Evaluation of complications developing during and after transvaginal ultrasound - guided oocyte retrieval.

OBJECTIVES: To investigate the complications of the oocyte retrieval procedure currently used in in vitro fertilisation. MATERIAL AND METHODS: We examined 1.031 patients who underwent oocyte retrieval in the IVF unit of our hospital for complications developed during and after the procedure. RESULTS: No complications developed related to sedation or general anaesthesia. Vaginal bleeding was observed in 3.1% of the patients. There was no intra-abdominal bleeding or pelvic organ injuries requiring surgery. Two patients developed pelvic abscesses. Ovarian hyperstimulation syndrome (OHSS) occurred in 1.45% of the patients. Almost all of the patients tolerated the oocyte retrieval process well. After the procedure, only 2% of the patients described their pain as severe, and 0.4% as the worst pain they had ever experienced. CONCLUSIONS: The most common complication during oocyte retrieval is vaginal bleeding, which is largely controlled by buffer application. In conclusion, the oocyte retrieval process can be considered a safe procedure.

Cornual heterotopic pregnancy after bilateral salpingectomy and uterine septum resection resulting in term delivery of a healthy infant.

Heterotopic pregnancy is the simultaneous occurrence of two or more implantation sites. A 25-year-old infertile patient with a history of bilateral salpingectomy, uterine septum resection, and left cornual resection was diagnosed with heterotopic pregnancy in her second in vitro fertilization trial. She attended our clinic when she was 7-week pregnant, complaining initially of severe abdominal pain. Findings associated with peritoneal irritation were positive during the physical examination. Transvaginal ultrasound revealed right cornual ectopic pregnancy with a live fetus in the middle of the uterine cavity. Also free fluid was noted in the pelvis. A diagnosis of heterotopic pregnancy with rupture of the cornual pregnancy was made. She underwent emergency laparoscopy with aspiration of the ruptured ectopic pregnancy, suturing to the entire visible cornual margins, and assurance of good haemostasis. Her recovery was uneventful and she continued receiving care in our obstetric unit. She delivered a healthy newborn by cesarean section at term.

The impact of familial Mediterranean fever on reproductive system.

Familial Mediterranean fever (FMF) is an autosomal recessive disease characterized by recurrent attacks of fever, peritonitis, pleuritis, arthritis, or erysipelas-like skin lesion. FMF is the most common periodic febrile syndrome affecting more than 150,000 people worldwide. The majority of patients develop FMF before the age of 20. FMF may cause amyloidosis, which mainly affects the kidneys but may also be accumulated in other organs such as the heart, gastrointestinal tract, and reproductive organs. FMF being a systemic disorder with a risk for amyloidosis, affecting patients in their childbearing years, and with its lifelong colchicine therapy raises concern about its effect on the reproductive system. In this article, we review the impact of FMF and its treatment to the reproductive system of male and female patients, pregnancy, and lactation.

Genitourinary symptoms and their effects on quality of life in women with uterine myomas.

INTRODUCTION AND HYPOTHESIS: This study was designed to determine the presence of genitourinary symptoms and their effects on quality of life (QOL) in women with uterine myomas. METHODS: A total of 145 women with ultrasonography (US) diagnosis of anterior myoma were divided into two groups according to myoma size: (1) those ≤5 cm (n = 75), and (2) those >5 cm (n = 70). The control group comprised previously matched 94 women with a normal-appearing uterus on US. Study participants answered the Urogenital Distress Inventory (UDI-6) and the Incontinence Impact Questionnaire (IIQ-7). Pelvic examination was performed, and urinary symptoms were recorded. The chi-square test and Fischer's exact test were used to compare qualitative data. The Kruskal-Wallis test and Dunn's test were used to compare groups. Statistical significance was set at P <0.05. RESULTS: The frequency of genitourinary symptoms was significantly higher in women with myomas, including stress urinary incontinence (SUI), urgency, frequency, urge urinary incontinence (UUI), and dyspareunia. SUI and mixed urinary incontinence (MUI) were the most common symptoms associated with myoma size. Total UDI-6 scores were significantly higher in women with myomas than in control patients (P < 0.0001). UDI scores associated with UI and obstructive symptoms were higher in women with myomas >5 cm than in other women. IIQ scores regarding physical activity, travel, and emotional health were significantly higher in women with myomas >5 cm than in other women (P < 0.001). CONCLUSIONS: Urinary tract dysfunction is associated with anterior myomas, increasing in association with myoma size, and significantly affects QOL.

Effects of the levonorgestrel-releasing intrauterine system on urinary symptoms in patients with adenomyosis.

OBJECTIVES: We hypothesized that treatment of adenomyosis with the levonorgestrel-releasing intrauterine system (LNG-IUS) can concurrently improve urinary incontinence along with irritative and obstructive symptoms and thus positively affect the patients' quality of life. STUDY DESIGN: Sixty-five patients suffering from heavy prolonged menstrual bleeding (menorrhagia) with dysmenorrhea diagnosed with uterine adenomyosis by ultrasound were enrolled in this study. LNG-IUS was inserted in the outpatient department for the treatment of the uterine adenomyosis. The patients filled out two validated questionnaires, the Urogenital Distress Inventory (UDI-6) and the Incontinence Impact Questionnaire (IIQ-7), before and 6 months after the insertion of the LNG-IUS. The before and after scores were compared using the non-parametric Mann-Whitney U test. RESULTS: The mean (± SD) age of the patients was 44.5 ± 6.5 years. Both UDI and IIQ scores were significantly lower at 6 months after treatment with the LNG-IUS (P<0.0001). UDI scores revealed improvement rates of 14.3%, 35.7%, and 22.7% for urinary incontinence, irritative symptoms, and obstructive symptoms, respectively. Moreover, improvements in irritative and obstructive symptoms were significantly correlated with improvements in menorrhagia and dysmenorrhea (P<0.04). IIQ scores demonstrated improvement rates of 18.9%, 14.6%, 19.7%, and 18.5% for physical activity, travel, social relations, and emotional health, respectively. CONCLUSIONS: LNG-IUS used for treating menorrhagia and dysmenorrhea improved urinary incontinence along with irritative and obstructive symptoms in patients with adenomyosis.

The comparison of hyaluronic acid vaginal tablets with estradiol vaginal tablets in the treatment of atrophic vaginitis: a randomized controlled trial.

OBJECTIVE: To compare the effectiveness of the vaginal tablets of hyaluronic acid and estrodiol for the treatment of atrophic vaginitis. MATERIALS AND METHODS: Forty-two postmenopausal women with symptoms of atrophic vaginitis were randomized to take vaginal tablets of 25 µg estradiol (n = 21) (group I) or 5 mg hyaluronic acid sodium salt (n = 21) (group II) for 8 weeks. The symptoms of atrophic vaginitis were evaluated by a self-assessed 4-point scale of composite score and the degree of epithelial atrophy was determined as, none, mild, moderate and severe. Vaginal pH and maturation index were measured and compared in both the groups. RESULTS: The symptoms were relieved significantly in both the groups (P < 0.001). The relief of symptoms was significantly superior in group I compared with group II (P < 0.05). A significant decrease in epithelial atrophy and vaginal pH were detected in both the groups (P < 0.01) after treatment. The vaginal maturation values were also significantly improved at both study groups (P < 0.001). The mean maturation value was significantly higher in group I when compared with group II (P < 0.001). CONCLUSION: Both treatments provided relief of vaginal symptoms, improved epithelial atrophy, decreased vaginal pH, and increased maturation of the vaginal epithelium. Those improvements were greater in group I. Hyaluronic acid vaginal tablets can be used in patients with atrophic vaginitis who do not want to or can not take local estrogen treatment.

Surgical repair of genitourinary fistulae: comparison of our experience at Turkey and Niger.

OBJECTIVE: Report of the personal experience at repairing urogenital fistulae comparing the etiology, management, and outcomes in a developed and underdeveloped countries. MATERIALS AND METHODS: Fifty-three patients with urogenital fistulae were surgically repaired at two different countries. Twenty-nine of those were treated in Istanbul, Turkey during last 10-year period and the other 24 patients were operated in Maradi, Niger in August 2007. Detailed information on obstetric history and previous surgical procedures were questioned in all of the patients. Specific evaluation included instillation of dye in the bladder to locate the site of the fistula and intravenous urography were applied to patients with suspected urogenital fistula to confirm the fistula tract. The site, number and the size of fistula, as well as the pliability of tissues was assessed before the operation. The position of patients for surgery and the route of repair were individualized according to the appropriate access to the fistulae. Patients were reviewed 4-10 weeks after surgery to determine the end results of the operations. RESULTS: Over all, obstetric complications (47%) were the most common cause of urogenital fistulae. Gynecologic surgeries were responsible for 41% of the cases. Although obstetric causes were prominent at patients in Niger, gynecological surgery was the main cause in Turkey. The most common type of fistulae was vesicovaginal. With regard to surgical approach to urogenital fistulae; the transabdominal approach was chosen in 12 (22.6%) of patients and transvaginal repair was performed in 41 (77.4%) of patients; 94.34% of the patients were completely dry after the first attempt. CONCLUSION: A high percentage of patients with genital fistulae can be rendered dry and continent by assessment of these conditions; meticulous attention must be applied for the absence of inflammation and infection at the fistula site before the operation. Surgical team must be experienced at both abdominal and vaginal repair. Broad-spectrum antibiotics and continuous bladder drainage must be applied to all patients for at least 2 weeks. Interposition flaps must be used in complex cases.

A practical guide to determine the incision line in the treatment of septate uterus: "Süha-Levent's Sign".

OBJECTIVE: To evaluate the significance of a new sign in the hysteroscopic incision process of the septate uterus. DESIGN: This is a prospective case control study. DESIGN CLASSIFICATION: II-2. SETTINGS: The study was performed in a research hospital. PATIENTS: Fourty-seven consecutive cases were operated for septate uterus. INTERVENTION: Septum incision was performed in all cases with a hysteroscopic resectoscope under laparoscopic supervision. MEASUREMENTS AND MAIN RESULTS: Methylene blue 0.25% was injected through a Rubin canula in all cases for the assessment of tubal patency. Following the methylene blue injection, hysteroscopic septum incision was performed. CONCLUSION: A line (blue line) on the top of the cavity has been observed in 33 of 47 (70.2%) cases. This line (blue line) can be used for determining the midline especially before hysteroscopic incision of uterine septum and can also shorten the operation time.

Effect of misoprostol on bone mineral density in women with postmenopausal osteoporosis.

OBJECTIVE: To evaluate the effect of misoprostol on bone mineral density in postmenopausal women. MATERIALS AND METHODS: The study was performed in a randomized controlled prospective manner in 90 women with menopause at Süleymaniye Maternity and Women's Diseases Teaching and Research Hospital between January and December 2003. Cases were divided into three groups each consisting of 30 women who were in menopause for at least 1 year and had t-scores less than -1 by dual energy X-ray densitometry (DEXA). Group I was treated with misoprostol and calcium, Group II received tibolone and calcium and Group III was given calcium only and considered as control group. In all patients, bone mineral density in L1-L4 vertebrae, femur neck and Ward triangle were measured by DEXA and t and z scores were calculated. RESULTS: All groups were similar demographically. Bone mineral density in L1-L4 vertebrae, femur neck and Ward triangle in the group treated with misoprostol, increased by 5, 8.1 and 3.6%, respectively. In the tibolone group, bone mineral density in L1-L4 vertebrae, femur neck and Ward triangle increased by 8.3, 5.3 and 7.8%, respectively. There was not a significant difference in t and z-scores and bone mineral density measurements between misoprostol and tibolon groups. CONCLUSION: Misoprostol may be an alternative treatment for patients with osteopenia and osteoporosis who are not suitable for hormone replacement therapy.

Addition of human chorionic gonadotropin to clomiphene citrate ovulation induction therapy does not improve pregnancy outcomes and luteal function.

In a randomized prospective study, 125 women with World Health Organization class II anovulation received 50 mg of clomiphene citrate alone (group A, n = 65) or 50 mg of clomiphene citrate plus hCG (group B, n = 60) in a total of 125 cycles during natural intercourse-advised cycles. There were no statistically significant differences between groups regarding pregnancy outcomes and midluteal P levels, but luteal phase length was longer in group A.

Hormonal and ovarian stromal blood supply changes after laparoscopic tubal sterilization: a prospective controlled study.

OBJECTIVES: The purpose of this study is to determine if the effects of tubal sterilization (TS) by laparoscopy have any risk of a subsequent significant decrease in ovarian reserve and vascular support within the ovary by means of stromal artery Doppler study, and to compare the results with matched paired controls. DESIGN: Between February 2002 and January 2005, 148 healthy volunteers were enrolled sequentially, 74 undergoing laparoscopic TS (study group) and 74 age-, parity-, body mass index-matched women were recruited as a control group. The main outcome measurements were blood levels of follicle-stimulating hormone (FSH), luteinizing hormone and E2, ovarian volume, number of antral follicles and Doppler study of ovarian stromal artery pulsatile index (PI) and maximum velocity (Vmax) on the third day of the cycle immediately before, and 1 and 12 months after the surgical intervention. RESULTS: There were significant elevations in both serum FSH levels and PI values observed 1 month after TS, compared to the preoperative levels (p < .05), and also when compared to controls. However, there were no significant elevations at 12 months postoperation in both study and control groups. The other outcome measurements did not show any significant differences between the two groups. CONCLUSIONS: Tubal sterilization by laparoscopic electrocoagulation does not cause any decrease in ovarian reserve or ovarian stromal blood supply, except an early postoperative increase in FSH and PI.

Significance of maternal plasma lead level in early pregnancy loss.

This study was undertaken to investigate the relation of plasma lead levels, and early pregnancy losses. The concentration of lead in the plasma was measured in 20 women with a history of pregnancy loss before the 20th gestational week, and the results were compared with 20 control patients with viable intrauterine pregnancy. The results showed a mean lead level of 18.8 microg/dL in the cases of pregnancy loss and 22.1 microg/dL in the control patients, thereby indicating that there is no significant relation between early pregnancy loss and maternal plasma lead levels.

Incomplete healing of the uterine incision after caesarean section: Is it preventable?

OBJECTIVE: To find out whether a change in suturing technique might affect the healing of the uterine scar after caesarean section (CS). STUDY DESIGN: In this randomised prospective study, 78 term pregnant patients delivered by CS were allocated to two different suturing techniques either including or excluding the endometrial layer. The integrity of the uterine incision was checked by ultrasound 40-42 days after the operation. Any deviation from the full thickness apposition of the anterior uterine wall (with the ratio: [anterior wall thickness/(anterior wall thickness+height of the wedge shaped defect)]<1) was considered to represent incomplete healing. Both groups were then compared in terms of the frequency of incomplete healing. Chi square and Student's t-test were used where appropriate. A logistic regression model was used to adjust for confounding factors. RESULTS: The frequency of incomplete healing was significantly lower in the group treated by full thickness suturing (44.7% versus 68.8%); (OR: 2.718; CI: 1.016-7.268). Similarly the mean values for the incomplete healing ratio were 0.77+/-0.17 and 0.86+/-0.17 (p = 0.03) in split and full thickness groups, respectively. After adjusting for other confounding factors the suture technique still remained as a significant determinant of the incisional healing (p = 0.04). CONCLUSION: By selecting full thickness suturing technique one may significantly lower the incidence of incomplete healing of the uterine incision after CS.

Ovarian reserve and ovarian stromal blood supply after tubal ligation by the Pomeroy technique: comparison with controls.

OBJECTIVE: To determine if women who undergo tubal sterilization by the Pomeroy technique have any risk of a subsequent significant decrease in ovarian reserve and vascular support inside the ovary, by means of stromal artery Doppler ultrasonography. METHODS: Between March 2000 and September 2004, 108 healthy volunteers underwent mini-laparatomic tubal ligation using the modified Pomeroy technique (study group). As a control group, 102 age-matched women were recruited. The main outcome measurements were blood levels of follicle-stimulating hormone (FSH), luteinizing hormone and estradiol, ovarian volume, number of antral follicles and Doppler indices of the ovarian stromal arteries on the third day of the cycle immediately before, 1 month and 12 months after the surgical intervention. RESULTS: In the study group and control group, results of the main outcome measurements immediately before, 1 month and 12 months after the surgical intervention did not show any significant difference except one. There was a significant elevation of FSH levels after 1 and 12 months, which was statistically significant (p < 0.05) in the study group. CONCLUSION: The 12-month follow-up of patients suggests that there is neither a decrease in ovarian reserve nor an adverse effect on the blood supply of ovarian stroma after tubal sterilization by the modified Pomeroy technique. A significant elevation of FSH levels was observed at 1 and 12 months after the operation.

Risk factors for tubal ligation: regret and psychological effects impact of Beck Depression Inventory.

OBJECTIVE: To investigate the relation of sterilization and depression in association with Beck Depression Inventory (BDI) and to analyze whether preoperative BDI scores have predictive value on satisfaction. METHODS: One hundred sixty-two women who had laparoscopic surgical sterilization were recruited into the study. Patients identified to have an intra-abdominal disease such as pelvic inflammatory disease, endometriosis or adnexal lesions, myoma uteri and previous cesarean delivery were excluded from the study. Women were administered the BDI 1 week prior to the operation and 1 year after the procedure, and patients were asked if they were satisfied with their new state of fertility. RESULTS: Mean BDI scores were 10.1+/-2.7 and 12.9+/-4.0, preoperatively and postoperatively, respectively (p<.001). The difference between preoperative and postoperative BDI scores was affected by age and satisfaction status; younger patients had significantly increased postoperative scores. Dissatisfied women had higher pre- and postoperative BDI scores (p<.001). The difference between pre- and postoperative scores was increased significantly in the dissatisfied group. Preoperative BDI score was found to be a significant predictor of satisfaction status 1 year after the operation. CONCLUSION: Preoperative application of BDI can identify women who are at greater risk for regret and dissatisfaction.

Effect of tubal ligation on ovarian reserve and the ovarian stromal blood supply.

AIM: Our aim was to evaluate possible adverse effects of tubal ligation on ovarian reserve and ovarian stromal vascular support. METHODS: Ninety-one women who underwent tubal ligation, using a modified Pomeroy technique, were studied. The main outcome measurements were serum follicle stimulating hormone, luteinising hormone and oestradiol levels, ovarian volume, number of antral follicles and Doppler study of ovarian stromal artery on the third day of the menstrual cycle immediately before, 1 month and 12 months after the surgical intervention. RESULTS: Statistically significant elevation of follicle stimulating hormone levels was observed at 1 and 12 months after tubal ligation (P < 0.05). CONCLUSION: Doppler flow studies of the ovarian stromal arteries showed that there were no significant differences before and after tubal ligation.