: Each woman underwent an evaluation of body habitus, acne, hirsutism, seborrhea, androgenic alopecia and acanthosis nigricans. Associations between cutaneous features and hormonal and metabolic parameters were analyzed by means of multivariate logistic regression models. MAIN OUTCOME MEASURES: Prevalence of cutaneous features in PCOS and associations among the features and biochemical and metabolic parameters. RESULTS: The prevalence of acne, hirsutism, seborrhea, androgenetic alopecia and acanthosis nigricans was 53%, 73.9%, 34.8%, 34.8% and 5.2%, respectively. Acne was not associated with the hormonal, metabolic and anthropometric variables. Hirsutism had positive associations with total testosterone, fasting glucose and total cholesterol, and a negative association with age. Seborrhea was found to be related with free testosterone, fasting glucose and insulin. A negative association was determined among androgenic alopecia and free testosterone, low-density lipoprotein and insulin. CONCLUSIONS: Acne and androgenic alopecia are not good markers for the hyperandrogenism in PCOS. Hirsutism appears to be strongly related with hyperandrogenism and metabolic abnormalities in PCOS women.

Compared effects of surgical and natural menopause on climacteric symptoms, osteoporosis, and metabolic syndrome.

OBJECTIVE: To compare the effects of surgical (ie, earlier) and natural (ie, later) menopause on climacteric symptoms, osteoporosis, and metabolic syndrome. METHOD: The study was conducted with 94 women who underwent hysterectomy and bilateral oophorectomy and 95 women who were older than 40 years and in natural menopause. None had received hormone therapy or osteoporosis treatment. Metabolic syndrome was defined according to the National Cholesterol Education Program Adult Treatment Panel III. RESULTS: The rates of hot flushes (P=0.001), sweating (P=0.001), poor memory (P=0.04), change in sexual desire (P=0.04), and osteoporosis (diagnosed in the hip bone, P=0.005) were significantly higher among the women in surgical menopause, but the rate of metabolic syndrome was similar in the 2 groups (47.8% and 40%; P=0.28). CONCLUSION: Compared with natural menopause, surgical menopause was found to be associated with higher rates of climacteric symptoms and osteoporosis but not of metabolic syndrome.

Long-term effects of valproic acid on reproductive endocrine functions in Turkish women with epilepsy.

The long-term effects of valproic acid (VPA) on reproductive endocrine functions in women with epilepsy (WWE) were studied. Serum reproductive hormone concentrations, clinical findings and ovarian morphology were analyzed in 71 WWE who had been receiving antiepileptic drugs (AED) for a minimum of 2 years. Of the 71 WWE, polycystic ovarian syndrome (PCOS) (p = 0.011) and menstrual irregularities (p = 0.009) were found to be more prevalent in women receiving VPA treatment when compared to women on non-VPA treatment. There was no statistically significant dose or duration-related rise of risk for patients who developed PCOS and menstrual irregularities and those who were not on long-term VPA therapy. The lack of a duration-related reproductive dysfunction in this patient population may support the hypothesis of early occurring VPA-associated metabolic and endocrine changes.

Repeated in vitro fertilization failure and its relation with thrombophilia.

BACKGROUND: The objective of this study was to determine the prevalence of some thrombophilic factors and its relation to in vitro fertilization (IVF)-embryo transfer failure in women who had had three or more previously failed IVF-embryo transfer cycles. METHODS: The study group included 51 consecutive women with three or more previously failed IVF-embryo transfer cycles (group 1). The control group included 50 women who conceived spontaneously with at least one uneventful pregnancy and no previous history of miscarriage. All women were tested for the presence of factor V Leiden, prothrombin (G20210A), and methylenetetrahydrofolate reductase (C677T) mutations. RESULTS: A similar prevalence of factor V Leiden, prothrombin, and methylenetetrahydrofolate reductase mutations was found in both groups. At least one inherited thrombophilic factor was detected in 62.7% of women with repeated IVF failure and in 53.9% of women in group 2. No association between repeated IVF failure and these thrombophilic factors was found statistically. CONCLUSION: These data suggest that factor V Leiden, methylenetetrahydrofolate reductase and prothrombin gene mutation do not have a significant role in IVF-embryo transfer implantation failure.

Pyosalpinx caused by the tubal migration of an intrauterine device--a case report.

Migration of an intrauterine device (IUD) is a complication occurring at or following insertion. After having perforated the uterine wall, the IUD usually will settle into the peritoneal cavity. Tubal migration of an IUD is extremely rare and little is known about its mechanism. We describe a case of pyosalpinx caused by the tubal migration of a copper IUD. The tail of the device was embedded in the mesocolon.

Clinical and metabolic effects of medroxyprogesterone acetate and ethinyl estradiol plus drospirenone in women with polycystic ovary syndrome.

OBJECTIVES: To investigate the effects of treatment with medroxyprogesterone acetate (MPA), 10 days per month for 6 months, on lipid and carbohydrate metabolism in women with polycystic ovary syndrome (PCOS). METHODS: Sixty-three women with PCOS were randomized to receive MPA or ethinyl estradiol plus drospirenone. RESULTS: There were no changes in lipid or carbohydrate metabolism in the MPA group, but serum levels of luteinizing hormone (P<0.001) and total testosterone (P<0.003) significantly decreased, as did the free androgen index (P<0.02) and acne (P<0.03) and seborrhea (P<0.04) scores. In the ethinyl estradiol plus drospirenone group lipid and hormone values significantly increased whereas acne, seborrhea, hair loss, and Ferriman-Gallwey scores decreased. There was no statistically significant change in the total cholesterol to high-density cholesterol ratio in either group. CONCLUSION: Treatment of PCOS patients with MPA provided good menstrual cycle control, beneficial changes in hormonal values associated with hyperandrogenism, and no significant changes in lipid or carbohydrate metabolism.

Comparison of single versus double intrauterine insemination.

OBJECTIVE: To compare the outcomes of single versus double intrauterine insemination. MATERIALS AND METHODS: This prospective randomized study was carried out in 100 infertile patients. One intrauterine insemination was applied 36 hours after human chorionic gonadotropin (hCG) injection to 50 patients in the first group. To 50 patients in the second group, two intrauterine inseminations were applied, of which the first was applied 24 hours after and the second 48 hours after the hCG injection. RESULTS: In the first group, pregnancies were detected in eight patients (pregnancy rate per patient was 16%, pregnancy rate per cycle was 10.6%). In the second group, pregnancies were detected in five patients (pregnancy rate per patient was 10%, pregnancy rate per cycle was 6.4%). There was no statistically significant difference between the two groups ( p > 0.05). CONCLUSION: Single intrauterine insemination can be considered to be more reasonable than double intrauterine insemination treatment, taking into consideration the economic cost and the psychologic trauma to the patients. However, further studies with larger sample sizes are needed in order to reveal any actual differences between the two methods.

Comparison of multiple dose GnRH antagonist and minidose long agonist protocols in poor responders undergoing in vitro fertilization: a randomized controlled trial.

OBJECTIVE: To investigate the efficacy of gonadotropin releasing hormone antagonist (GnRH) in poor responders undergoing in vitro fertilization. STUDY DESIGN: Ninety-six patients with poor ovarian response in previous treatment cycles were prospectively randomized into two groups. Forty-four patients were stimulated with GnRH antagonist multidose protocol and 45 patients received a standard long agonist protocol. Ovarian response was evaluated by transvaginal ultrasound and hormonal parameters. Cycle characteristics and treatment outcomes were statistically compared between groups. RESULTS: There was significantly reduced duration of stimulation and consumption of gonadotrophins in the antagonist group when compared to the agonist group. The estradiol concentrations on the day of human chorionic gonadotropin (hCG) injection, the number of oocytes retrieved, and the number of embryos transferred were similar for both groups. In the antagonist group, eight (18.1%) ongoing pregnancies were achieved and in the agonist group, ten (22.2%) clinical pregnancies were achieved but the difference was not statistically significant. CONCLUSION: The present study was not powered to detect clinically relevant differences between two protocols in outcomes such as pregnancy rate, with confidence.

A new approach to chromosomal abnormalities in sperm from patients with oligoasthenoteratozoospermia: detection of double aneuploidy in addition to single aneuploidy and diploidy by five-color fluorescence in situ hybridization using one probe set.

OBJECTIVE: To determine the frequencies of disomy, nullisomy, total aneuploidy, and diploidy in the sperms of infertile men. DESIGN: A controlled prospective study. SETTING: Assisted reproductive technology (ART)/IVF Unit and Department of Medical Biology and Genetics, Meram Medical Faculty, Konya, Turkey. PATIENT(S): Infertile men with oligoasthenoteratozoospermia (OAT) and normal fertile donors. INTERVENTION(S): After slide preparation from semen samples, sperm nuclei were analyzed for chromosomes 13, 18, 21, X, and Y by five-color fluorescence in situ hybridization. MAIN OUTCOME MEASURE(S): The sperm aneuploidy (disomy and nullisomy) and diploidy rates were determined according to the number of signals detected for each probe in infertile and fertile men. RESULTS: Patients with OAT had a significantly higher incidence of disomy (except chromosome 18 and XX disomy), nullisomy (except chromosome 18), and diploidy than normal fertile controls. In addition to double disomy, double nullisomy and disomy+nullisomy were observed in patients with OAT, but none of these were seen in controls. CONCLUSION(S): In this study patients with OAT had an increased rate of sperm aneuploidy and diploidy. This finding suggest that patients with OAT may be at an increased risk of producing aneuploid and triploid offsprings. For this reason, it may be very important to perform the sperm fluorescence in situ hybridization in patients with OAT. Thus, a more informative genetic counseling might be given to couples with male factor infertility who are at an increased risk of having aneuploid offsprings and triploid conceptions before intracytoplasmic sperm injection (ICSI).