Second look hysteroscopy following hysteroscopic septum resection improves reproductive outcomes in patients undergoing ICSI.

The aim of this study was to compare the reproductive outcomes between infertile women who underwent hysteroscopic uterine septum resection and those who required a second look hysteroscopy due to residual septum prior to intracytoplasmic sperm injection (ICSI) cycles with selective single 'Grade A' embryo transfer (ET). All second look hysteroscopies were performed due to partial remnant septum in a control three dimensional transvaginal ultrasonography (3D TVUSG) after the first hysteroscopic resection. Miscarriage and biochemical pregnancy rates were not different between the groups while clinical pregnancy and live birth rates were significantly higher in Group 2 than in Group 1. Second look hysteroscopic metroplasty performed to restore remnant septum significantly improves live birth rate as well as clinical pregnancy rates while it appears not to alleviate abortion and biochemical pregnancy rates in women undergoing ICSI-ET.IMPACT STATEMENTWhat is already known on this subject? The effect of hysteroscopic septum resection on reproductive outcomes in IVF treatment in infertile patients with uterine septum is not clearly known.What do the results of this study add? With the selective single ET strategy, complete or partial hysteroscopic correction of the uterine septum before ICSI and subsequent resection of the residual septum with control hysteroscopy significantly increases the live birth rates in the infertile population.What are the implications of these findings for clinical practice and/or further research? In the group of infertile patients with uterine septum, second control hysteroscopy should be performed 1 month later for residual septum or adhesions after hysteroscopic septum resection performed once.

Prevention of Premature Ovulation by Administration of Gonadotropin Releasing Hormone Antagonist the day After Ovulation Triggering in Diminished Ovarian Reserve Patients / Prevenção da ovulação prematura por meio da administração de antagonismo de liberação de gonadotropismo no dia seguinte à ovulação

Abstract Objective The aim of the present retrospective study was to investigate the effectiveness of single-dose gonadotropin releasing hormone (GnRH) antagonist administration, the day after human chorionic gonadotropin (hCG) triggering for final oocyte maturation, on the prevention of premature luteinization in patients with diminished ovarian reserve in in-vitro fertilization (IVF) cycles. The secondary objective of the study was to search the effect of this protocol on pregnancy outcomes. Methods This is a retrospective study including 267 infertile patients who have single antral follicle seen with ultrasonography on the 2nd or 3rd day of the menstrual cycle before starting IVF treatment. We randomized patients into two groups. The case group comprised patients who had single-dose GnRH antagonist injection the day after hCG triggering formed, and the patients who had the standard treatment regime formed the control group. In both groups, the oocytes were collected 36 hours after hCG injection. Results The premature ovulation rate was significantly low in the case group compared with the control group (6.86 versus 20.6% per scheduled cycle) (p=0.022). Also, the oocyte retrieval rate (93.14 versus 67.87% per scheduled cycle) (p=0.013), the oocyte maturity rate (79.42 versus 47.87%) (p=0.041), the fertilization rate (65.68 versus 34.54%) (p=0.018), and the embryo transfer rate per scheduled cycle (44.11 versus 18.78%) (p=0.003) were higher in the GnRH antagonist group than in the control group. Conclusion The administration of GnRH antagonist the day after hCG trigger in IVF treatments of patients with diminished ovarian reserve enabled a significant decrease in the rate of premature ovulation but had no effect on live birth rate.

Resumo Objetivo O objetivo do presente estudo retrospectivo foi investigar a eficácia da administração do antagonista do hormônio liberador da gonadotrofina (GnRH) em dose única no dia seguinte ao desencadeamento da gonadotrofina coriônica humana (hCG) para a maturação final do oócito, na prevenção da luteinização prematura em pacientes com diminuição do ovário reserva em ciclos de fertilização in vitro (FIV). O objetivo secundário do estudo foi pesquisar o efeito deste protocolo nos resultados da gravidez. Métodos Trata-se de um estudo retrospectivo incluindo 267 pacientes inférteis que apresentam um único folículo antral visto por ultrassonografia no 2° ou 3° dia do ciclo menstrual antes de iniciar o tratamento de FIV. Nós randomizamos os pacientes em dois grupos. Os pacientes que receberam injeção de antagonista de GnRH em dose única no dia seguinte ao desencadeamento do hCG formaram o grupo caso, e os pacientes que receberam o regime de tratamento padrão formaram o grupo controle. Em ambos os grupos, os oócitos foram coletados 36 horas após a injeção de hCG. Resultados A taxa de ovulação prematura foi significativamente baixa no grupo caso em comparação com o grupo controle (6,86 versus 20,6% por ciclo programado) (p=0,022). Além disso, a taxa de recuperação de oócitos (93,14 versus 67,87% por ciclo programado) (p=0,013), a taxa de maturidade do oócito (79,42 versus 47,87%) (p=0,041), a taxa de fertilização (65,68 versus 34,54%) (p=0,018) e a taxa de transferência de embriões por ciclo programado (44,11 versus 18,78%) (p=0,003) foram maiores no grupo antagonista de GnRH do que no grupo controle. Conclusão A administração de antagonista de GnRH, no dia seguinte ao desencadeamento de hCG em tratamentos de FIV de pacientes com reserva ovariana diminuída permitiu uma redução significativa na taxa de ovulação precoce,mas não teve efeito na taxa de nascidos vivos.

Prevention of Premature Ovulation by Administration of Gonadotropin Releasing Hormone Antagonist the day After Ovulation Triggering in Diminished Ovarian Reserve Patients.

OBJECTIVE: The aim of the present retrospective study was to investigate the effectiveness of single-dose gonadotropin releasing hormone (GnRH) antagonist administration, the day after human chorionic gonadotropin (hCG) triggering for final oocyte maturation, on the prevention of premature luteinization in patients with diminished ovarian reserve in in-vitro fertilization (IVF) cycles. The secondary objective of the study was to search the effect of this protocol on pregnancy outcomes. METHODS: This is a retrospective study including 267 infertile patients who have single antral follicle seen with ultrasonography on the 2nd or 3rd day of the menstrual cycle before starting IVF treatment. We randomized patients into two groups. The case group comprised patients who had single-dose GnRH antagonist injection the day after hCG triggering formed, and the patients who had the standard treatment regime formed the control group. In both groups, the oocytes were collected 36 hours after hCG injection. RESULTS: The premature ovulation rate was significantly low in the case group compared with the control group (6.86 versus 20.6% per scheduled cycle) (p = 0.022). Also, the oocyte retrieval rate (93.14 versus 67.87% per scheduled cycle) (p = 0.013), the oocyte maturity rate (79.42 versus 47.87%) (p = 0.041), the fertilization rate (65.68 versus 34.54%) (p = 0.018), and the embryo transfer rate per scheduled cycle (44.11 versus 18.78%) (p = 0.003) were higher in the GnRH antagonist group than in the control group. CONCLUSION: The administration of GnRH antagonist the day after hCG trigger in IVF treatments of patients with diminished ovarian reserve enabled a significant decrease in the rate of premature ovulation but had no effect on live birth rate.

OBJETIVO: O objetivo do presente estudo retrospectivo foi investigar a eficácia da administração do antagonista do hormônio liberador da gonadotrofina (GnRH) em dose única no dia seguinte ao desencadeamento da gonadotrofina coriônica humana (hCG) para a maturação final do oócito, na prevenção da luteinização prematura em pacientes com diminuição do ovário reserva em ciclos de fertilização in vitro (FIV). O objetivo secundário do estudo foi pesquisar o efeito deste protocolo nos resultados da gravidez. MéTODOS: Trata-se de um estudo retrospectivo incluindo 267 pacientes inférteis que apresentam um único folículo antral visto por ultrassonografia no 2° ou 3° dia do ciclo menstrual antes de iniciar o tratamento de FIV. Nós randomizamos os pacientes em dois grupos. Os pacientes que receberam injeção de antagonista de GnRH em dose única no dia seguinte ao desencadeamento do hCG formaram o grupo caso, e os pacientes que receberam o regime de tratamento padrão formaram o grupo controle. Em ambos os grupos, os oócitos foram coletados 36 horas após a injeção de hCG. RESULTADOS: A taxa de ovulação prematura foi significativamente baixa no grupo caso em comparação com o grupo controle (6,86 versus 20,6% por ciclo programado) (p = 0,022). Além disso, a taxa de recuperação de oócitos (93,14 versus 67,87% por ciclo programado) (p = 0,013), a taxa de maturidade do oócito (79,42 versus 47,87%) (p = 0,041), a taxa de fertilização (65,68 versus 34,54%) (p = 0,018) e a taxa de transferência de embriões por ciclo programado (44,11 versus 18,78%) (p = 0,003) foram maiores no grupo antagonista de GnRH do que no grupo controle. CONCLUSãO: A administração de antagonista de GnRH, no dia seguinte ao desencadeamento de hCG em tratamentos de FIV de pacientes com reserva ovariana diminuída permitiu uma redução significativa na taxa de ovulação precoce, mas não teve efeito na taxa de nascidos vivos.

Live birth rate with double ovarian stimulation is superior to follicular phase ovarian stimulation per started cycle in poor ovarian responders.

AIM: To compare the outcome of double ovarian stimulation (DOS) with follicular phase ovarian stimulation (FPS) per started cycle in poor ovarian responders (PORs). METHODS: A total of 204 PORs who underwent ovulation induction for in vitro fertilization, cryopreservation of all embryos available, and frozen embryo transfer cycle were retrospectively analyzed. Of those, 146 received single FPS, and 58 received DOS. All viable embryos were cryopreserved and subsequently transferred within 1-6 months. RESULTS: The number of oocytes collected and the number of mature oocytes per started cycle were higher in the DOS group compared to the FPS group (6.0 ± 1.9 vs. 2.8 ± 1.3 and 4.3 ± 1.3 vs. 2.2 ± 1.2, respectively, p = 0.001). Clinical pregnancy rate and live birth rate per started cycle were also significantly higher in the DOS group than the FPS group (41.4% vs. 16.4% and 36.2% vs. 15.1%, respectively, p < 0.001). The cancellation rate of embryo transfer due to no viable embryo was significantly lower in the DOS group (10.3%) than the FPS group (40.4%) (p = 0.001). In the DOS group, numbers of oocytes (3.2 ± 1.2 vs. 2.7 ± 1.1, p = 0.006), MII oocytes (2.6 ± 1.0 vs. 2.1 ± 0.8, p = 0.001), and cryopreserved blastocysts (1.5 ± 0.8 vs. 1.1 ± 0.7, p = 0.002) were significantly higher in the luteal ovarian stimulation compared to follicular ovarian stimulation. CONCLUSIONS: Live birth per started cycle with DOS is superior to FPS in PORs. Luteal phase stimulation contributes to improving pregnancy rates in these patients.

Pregnancy results after fresh embryo transfer and selective frozen-thawed embryo transfer: Single-center experience.

OBJECTIVE: To compare the clinical pregnancy and live birth results of fresh embryo transfer (ET) and selective frozen embryo transfer (sFET) in cohort of infertile patients aged between 18-42 years of age in single IVF center. MATERIALS AND METHODS: In this retrospective cross-sectional study, the clinical and live birth results of 620 fresh embryo transfer cycles and 580 frozen embryo transfer cycles were investigated in Sisli Kolan International Hospital Fertility Unit between 2015-2018. RESULTS: Age, BMI, causes of infertility, duration of infertility, ovulation induction protocols, the number of oocytes collected and the thickness of endometrium on the day of transfer were similar in the ET and sFET groups. More good quality embryos were obtained in sFET group. The clinical pregnancy and live birth rates were 71.04 % and 59.31 % in the sFET groups, and 56.77 % and 44.52 % in the ET group, respectively (p < 0.05). CONCLUSION: Pregnancy, clinical pregnancy and live birth rates were higher in frozen embryo transfer cycles than in fresh embryo cycles. However, appropriate in vitro fertilization and embryo transfer methods suitable for each patient should be determined before choosing fresh ET or sFET treatment modalities.

Comparison of cabergoline and bromocriptine in patients with asymptomatic incidental hyperprolactinemia undergoing ICSI-ET.

We retrospectively assessed outcomes of in vitro fertilisation in groups of women with asymptomatic incidentally discovered hyperprolactinaemia (AIH) undergoing ovarian stimulation and ICSI-ET relative to the types of dopamine agonist and gonadotropin releasing hormone analogue used. Of 5840 women who underwent COH and ICSI-ET, 239 were included in the study; 122 had been treated with cabergoline, and 117 with bromocriptine, during the COH. The mean age, duration of stimulation, and total number of gonadotropin ampules employed were comparable in the two groups using the agonist and antagonist protocols, as were the number of oocytes retrieved and the proportion of mature MII and fertilised (2pn) oocytes. There were no significant differences in implantation, pregnancy, and miscarriage rates between the agonist and antagonist arms of the study. The cost of treatment was significantly higher with cabergoline than with bromocriptine (p = 0.0001). However, side effect rate was significantly higher with bromocriptine than with cabergoline (15.3% vs. 2.5%; p = 0.0004). In conclusion, we found that cabergoline and bromocriptine showed no differences in IVF outcomes and pregnancy results in patients with AIH.

Early pregnancy loss rates were different among singleton gestations conceived by ICSI using GnRH agonist and antagonist.

This study compared early pregnancy losses (termination of pregnancy before 12 weeks of gestation, EPL) among conceptions achieved by ICSI according to the type of GnRH analogue for ovarian stimulation. Only singleton gestations (2,184) and fresh embryo transfers were included. GnRH agonist was used in 848 gestations out of 2,184 and GnRH antagonist was used in the remaining 1,336 gestations. EPL was found to be significantly higher in GnRH antagonist gestations compared to GnRH agonist (27.2% vs 18.9%). This significant difference persisted when gestations were segregated according to maternal age, especially among women younger than 35 years old. Therefore our results suggest that gestations conceived by ovarian stimulation including GnRH antagonists may have higher probability of having EPL.

Spontaneous perforation of pyometra.

Pyometra is the accumulation of purulent material in the uterine cavity. Its reported incidence is 0.01-0.5% in gynecologic patients; however, as far as elderly patients are concerned, its incidence is 13.6% [3]. The most common cause of pyometra is malignant diseases of genital tract and the consequences of their treatment (radiotherapy). Other causes are benign tumors like leiomyoma, endometrial polyps, senile cervicitis, cervical occlusion after surgery, puerperal infections, and congenital cervical anomalies. Spontaneous rupture of the uterus is an extremely rare complication of pyometra. To our knowledge, only 21 cases of spontaneous perforation of pyometra have been reported in English literature since 1980. This paper reports an additional case of spontaneous uterine rupture.

Subclinical pregnancy losses among women undergoing in-vitro fertilization with ICSI.

BACKGROUND: The purpose of this study is to asses the frequency of subclinical pregnancy loss (SPL) among women undergoing controlled ovarian hyperstimulation (COH) and in-vitro fertilization with ICSI. METHODS: The study was retrospectively conducted in a private IVF center. SPL was defined by a temporary rise in serum beta hCG, along with the absence of signs of intra- and extra-uterine pregnancy by transvaginal ultrasonography. Overall 5273 COH and ICSI cycles with embryo transfer (ET) were segregated according to serum E(2) levels percentiles (-24th, 25th, 74th, and 75th), women age and the type of spermatozoa for assisted fertilization (ejaculated and surgically retrieved). Those groups were assessed for SPL rates. RESULTS: Among the 3125 (59.25) conception cycles, 305 (9.7%) were diagnosed as SPL. There was no difference in SPL rate among E(2) percentile groups. Women older than 35 years of age had significantly higher rate of SPL compared to younger women. There was also no difference in SPL rate among pregnancies in whom surgically retrieved spermatozoa used or ejaculated spermatozoa used for assisted fertilization. CONCLUSION: Our results demonstrated that SPL rate was not influenced by the levels of E(2) during COH or the origin of spermatozoa used for assisted fertilization. However, maternal age was found to be detrimental for SPL.

Primary malignant melanoma of the vagina: a case report and review of the current treatment options.

A case with primary malignant melanoma located in the posterior lower third of the vagina was encountered and treated by surgery, postoperative immunotherapy and chemotherapy. The tumor was close to the anal sphincter and posterior exenteration was done to achieve tumor-free surgical margins. The need for such radical treatment prompted us to review the literature and discuss our case with the rarest localization of the tumor in the vagina. We focused on the treatment options and the possible complication that may arise during the treatment of the primary malignant melanoma of the vagina. The need for radical surgery was discussed and the current treatment options were reviewed.

Intercycle variabilities of basal antral follicle count and ovarian volume in subfertile women and their relationship to reproductive aging: a prospective study.

BACKGROUND: Reproducibility is an important issue when using tests for estimating ovarian reserve and counseling patients. However, little is known about the intercycle variabilities of basal antral follicle count and ovarian volume. In this prospective study, we analysed the intercycle variabilities of the antral follicle count and ovarian volume, and compared them with those of other basal ovarian reserve tests in subfertile patients. METHOD: Fifty-two ovulatory and infertile women were followed for two consecutive spontaneous cycles. The antral follicle count, ovarian volume, serum follicle stimulating hormone and estradiol levels were determined on day 3 of both cycles. Limits of agreement between two measurements were determined. RESULTS: Limits of agreement were -6.9 and 6.5 for the antral follicle count, and -8.3 and 8.6 for the ovarian volume. These degrees of variation corresponded to a range of 1.30 and 1.45 times their means for the ovarian volume and antral follicle count, respectively. The variability in the antral follicle count was greater in women who were younger than 24.5 years than in those who were older. CONCLUSIONS: Intercycle variabilities of the antral follicle count and ovarian volume were clinically significant. More variation was observed in the antral follicle count of young infertile patients. Therefore, a low antral follicle count in young, infertile, but ovulatory women should be cautiously interpreted. This may not reflect a low ovarian reserve, and these women may have a high antral follicle count in the next cycle.

Differential diagnosis of smooth muscle tumors utilizing p53, pTEN and Ki-67 expression with estrogen and progesterone receptors.

BACKGROUND/AIM: To investigate the expression and value for diagnosis of the genes, p53 and pTEN, the protein, Ki-67, and the receptors, estrogen and progesterone, in differentiating smooth muscle tumors of the uterus. MATERIAL AND METHOD: Seventeen samples of leiomyosarcoma, 2 smooth muscle tumors with uncertain malignant potential (STUMP), 9 atypical myomas and 15 leiomyomas were stained immunohistochemically. The chi(2) test was used for the statistical analysis of the data. RESULTS: The malignant side of the spectrum was strongly stained for Ki-67 and p53 while uniformly decreasing toward the benign tumors. The results were found to be statistically significant (p < 0.0001). The staining for progesterone receptor was also statistically significant, but the tumors that were considered benign, such as leiomyoma and atypical myoma, were the ones strongly stained (p = 0.005). The expression of estrogen receptor was significant in these tumors, but the p value was very close to the cut-off value (p = 0.07). As the degree of differentiation of the tumor increased, the trend showed stronger staining for estrogen receptor. However, no difference was detected in the staining properties of the tumors for pTEN (p = 0.2457). CONCLUSION: The expression of Ki-67, p53 and progesterone receptors is promising in immunodifferentiation of smooth muscle tumors of the uterus with malignant potential.

Intravesical stone formation on intrauterine contraceptive device.

Since more than 30 years, intrauterine contraceptive devices (IUCD) have been used for a contraceptive opportunity. Although they are termed to be a safe and effective method for contraception, they also have some type of complications and uterine perforation, septic abortion, pelvic abscess are the serious complications of these devices. The incidence of uterine perforation is very low, but in the literature nearly 100 cases were reported about the extra uterine localization of IUCD. Migration may occur to the adjacent organs. We here in describe a case of a 31 year-old woman who had an IUCD with stone formation in the bladder. In the literature all of the cases were reported as IUCD migration, but although it seems technically impossible, IUCD placement into the bladder should also be considered in misplaced IUCDs.

Incidental carcinoid of appendix in cesarean section.

A case with carcinoid tumor of the appendix was encountered incidentally during an elective cesarean section. The tumor was discovered as a result of the routine exploration of the whole abdomen. The investigation for metastasis proved no evidence of spread and the patient was treated solely by surgery.