Differentiating Polycystic Ovary Syndrome from Adrenal Disorders.

Although polycystic ovary syndrome (PCOS) is primarily considered a hyperandrogenic disorder in women characterized by hirsutism, menstrual irregularity, and polycystic ovarian morphology, an endocrinological investigation should be performed to rule out other hyperandrogenic disorders (e.g., virilizing tumors, non-classical congenital adrenal hyperplasia (NCAH), hyperprolactinemia, and Cushing's syndrome) to make a certain diagnosis. PCOS and androgen excess disorders share clinical features such as findings due to hyperandrogenism, findings of metabolic syndrome, and menstrual abnormalities. The diagnosis of a woman with these symptoms is generally determined based on the patient's history and rigorous clinical examination. Therefore, distinguishing PCOS from adrenal-originated androgen excess is an indispensable step in diagnosis. In addition to an appropriate medical history and physical examination, the measurement of relevant basal hormone levels and dynamic tests are required. A dexamethasone suppression test is used routinely to make a differential diagnosis between Cushing's syndrome and PCOS. The most important parameter for differentiating PCOS from NCAH is the measurement of basal and ACTH-stimulated 17-OH progesterone (17-OHP) when required in the early follicular period. It should be kept in mind that rapidly progressive hyperandrogenic manifestations such as hirsutism may be due to an androgen-secreting adrenocortical carcinoma. This review discusses the pathophysiology of androgen excess of both adrenal and ovarian origins; outlines the conditions which lead to androgen excess; and aims to facilitate the differential diagnosis of PCOS from certain adrenal disorders.

Does the use of microfluidic sperm sorting for the sperm selection improve in vitro fertilization success rates in male factor infertility?

AIM: To evaluate the clinical outcome of assisted reproductive technology (ART) cycles in couple with male infertility, where the spermatozoa were selected using either a conventional gradient-density centrifugation technique or microfluidic sperm sorting. METHODS: A total of 181 patients who underwent in vitro fertilization (IVF) because of male factor infertility at the IVF center of Bezmialem and Yeditepe University Hospital were included in this study. All patients were divided into two groups according to the sperm selection method: group I (n = 91): microfluidic sperm-sorting chip; group II (n = 90): density-gradient centrifugation. Data collected included male and female age, type of infertility, duration of infertility, previous IVF attempts, smoking, antral follicle count, total dosage of gonadotropins, maximum estradiol levels, duration of stimulations, endometrial thickness on human chorionic gonadotropin day, total number of oocytes retrieved, number of mature oocytes retrieved, number of pronuclear (PN), sperm parameters, clinical PR and ongoing PR. RESULTS: There was no statistically significant difference in clinical PR and ongoing PR between groups (49.5% vs 40%, P = 0.2; 44% vs 36.7%, P = 0.3; respectively). The improvement in pregnancy rate was more prominent in patients where the female partner's age is higher than 35 (P = 0.09) and men have a total motile sperm count between 1 and 5 million (P < 0.01). CONCLUSION: Microfluidic devices, "labs-on-a-chip," are a disposable, easy to use, and inexpensive method for sperm sorting. Our results show that IVF success rates might improve with the use of a microfluidic sperm-sorting chip for sperm selection in male infertility.

Successful pregnancy and delivery following surgical treatment of postmyomectomy uterocutaneous fistula.

Uterocutaneous fistula is an extremely rare clinical condition that may be caused by postoperative or postpartum complications, such as infection or inflammation. Although fibroids and myomectomy are common clinical entities among women of reproductive age, there are very few postmyomectomy uterocutaneous fistula cases in the literature. This article presents the first reported case of a succesful pregnancy and live birth following treatment of a postmyomectomy uterocutaneous fistula. After laparoscopic adhesiolysis, a minilaparotomy was performed to excise the fistula tract completely from both the abdominal wall and the uterus. The uterine wall defect was repaired in multiple layers. The patient had a good recovery after surgery, and the uterocutaneous fistula resolved completely. Due to obliteration of both tubal ostia, the patient was referred for in vitro fertilisation treatment. She conceived after the third frozen embryo transfer procedure and gave birth to a 4.4 kg baby at full term by caesarean section.

Effect of air bubbles localization and migration after embryo transfer on assisted reproductive technology outcome.

OBJECTIVE: To evaluate the effect of embryo flash position and movement of the air bubbles at 1 and 60 minutes after ET on clinical pregnancy rates (PRs). DESIGN: Prospective clinical trial. SETTING: University fertility clinic. PATIENT(S): A total of 230 fresh ultrasound-guided ETs performed by a single physician (C.F.) at the IVF center of Yeditepe University Hospital between September 2016 and February 2017 were included. INTERVENTION(S): Transabdominal ultrasonographic guidance at ET. MAIN OUTCOME MEASURE(S): Clinical PRs. RESULT(S): There was no significant difference in terms of clinical PRs between women with embryo flash located >15 mm and <15 mm from the fundus at 1 or 60 minutes (P=.6 and P=.7, respectively). The PRs in women with embryo flash located <15 mm and >15 mm from the fundus were 47% and 60%, respectively (P=.6). The clinical intrauterine PRs were 69.5%, 38.5%, and 19.1% in fundal, static, and cervical, respectively. The highest PR was in fundal when compared with others (P<.01). The clinical PR appears to be associated with the embryo flash movement/migration and the PR was dramatically reduced when the embryo migrated from its original position toward the cervix at 60 minutes. CONCLUSION(S): We concluded that clinical PR appears to be associated with the embryo flash movement/migration at 60 minutes after ET and embryo flash movement toward the fundus is associated with higher clinical PRs. Further well-designed randomized controlled trials are required to optimize ET technique in the future.

The cutoff values of serum AMH levels and starting recFSH doses for the individualization of IVF treatment strategies.

OBJECTIVE: The main purpose of our study is to categorize starting doses of recombinant follicle-stimulating hormone (recFSH) based on various cutoff values of anti-Mullerian hormone (AMH) and to determine the effectiveness of serum AMH levels in the prediction of poor ovarian response. MATERIAL AND METHODS: Prospective data analysis was conducted at IVF center. A total of 323 patients were included. All patients were divided into four groups according to the patients' serum AMH concentrations: Group 1 (AMH < 1 ng/ml; 450 IU/day n = 157); Group 2 (AMH 1-2 ng/ml; 375 IU/day, n = 55); Group 3 (AMH 2-3 ng/ml; 225 IU/day, n = 48); and Group 4 (AMH > 3 ng/ml; 150 IU/day, n = 63). Collected data included age, total gonadotropin dosage, duration of stimulations, the total number of oocytes retrieved, ovarian response, cancelation rate, and cPRs. RESULTS: As serum AMH levels increased, there were significant decreases in the starting recFSH dose and total gonadotropin dosage, and a significant increase in the total number of oocytes retrieved. There was a significant trend toward increasing cycle cancelation rates and decreasing cPRs with decreasing serum AMH levels. Although there were no significant differences with regard to the proportion of cycles with hypo-response between all groups. A result of ≤0.83 was considered the cutoff value of AMH to predict a hypo-response to ovarian stimulation. CONCLUSIONS: AMH is a useful marker in selecting the starting dose of recFSH and prediction of poor ovarian response. Our protocol may allow clinicians to modulate the starting dose of recFSH according to these cutoff values for serum AMH levels.

Can Coenzyme Q10 supplementation protect the ovarian reserve against oxidative damage?

PURPOSE: We investigated antioxidant effects of CoQ10 supplementation on the prevention of OS-induced ovarian damage and to evaluate the protective effect of such supplementation against OS-related DNA damage. METHODS: Twenty-four adult female Sprague-Dawley rats were randomly divided into three groups (8 rats per group): group 1 (control): saline, ip, and orally; group 2 (cisplatin group): cisplatin, 4.5 mg/kg ip, two times with an interval of 7 days; and group 3 (cisplatin + CoQ10 group): cisplatin, 4.5 mg/kg ip, two times with an interval of 7 days, and 24 h before cisplatin, 150 mg/kg/day orally in 1 mL of saline daily for 14 days. Serum concentrations of anti-Mullerian hormone (AMH), number of AMH-positive follicles, the assessment of the intensity of 8'OHdG immunoreactivity, the primordial, antral and atretic follicle counts in the ovary were assessed. RESULT(S): The mean serum AMH concentrations were 1.3 ± 0.19, 0.16 ± 0.03, and 0.27 ± 0.20 ng/mL in groups 1, 2, and 3, respectively (p < 0.01). Serum AMH levels were significantly higher in group 1 compared to groups 2 and 3 (p < 0.01 and p = 0.01, respectively). There was a statistically significant difference in AMH-positive follicle count between the groups (p < 0.01). Group 1 showed higher numbers of AMH-positive granulosa cells compared to group 2 (p = 0.01). A significant difference was found in the primordial, the atretic, and antral follicle counts between the three groups (p < 0.01, p < 0.01, and p < 0.01, respectively). The atretic follicle count was significantly lower in the cisplatin plus CoQ10 group compared to the cisplatin group (p < 0.01). The antral follicle counts were significantly higher in the cisplatin plus CoQ10 group compared with the cisplatin group (p < 0.01). There was a statistically significant difference in the intensity of staining of the follicles that were positive for anti-8'OHdG between the groups (p = 0.02). Group 1 showed a significant lower intensity of staining of the follicles positive for anti-8'OHdG compared with group 2 (p = 0.03). CONCLUSION(S): CoQ10 supplementation may protect ovarian reserve by counteracting both mitochondrial ovarian ageing and physiological programmed ovarian ageing although the certain effect of OS in female infertility is not clearly known.

The comparision of effect of microdose GnRH-a flare-up, GnRH antagonist/aromatase inhibitor letrozole and GnRH antagonist/clomiphene citrate protocols on IVF outcomes in poor responder patients.

PURPOSE: To compare the effects of microdose GnRH-a flare-up, GnRH antagonist/aromatase inhibitor letrozole and GnRH antagonist/clomiphene citrate protocols on IVF outcomes in poor responder patients. METHODS: Of 225 patients, 83 patients were in microdose flare-up group (Group 1), 70 patients were in GnRH antagonist/letrozole group (Group 2) and 72 patients were in GnRH antagonist/clomiphene citrate group (Group 3). Demographic and endocrine characteristics, the total number of oocytes retrieved, cancellation rate and clinical pregnancy rate were collected Results: Total dosage of gonadotropins (p=0.002) and serum E2 levels on the day of hCG administration (p=0.010) were significantly higher and duration of stimulations (p=0.03) was significantly longer in group 1. The number of oocytes retrieved was significantly greater in group 1 and 2 when compare to those of group 3 (p=0,000). There was a trend towards increasing cycle cancellation rates with GnRH antagonist/clomiphene citrate and GnRH antagonist/letrozole. CONCLUSION: Our finding suggest that the results of microdose flare-up protocol are better than other two used treatment protocols, in terms of maximum estradiol levels, number of mature oocytes retrieved, and cancellation rate and it still seems to be superior the ovarian stimulation regime for the poor responder patients.

The importance of the length of uterine cavity, the position of the tip of the inner catheter and the distance between the fundal endometrial surface and the air bubbles as determinants of the pregnancy rate in IVF cycles.

OBJECTIVE: To evaluate the relationship between the pregnancy rate (PR) and the positioning of the intrauterine catheter at embryo transfer (ET) under transabdominal ultrasound (US) guidance in in vitro fertilization (IVF) cycles. STUDY DESIGN: Prospective data analysis of 281 consecutive US-guided fresh ETs performed by a single physician at Yeditepe University Hospital IVF Center, Istanbul, Turkey, after controlled ovarian hyperstimulation between April 2012 and March 2013. The length of the uterine cavity (A), the distance between the fundal endometrial surface and the tip of inner catheter (B), the distance between the fundal endometrial surface and the air bubbles (C), and the pregnancy rates (PRs) were recorded. RESULTS: The mean age of the patients was 33.25±5.5 years. Of all transfers, 115 (40.9%) resulted in a clinical pregnancy. With regard to distance (C), the clinical intrauterine pregnancy rates were 65.2%, 32.2% and 2.6% in the <10mm, 10-20mm, and 20mm distance groups, respectively. The PR was dramatically reduced in cases with >10mm between the fundal endometrial surface and the air bubbles, although this did not reach statistical significance. Between those patients who conceived and those who did not, there was no significant difference in terms of the distance between the fundal endometrial surface and the tip of inner catheter, the ratio of A/B or the ratio of B/C. CONCLUSIONS: The final position of the air bubble used as an identifier of the position of the embryo at ET can be determinative for PR, although it cannot be predicted. Clinical pregnancy rates appeared higher in cases with air bubbles closer to the fundus and the optimal position of the air bubble seems to be a distance of <10mm from the fundal endometrial surface. It could be advisable to monitor the final position of air bubble at ET for identifying PR. In addition, the depth of uterine cavity may be considered to indirectly be important factor as it affects ET depth. The optimal distance between the fundal endometrial surface and the tip of inner catheter is 1.5-2cm. Further well-designed randomized controlled trials are required to optimize ET technique in the future.

The Diagnosis and Management of Asherman's Syndrome Developed after Cesarean Section and Reproductive Outcome.

Intrauterine adhesions (IUAs) frequently occur as a result of trauma to the basal layer of endometrium following pregnancy-related curettage such as incomplete abortion (33,3%), postpartum hemorrhage (37,5%), and elective abortion (8,3%). Hysterotomy, myomectomy, Cesarean section, hysteroscopic procedures, such as resection of submucosal leiomyomata or uterine septae, and endometrial ablation are less common etiologic factors resulting in IUA formation. Patients with Asherman's syndrome usually present with menstrual disturbances, infertility, or recurrent pregnancy loss. A successful treatment of infertility could be achieved by restoration of the uterine cavity, prevention of IUA reformation, and promotion of healing process. We presented the diagnosis and management of a case that suffers from menstrual disturbances and secondary infertility resulted from IUA formation developed after Cesarean section.

Hysteroscopic findings in women with recurrent IVF failures and the effect of correction of hysteroscopic findings on subsequent pregnancy rates.

INTRODUCTION: Our aim is to evaluate the incidence of unrecognized uterine abnormalities in cases with recurrent IVF failure by screening office hysteroscopy (OH), and impacts of treatment of hysteroscopic findings on the success rate of IVF. MATERIALS AND METHODS: The retrospective and descriptive study was conducted at assisted reproduction unit in a tertiary medical center. One hundred and fifty-seven patients with a history of recurrent IVF failures underwent hysteroscopy between May 2009 and March 2012. Hysteroscopy (diagnostic or operative, as appropriate) was performed to evaluate the endometrial cavity in patients with two or more IVF failures and Incidence of abnormal hysteroscopic findings and the clinical pregnancy rate (CPR) in subsequent IVF cycles were assessed. RESULTS: In all, 44.9 % of the patients included in this study had abnormal hysteroscopic findings and 75 women (48.1 %) became pregnant following hysteroscopy. Of these pregnancies, 36 occurred in women with corrected endometrial pathology, the majority of which was identified as endometrial polyps. Implantation rate and clinical pregnancy rate were statistically significant increased after polipectomy. CONCLUSION: Abnormal findings on hysteroscopy are significantly higher in patients with previous ART failure and hysteroscopy could be seen as a positive prognostic factor for achieving pregnancy in subsequent IVF procedure in women with a history of RIF.