The effect of folate on ischemia/reperfusion injury in a rat adnexal torsion model.

PURPOSE: The ischemia/reperfusion (I/R) injury of ovaries in adnexal torsion may have inadvertent consequences. Many agents have been studied in terms of their ability to prevent reperfusion damage to ovaries in suspected cases. In this study, folic acid, known to have antioxidative properties, was investigated to determine whether it played a role in the prevention of I/R damage in a rat ovarian torsion model. METHODS: In this experimental study, 40 female adult Wistar-Albino rats were randomly divided into five groups as control, ischemia, I/R, Fol2 (2 mg/kg folic acid), and Fol4 (4 mg/kg folic acid). In the Fol2 and Fol4 groups, folic acid was intraperitonelly administered 30 min before reperfusion. Blood samples were obtained from the tails of each rat at the second hour of reperfusion. RESULTS: The total oxidant status (TOS), total antioxidant status, cystatin C and folic acid levels of the five groups were investigated. Folic acid in 2 mg/kg dose could moderately increase the serum folic acid concentration (15.75-19.95 ng/ml, p < 0.05), reduce the level of cystatin C (0.18-0.12 µg/L, p < 0.05), and had a tendency to improve the oxidative stress injury (OSI: 76.05-33.06, p > 0.05), although there was no statistical difference in TOS levels (p = 0.07). Folic acid in 4 mg/kg dose, could significantly increase the serum folic acid concentration (15.75-37.65 ng/ml). However, it did not significantly reduce the level of cystatin C (0.18-0.19 µg/L, p > 0.05), and did not improve oxidative stress injury (76.05-130.58, p > 0.05). CONCLUSION: Folic acid in 2 mg/kg dose might improve the ovarian I/R injury though this was not statistically significant. Further studies are required to reach a definitive conclusion about the protective effect of folic acid in I/R injury.

Pregnancy outcome of laparoscopic tubal reanastomosis: retrospective results from a single clinical centre.

Objective Tubal sterilization is a widespread method of contraception. Post-sterilization regret is encountered, despite careful consideration prior to the procedure. Two treatment options are available for women after having had tubal sterilization: microsurgical reversal and IVF treatment. Recent improvements in laparoscopy have allowed tubal reanastomosis to be performed. This study aimed to evaluate the reproductive outcome after laparoscopic tubal reanastomosis and surgical features of the patients. Methods From June 2007 to January 2010, 27 patients with bilateral tubal ligation who underwent laparoscopic tubal reanastomosis were evaluated retrospectively. Tubal sterilization was performed by Pomeroy's technique during caesarean section in all of the patients. Before surgery, all of the patients were evaluated for possible other causes of infertility and the results of the evaluation were normal. Results The mean age of the patients was 31.8 years (range, 27-38 years). The mean interval between sterilization and reversal was 5.1 years (range, 1-14 years). Bilateral reversal was achieved in 24 patients. The operation time ranged from 85 to 140 minutes with a mean time of 105 minutes. All of the patients were discharged on the next day. There were no postoperative complications. Overall pregnancy, intrauterine pregnancy, and ectopic pregnancy rates were 55.5% (15/27), 51.8% (14/27), and 3.7% (1/27), respectively. Of the 14 intrauterine pregnancies, one ended with abortion at 6 weeks' gestation (1/14). The mean interval from surgery to pregnancy was 270 days (range, 147-420 days). Conclusion Laparoscopic tubal reanastomosis has the advantages of fewer complications, less postoperative discomfort, a smaller incisional scar, a shorter recovery time, and earlier resumption of normal activities. This technique has a satisfactory pregnancy rate in selected patients who desire reversal of tubal sterilization.

Effects of pentoxifylline and platelet activating factor on sperm DNA damage.

OBJECTIVE: Pentoxifylline and platelet-activating factor (PAF) have been used to increase sperm motility in embryology laboratories. In the present study, we aimed to investigate whether these agents pose sperm DNA damage using DNA sperm chromatin dispersion (SCD) assay. STUDY DESIGN: Following application of pentoxifylline and PAF, sperm samples of 50 individuals with different sperm parameters were compared to baseline in terms of DNA damage using SCD assay. Furthermore, the relationship between DNA damage and sperm parameters in predicting DNA damage was assessed. RESULTS AND CONCLUSIONS: Significant increase in DNA damage was observed following application of PAF and pentoxifylline. Furthermore, DNA damage was significantly increased with application of pentoxifylline compared to PAF. Sperm motility was observed to be a statistically significant indicator in predicting alterations in DNA damage in baseline and subsequent to application of PAF and pentoxifylline independent of sperm concentration and morphology. Increased DNA damage was observed in both groups following application of pentoxifylline and PAF. Furthermore, the increase in DNA damage was higher in samples treated with pentoxifylline compared to samples treated with PAF. Thus, PAF seems to be more innocent in choosing viable sperm cells and in achieving sperm motility in the in vitro fertilization laboratory.

Immediate postplacental insertion of a copper intrauterine device: a pilot study to evaluate expulsion rate by mode of delivery.

BACKGROUND: The present study aimed to investigate risk factors for expulsion in immediate postplacental IUD insertion. We specifically sought to determine whether cesarean delivery before or during labor have an impact on IUD expulsion. METHODS: The study included 160 pregnant women for immediate IUD insertion following vaginal or cesarean delivery. Three groups of patients were recruited: Patients who underwent pre-planned cesarean delivery (group 1, n: 51), patients who underwent cesarean delivery during active labor (group 2, n: 47), patients who delivered vaginally (group 3, n: 62). RESULTS: The cumulative expulsion rates were similar with a frequency of 8.7, 8.9 and 11.3% respectively in groups 1 to 3 (p > 0.05 in all pairwise comparisons). The rate of patients who had the IUD removed at 12th month was 4,3, 6.7 and 11.3% for groups 1, 2 and 3 respectively (p > 0.05 in all pairwise comparisons). Multiparity increased the risk of cumulative expulsion within 12 months by 2.1 fold (95% 1,03-4,37) in the logistic regression model. Previous vaginal deliveries or IUD use did not have an impact on the expulsion of the IUD. The risk of spontaneous expulsion was similar in patients whose IUD was placed after cesarean in the active and latent phase or after spontaneous vaginal delivery. CONCLUSIONS: The rates of IUD expulsion are similar in patients who underwent cesarean section before and during labor and who delivered vaginally. Parity was the only factor independently associated with IUD expulsion.

Comparison of tissue trauma after abdominal, vaginal and total laparoscopic hysterectomy.

OBJECTIVE: The aim of the study was to compare the extent of tissue trauma atter abdominal hysterectomy(AH), vaginal hysterectomy (VH), and total laparoscopic hysterectomy (TLH) using biochemical markers. MATERIAL AND METHODS: Seventy-one patients requiring hysterectomy for benign uterine diseases were enrolled in the study and divided into three treatment groups: AH (n=24), VH (n=23), and TLH (n=24). Blood samples for assay of interleukin-6 (IL-6) and creatine phosphokinase (CPK) were collected pre-, intra-operatively and 2, 6 and 24 h after surgery. RESULTS: Serum levels of IL-6, and CPK were significantly elevated over basal values after surgery in all groups. IL-6 and CPK levels were significantly higher after AH as compared to VH and TLH. IL-6 concentrations were significantly higher in the VH group than the TLH group (p=0.00 1). There were no significant differences in CPK levels between the VH and TLH groups (p=0.824). TLH group had the smallest decrease in blood hemoglobin concentration and the shortest hospital stay CONCLUSIONS: AH causes more tissue trauma as compared to VH and TLH. Owing to the fact that TLH is associated with less tissue trauma and offers significant clinical benefits, including less blood loss and shorter hospital stay it should be considered in women with benign gynecologic conditions, especially in experienced centers.

Office hysteroscopy improves pregnancy rates following IVF.

The aim of the study was to evaluate the effect of office hysteroscopy (OH) on pregnancy rate in patients undergoing IVF. A total of 1258 patients attending an IVF clinic with normal hysteroscopic findings were enrolled. The impact of timing of OH before embryo transfer on pregnancy rate was investigated. The women were evaluated in three groups: group 1, OH performed 50 days or less before embryo transfer (n=407), group 2, OH between 51 days to 6 months, (n=280) and group 3, OH more than 6 months before embryo transfer (n=571). The implantation rates were 22.1%, 16.1% and 11.1% in groups 1, 2 and 3, respectively. Overall pregnancy rates were 48.2%, 38.9% and 29.9% in groups 1, 2 and 3, respectively. The clinical pregnancy rates were 45.2%, 34.3% and 27.1% and the live birth rates were 36.9%, 27.9% and 22.6%, respectively. Implantation, pregnancy, clinical pregnancy and live birth rates were significantly higher in group 1 compared with groups 2 and 3 (all P<0.05). OH may improve pregnancy rates, but timing of the procedure is important. The endometrial effect is highest when hysteroscopy is performed 50 days or less before embryo transfer. Office hysteroscopy (OH), which helps the clinician for the evaluation of the uterine cavity before IVF treatment, may affect the pregnancy rates depending on when the procedure is performed. A total of 1258 patients attending an outpatient IVF clinic were enrolled in the study. The women were evaluated in three groups: group 1, OH performed 50 days or less before embryo transfer (n=407), group 2, OH between 51 days to 6 months, (n=280) and group 3, OH more than 6 months before embryo transfer (n=571). The implantation, pregnancy and clinical pregnancy rates were significantly higher in group 1 compared with groups 2 and 3. OH may improve pregnancy rates when performed 50 days or less before embryo transfer.

Serum and follicular fluid Anti-Mullerian hormone concentrations at the time of follicle puncture and reproductive outcome.

OBJECTIVE: The objective of the study is to determine and compare the levels of Anti-Mullerian hormone (AMH) and estradiol (E2) in serum and follicular fluid (FF) on the day of oocyte pick up (OPU) with the cycle parameters and the outcome of in vitro fertilization (IVF) treatment. MATERIAL AND METHODS: The long stimulation protocol was used in 37 (86%) women; the microdose flare-up protocol was used in 6 (14%) women. Concentrations of AMH and E2 were measured in serum and FF of 43 women undergoing IVF treatment on the day of OPU. RESULTS: Significant positive associations were observed between serum AMH concentrations and the total number of oocytes retrieved (r=0.343, p=0.024). Serum AMH and FF AMH levels on the day of OPU were significantly increased in the group of women who achieved clinical pregnancy (p=0.017, p=0.028). For serum AMH, a cut-off level of 1.64 ng/ml was used for the prediction of clinical pregnancy; for FF AMH, a cut-off level of 3.8 ng/ml was used for the prediction of clinical pregnancy. Serum AMH and FF AMH levels were significantly and positively correlated with implantation rate (r=0.401, p=0.008; r=0.317, p=0.039). No significant correlation was found between serum and FF AMH concentrations and fertilization rate. CONCLUSION: Serum AMH and FF AMH concentrations are positively correlated with implantation and clinical pregnancy rates.

Emergency peripartum hysterectomy.

PURPOSE: To determine the incidence, indications, risk factors and complications of peripartum hysterectomy in a tertiary teaching hospital. METHODS: The medical records of 73 patients who had undergone emergency peripartum hysterectomy between 2003 and 2008 were reviewed retrospectively. Maternal characteristics and characteristics of the present pregnancy and delivery, hysterectomy indications, operative complications, postoperative conditions and maternal outcomes were evaluated. RESULTS: There were 73 emergency peripartum hysterectomies out of 114,720 deliveries, a rate of 0.63 per 1,000 deliveries. Eleven hysterectomies were performed after vaginal delivery (0.12/1,000 vaginal deliveries) and the remaining 62 hysterectomies were performed after cesarean section (2/1,000 cesarean sections). The most common indication for hysterectomy was placenta previa and/or accreta (31 patients, 42.4%), followed by uterine atony (26 patients, 35.6%). In this study, 22 of 29 patients (75.8%) with placenta previa and 12 of 16 patients (75%) with placenta accreta had previously had cesarean sections. Cesarean section is associated with placenta previa and accreta, which are the most common causes of emergency peripartum hysterectomy. CONCLUSION: The increase in the cesarean delivery rate is leading to an increase in the rate of abnormal placentation (placenta previa and accreta), which in turn give rise to an increase in the peripartum hysterectomy rate. Cesarean section itself is also a risk factor for emergency peripartum hysterectomy. Therefore, every effort should be made to reduce the cesarean rate by performing this procedure only for valid clinical indications. The risk factors for peripartum hysterectomy should be identified antenatally. The delivery and operation should be performed in appropriate clinical settings by experienced surgeons when risk factors are identified.

Conservative laparoscopic management of adnexal torsion.

OBJECTIVE: To evaluate our experience with adnexal torsion (AT) in 36 patients and the outcomes of the patients who were managed conservatively via laparoscopy. MATERIAL AND METHODS: A prospective study was conducted on 36 patients who underwent operations for AT via laparoscopy between January 2008 and December 2009. Data including age, previous history, time of onset of symptoms, time of admission to hospital, gray-scale and color Doppler US findings, time interval between hospital admission and surgery, type of intervention, operative findings and postoperative gray-scale and Doppler US findings were recorded. RESULTS: In 29 (80.5%) patients, a preoperative diagnosis of AT was confirmed clinically. The mean age of the patients was 26.5, with a range of 11 to 44. Ovarian blood flow was assessed by color Doppler US ultrasonography in 30 patients preoperatively. In 11 (36.6%) patients, this was found to be normal. In 19 (63.3%) patients, ovarian blood flow was found to be pathological or absent. Laparoscopic conservative treatment was performed in 34 patients. In two patients, salpingo-oophorectomy was performed. No thromboembolic complications were seen. Postoperative ultrasonographic examinations confirmed normal ovarian morphology and Doppler blood flow in all patients with no recurrence. CONCLUSION: Early diagnosis and treatment are key factors in managing AT. According to the results of the present study, given its demonstrated safety and benefits, in women of reproductive age, a conservative approach of untwisting the adnexa and salvaging the ovary via laparoscopy should be considered in AT cases in which the time from the onset of symptoms to surgery does not exceed 44 hours, regardless of the color and number of twists.

Large solitary paravaginal hydatid cyst: a rare cause of urethral injury.

Hydatid cyst is a parasitic infectious disease caused by Echinococcus granulosus. Although the most common site for this parasite is liver, it can be seen in almost all organs. Extrahepatic localization is reported in 14-19% of all cases of abdominal hydatid disease. We report the case of a large echinococcal cyst localized in the paravaginal area in the lower pelvis. A 43-year-old woman was admitted to our gynecology clinic for pelvic discomfort and dyspareunia. During her physical examination, a paravaginal cystic mass was found. Ultrasonography and magnetic resonance imaging revealed a large paravaginal cystic mass. During cyst wall dissection, distorted and fibrotic distal urethra was injured. End-to-end urethroplasty was performed. She had urinary continence after the surgery. Pathology revealed the diagnosis of echinococcosis. Antihelmintics were administered postoperatively, and the patient was discharged after day 7 uneventfully and has been under follow-up for 1 year.

Results of 2500 office-based diagnostic hysteroscopies before IVF.

The aim of the study is to assess the diagnostic accuracy, findings and feasibility of office-based diagnostic hysteroscopy in an IVF population. A total of 2500 consecutive infertile patients were enrolled prospectively prior to IVF treatment. Diagnostic hysteroscopy was performed on each subject in an office setting in the study IVF centre. A total of 1927 patients (77.1%) had a normal uterine cavity, while the remainder of the sample (n=573) demonstrated endometrial pathology on hysteroscopy (22.9%). Of the patients with endometrial pathology, 192 patients had endometrial polyps (7.68%), 96 patients had submucosal fibroids (3.84%), 31 patients had polypoid endometria (1.24%), 27 patients had intrauterine adhesions (1.08%) and 73 patients had uterine septa (2.92%). Diagnostic office-based hysteroscopy is routinely performed in the IVF clinic to assess the endometrial cavity. In such an unselected population, a significant percentage of patients had evidence of uterine pathology that may have impaired the success of IVF. Safety, ease of use, high diagnostic accuracy and high patient tolerance makes office-based hysteroscopy an ideal procedure.

The effectiveness of intracytoplasmic sperm injection combined with piezoelectric stimulation in infertile couples with total fertilization failure.

OBJECTIVE: To assess the effectiveness of intracytoplasmic sperm injection (ICSI) combined with piezoelectric stimulation in infertile couples with a history of total fertilization failure (TFF). DESIGN: Prospective controlled trial. SETTING: Clinical IVF laboratory. PATIENT(S): Seventy-one couples undergoing ICSI on sibling oocytes having at least one previous ICSI attempt with TFF. INTERVENTION(S): ICSI or ICSI with piezoelectric activation. MAIN OUTCOME MEASURE(S): Fertilization rate. RESULT(S): The patients were allocated to two groups: group I included 21 patients with only one previous TFF and group II included 50 patients with more than one previous TFF. Collectively, a total of 823 metaphase II (MII) oocytes were retrieved in 78 oocyte retrievals. In Group I, combined ICSI with piezoelectric stimulation was applied to 123/211 (58.2%) of MII oocytes (group IA), whereas standard ICSI procedure was applied to 88/211 (41.8%) of MII oocytes (group IB). The fertilization rate was 62% and 12% in group IA and group IB respectively. In group II, piezoelectric activation was applied in all 612 MII oocytes, of which 296 (48.3%) were fertilized. The rates for implantation and pregnancy/embryo transfer were obtained as 30.6% and 44.1%, respectively. CONCLUSION(S): Piezoelectric activation seems to improve IVF outcome in patients with previous TFF history.

Successful application of preimplantation genetic diagnosis for Leigh syndrome.

OBJECTIVE: To perform preimplantation genetic diagnosis (PGD) for a SURF1 gene mutation of the Leigh syndrome to transfer unaffected or carrier embryo/embryos. DESIGN: Case report. SETTING: Clinical IVF laboratory. PATIENT(S): A couple carrying an nt769 G/A mutation that is associated with Leigh syndrome. INTERVENTION(S): Oocytes were fertilized by means of intracytoplasmic sperm injection. The resulting embryos were biopsied 3 days after fertilization. One blastomere was taken and whole-genome amplification was performed. Amplification of the mutation site was achieved by polymerase chain reaction (PCR) and restriction digestion was completed. Gel Imager was used to measure the digests of normal and mutant load. MAIN OUTCOME MEASURE(S): Embryo testing by means of PGD-PCR and pregnancy. Successful preimplantation genetic diagnosis for a SURF1 gene mutation and transfer of healthy or carrier embryos. RESULT(S): Successful singleton pregnancy resulting in the delivery of healthy baby girl. CONCLUSION(S): We report the first case of successful PGD for Leigh syndrome resulting in delivery of a healthy newborn.