Does obesity have detrimental effects on IVF treatment outcomes?

BACKGROUND: The aim of this study was to investigate the influence of body mass index (BMI) on the in vitro fertilization (IVF) treatment outcomes in a cohort of women undergoing their first IVF, using an intracytoplasmic sperm injection (ICSI). METHODS: This retrospective cohort study included 298 cycles from women younger than 38 years old undergoing IVF-ICSI at a university infertility clinic. The treatment cycles were divided into three groups according to the BMI of the women involved: normal weight (18.5 ≤ BMI < 25 kg/m(2), 164 cycles), overweight (25 ≤ BMI < 30 kg/m(2), 70 cycles), and obese (BMI ≥ 30 kg/m(2), 64 cycles). The underweight women (BMI < 18.5 kg/m(2)) were not included in the analysis due to small sample size (n = 22). The patient characteristics and IVF-ICSI treatment outcomes were compared between the BMI groups. RESULTS: The total gonadotropin dose (p <0.001) and duration of stimulation (p = 0.008) were significantly higher in the obese group when compared to the normal BMI group. There were no significant differences across the BMI categories for the other IVF-ICSI cycle outcomes measured, including the number of retrieved oocytes, mature oocytes, embryos suitable for transfer, proportion of oocytes fertilized, and cycle cancellation rates (p >0.05 for each). Additionally, clinical pregnancy, spontaneous abortion, and the ongoing pregnancy rates per transfer were found to be comparable between the normal weight, overweight, and obese women (p >0.05 for each). CONCLUSION: Obese women might require a significantly higher dose of gonadotropins and longer stimulation durations, without greatly affecting the pregnancy outcomes.

A Flexible Multidose GnRH Antagonist versus a Microdose Flare-Up GnRH Agonist Combined with a Flexible Multidose GnRH Antagonist Protocol in Poor Responders to IVF.

OBJECTIVE: To compare the effectiveness of a flexible multidose gonadotropin-releasing hormone (GnRH) antagonist against the effectiveness of a microdose flare-up GnRH agonist combined with a flexible multidose GnRH antagonist protocol in poor responders to in vitro fertilization (IVF). STUDY DESIGN: A retrospective study in Akdeniz University, Faculty of Medicine, Department of Obstetrics and Gynecology, IVF Center, for 131 poor responders in the intracytoplasmic sperm injection-embryo transfer (ICSI-ET) program between January 2006 and November 2012. The groups were compared to the patients' characteristics, controlled ovarian stimulation (COH) results, and laboratory results. RESULTS: Combination protocol was applied to 46 patients (group 1), and a single protocol was applied to 85 patients (group 2). In group 1, the duration of the treatment was longer and the dose of FSH was higher. The cycle cancellation rate was significantly higher in group 2 (26.1% versus 38.8%). A significant difference was not observed with respect to the number and quality of oocytes and embryos or to the number of embryos transferred. There were no statistically significant differences in the hCG positivity (9.5% versus 9.4%) or the clinical pregnancy rates (7.1% versus 10.6%). CONCLUSION: The combination protocol does not provide additional efficacy.

Comparison of markers of ovarian reserve between patients with complete müllerian agenesis and age-matched fertile and infertile controls.

OBJECTIVE: To investigate ovarian reserve in complete müllerian agenesis (CMA) patients and to compare the ovarian reserve of CMA patients with that of age-matched fertile and infertile controls. DESIGN: Prospective cohort study. SETTING: University gynecology outpatient clinic. PATIENT(S): Fifty-eight typical CMA (type A) patients, 8 atypical CMA (type B) patients, 39 fertile patients, and 38 infertile patients were compared for ovarian reserve. INTERVENTION(S): Ovarian reserve was evaluated via antimüllerian hormone (AMH) levels and antral follicle counts (AFCs). MAIN OUTCOME MEASURE(S): Investigation of ovarian reserve in CMA patients and a comparison of the ovarian reserve of the CMA patients with that of age-matched fertile and infertile controls. RESULT(S): Fifty-eight type A and eight type B CMA patients and 39 fertile and 38 infertile control patients were assessed for ovarian reserve. The mean (±SD) ages of the type A and type B CMA patients and the fertile and infertile groups were 25.8 ± 5.3, 33.3 ± 5.9, 32.6 ± 4.8, and 33.9 ± 3.3 years, respectively. After age standardization of the groups, AMH levels and AFCs were found to be lower in the atypical CMA group. The differences in AMH levels and AFC were found to be highly significant. CONCLUSION(S): The present study showed that atypical CMA patients had decreased ovarian reserve compared with age-matched fertile and infertile controls.

Might uterus transplantation be an option for uterine factor infertility?

Current data on uterus allotransplantation research has been reviewed and summarized. Over the past 15 years, progress in uterus transplantation research has increased dramatically. As a consequence, the first pregnancy and delivery following uterus allotransplantation in rats have been reported. The technique has been better defined. Although clinical pregnancy and delivery following uterus allotransplantation has been reported in humans, there are still many questions to be answered before clinical application. Gestational surrogacy still remains an important option for being a genetic parent in selected cases with uterine factor infertility.

A retrospective analysis of pregnancy outcomes after kidney transplantation in a single center.

BACKGROUND: We reported pregnancy outcomes after kidney transplantation in a single transplant center. METHODS: We reviewed the perinatal outcomes of female kidney transplant patients of reproductive age (18-40 years) from 1987 to 2011. RESULTS: A total of 246 patients were reviewed. Of these, 43 women registered a pregnancy following kidney transplantation. The mean patient age was 31.3 ± 4.2 years (range 24-40). The mean transplant-conception interval was 35.9 ± 12.6 months (range 24-120); 9 patients had a cadaveric allograft. The human leukocyte antigen match was ≥3/6 for 34 patients. The rate of live births was 29/43 (67.4%), miscarriage 10/43 (23.2%), preterm delivery 7/29 (24.1%), preeclampsia 5/29 (17.2%), and intrauterine growth retardation 2/29 (6.9%). Overall, 3/29 patients (10.3%) received a blood transfusion during pregnancy due to persistent symptomatic anemia, despite iron replacement and erythropoietin therapy; 24 patients (82%) had a cesarean section delivery; 3 patients had kidney rejection during pregnancy, with 2 occurring during the 6th postpartum month. CONCLUSION: Pregnancy should be considered a high risk in renal transplant recipients, necessitating close follow-up.

Assessment of women who applied for the uterine transplant project as potential candidates for uterus transplantation.

AIM: To review the medical charts of women who applied for the uterine transplant project from June 2008 to June 2011 in our hospital retrospectively (18-40 years). METHODS: The data for 144 women were retrieved, and information was collected on the etiology of uterine factor infertility(UFI); ovarian reserve tests; and accompanying anatomic, infectious, genetic and endocrinological problems. RESULTS: There were 119 patients with primary amenorrhea and uterovaginal agenesis and 25 patients with a history of hysterectomy. The complete Müllerian agenesis patients formed the largest group of the UFI patients with better anti-Müllerian hormone levels and antral follicle count. Anatomical anomalies such as a solitary pelvic kidney may accompany Mayer-Rokitansky-Kuster-Hauser syndrome (MRKH) and impede surgery. The mean ages in MRKH, hysterectomy and complete androgen insensitivity syndrome (CAIS) cases were 24.7, 35.0 and 34.4 years, respectively. The karyotype analysis showed 46XX (MRKH) in 109 patients and 46XY (CAIS) in 10 of the primary amenorrhea patients. CONCLUSION: Hysterectomy may deteriorate ovarian blood flow and decrease ovarian reserve. Fertility preservation may be considered in young woman undergoing hysterectomy.

Effects of salpingectomy and antituberculosis treatments on fertility results in patients with genital tuberculosis.

AIM: The aim of this study was to demonstrate the effects of tubal surgery and antituberculosis treatments in patients with genital tuberculosis. MATERIAL AND METHODS: A total of 38 infertile women who had been diagnosed with pelvic tuberculosis and who had had laparoscopy and hysteroscopy were recruited into the study. All women with female genital tuberculosis were divided into two groups: group 1 (salpingectomized, n=21) and group 2 (not salpingectomized, n=15). Both of the groups were treated with antitubercular therapy for 6-12 months. RESULTS: There was no significant difference in level of gonadotrophins used, estradiol levels on human chorionic gonadotrophin day, mean and mature oocytes retrieved, mean embryos transferred, or cancellation and fertilization rates. Only the number of days of stimulation was statistically significantly higher in group 1 compared to group 2 (10.4±2.3 vs 9.2±1.8; P=0.048). Although it did not reach the statistically significant level, clinical pregnancy rate was higher in group 1 (37.5%, 12/32 vs 23.8%, 5/21; P=0.306). Although not statistically significant, number of ongoing pregnancies per embryo transfer, spontaneous abortion rates before 20 weeks of gestation and take-home baby rates were higher in group 1 compared to group 2 (15.5%, 12/77 vs 6.6%, 3/45; P=0.150; 28.1%, 9 vs 23.8%, 5; P=0.600; 9%, 3 vs 0; P=0.160, respectively). CONCLUSION: Salpingectomy is an option for treatment in patients diagnosed with pelvic tuberculosis and infertility to improve both clinical pregnancy rates and take-home baby rates in patients treated with antituberculosis therapy for 12 months.

Fatal Disseminated Tuberculous Peritonitis following Spontaneous Abortion: A Case Report.

We describe a rare case of fatal disseminated tuberculous peritonitis in a young woman with rapid progressive clinical course following spontaneous abortion of 20-week gestation. Clinical and laboratory findings were initially unremarkable. She underwent diagnostic laparoscopy which revealed numerous tiny implants on the peritoneum and viscera. Histopathology showed chronic caseating granulomas, and the tissue culture grew Mycobacterium tuberculosis. At fifth day of the antituberculous treatment multiorgan failure occurred in terms of pulmonary, hepatic, and renal insufficiency. She developed refractory metabolic acidosis with coagulopathy and pancytopenia, and she died of acute respiratory distress syndrome and septic shock on her twelfth day of hospitalization.

Sexual function and long-term results following vaginal reconstruction with free vascular jejunal flap.

INTRODUCTION: Sexual adjustment and long-term results following vaginal reconstruction with free vascular jejunal flap are not well known. AIMS: The study aims to investigate sexual adjustment and long-term results among patients who underwent vaginal reconstruction with free vascular jejunal flap. METHODS: A total of 34 women, aged 16-31 years (mean 23.5), who underwent vaginal reconstruction with a vascular jejunal flap between 2005 and 2011 were evaluated. Indications for reconstruction included the following: Mayer Rokitansky Kuster Hauser syndrome (29 patients), isolated vaginal agenesis (2 patients), androgen insensitivity syndrome (2 patients), and (1) history of gynecologic-oncologic surgery. MAIN OUTCOME MEASURES: The study evaluates the perioperative results, complications, satisfaction with sexual function, length and width of the neovagina. RESULTS: All of the surgeries were completed without any intraoperative complications. Three patients required reoperation because of postoperative venous compromise in the grafts. The flap success rate was 100%, and no infection was observed for any case. The mean follow-up was 50 months (between 20 and 87 months). The mean vaginal depth and diameter were satisfactory for all cases. Postoperatively, six patients complained of jejunal hypersecretion, one patient complained of mucosal prolapse, and one patient complained of vaginal constriction. The neovaginal prolapse was repaired via minor surgery. Twenty-seven were married and sexually active. Twenty patients completed the questionnaire on sexual function. Sexual function was assessed using the Female Sexual Function Index (FSFI). Eleven patients were satisfied with their sexual lives after surgery (FSFI scores≥25). CONCLUSION: Based on our results, satisfactory sexual function was achieved using the free jejunal vascular flap.

Clinical pregnancy after uterus transplantation.

OBJECTIVE: To present the first clinical pregnancy after uterus transplantation. DESIGN: Case study. SETTING: Tertiary center. PATIENT(S): A 23-year-old Mayer-Rokitansky-Kuster-Hauser syndrome patient with previous vaginal reconstruction and uterus transplantation. INTERVENTION(S): Eighteen months after the transplant, the endometrium was prepared for transfer of the thawed embryos. MAIN OUTCOME MEASURE(S): Implantation of embryo in an allografted human uterus. RESULT(S): The first ET cycle with one day 3 thawed embryo resulted in a biochemical pregnancy. The second ET cycle resulted in a clinical pregnancy confirmed with transvaginal ultrasound visualization of an intrauterine gestational sac with decidualization. CONCLUSION(S): We have presented the first clinical pregnancy in a patient with absolute uterine infertility after uterus allotransplantation. Although the real success is the delivery of a healthy near-term baby, this clinical pregnancy is a great step forward and a proof of concept that the implantation phase works.

Comparison of intravaginal progesterone gel and intramuscular 17-α-hydroxyprogesterone caproate in luteal phase support.

The main objective of this study was to compare the pregnancy rates of intramuscular (IM) 17-α-hydroxyprogesterone caproate (17-HPC) and intravaginal (IV) progesterone gel administration in in vitro fertilization-embryo transfer (IVF-ET) cycles. The IM 17-HPC and IV progesterone groups included 632 (66.4%) and 320 (33.6%) women undergoing the first cycles of IVF-ET treatment, respectively. Multivariate analyses annotated for all potential confounders showed that the use of IV progesterone retained a predictive value for the total ß-human chorionic gonadotropin (hCG) positivity and clinical pregnancy rates [adjusted odds ratio (OR), 1.97; 95% confidence interval (CI), 1.28-3.03; P=0.002; and OR, 1.66; 95% CI, 1.07-2.60; P=0.03, respectively]. However, biochemical and on-going pregnancy rates did not differ significantly between the groups (OR, 1.85; 95% CI, 1.00-3.41; P=0.05; and OR, 1.43, 95% CI, 0.89-2.30; P=0.14, respectively). Luteal phase support (LPS) with IV progesterone gel in comparison with IM 17-HPC appears to be associated with higher clinical pregnancy rates in IVF-ET cycles. However, this benefit is clinically irrelevant in terms of on-going pregnancy outcomes.

Uterus transplantation from a deceased donor.

OBJECTIVE: To demonstrate the technique for uterus retrieval and transplantation from a multiorgan donor. DESIGN: Video presentation of our case report. The video uses animation to demonstrate the technique. Institutional Review Board (IRB) approval was obtained. SETTING: University hospital. PATIENT(S): A 21-year-old woman with complete müllerian agenesis. INTERVENTION(S): Uterus allotransplantation has been performed from a deceased donor. MAIN OUTCOME MEASURE(S): Acquirement of cyclic menstrual function. RESULT(S): This video demonstrates the technique for uterus retrieval, perfusion, and transplantation. The recipient patient has been monitored regularly for vascular flow, immunosuppression, and infection control since the operation. CONCLUSION(S): Uterus transplantation requires extensive evaluation of the recipient and donor by an experienced multidisciplinary transplantation team both pre- and postoperatively. It has major risks related to surgery, immunosuppression, and pregnancy. Uterus transplantation might be considered promising only after the birth of a near-term healthy baby.

Preliminary results of the first human uterus transplantation from a multiorgan donor.

OBJECTIVE: To describe the first-year results of the first human uterus transplantation case from a multiorgan donor. DESIGN: Case study. SETTING: University hospital. PATIENT(S): A 21-year-old woman with complete müllerian agenesis who had been previously operated on for vaginal reconstruction. INTERVENTION(S): Uterus transplantation procedure consisting of orthotopic replacement and fixation of the retrieved uterus, revascularization, end to site anastomoses of bilateral hypogastric arteries and veins to bilateral external iliac arteries and veins was performed. MAIN OUTCOME MEASURE(S): Resumption of menstrual cycles. RESULT(S): The patient had menarche 20 days after transplant surgery. She has had 12 menstrual cycles since the operation. CONCLUSION(S): We have described the longest-lived transplanted human uterus to date with acquirement of menstrual cycles.

Uterine preservation and vaginal reconstruction in a patient with congenital vaginal agenesis presenting with cyclic menouria.

Herein we report the case of a patient with primary amenorrhea and cyclic menouria. The patient was a 20-year-old woman with primary amenorrhea and inability to achieve sexual intercourse. Clinical examination revealed normally developed labia majora and minora, clitoris, and external urethral orifice, but no vaginal opening. A mature female pubic hair pattern was present, and axillary hair development was normal. Breasts were normally developed. Abdominopelvic magnetic resonance imaging demonstrated a remnant upper vagina and unicornuate uterus filled with fluid, and left-sided renal agenesis. Intraoperatively, a congenital vesicouterine fistulous tract was observed. The fistulous tract was completely resected. Vaginal reconstruction using a sigmoid colon pedicled flap was performed. The proximal part of the neovagina was connected to the remnant cervix, and a Foley catheter was left in the uterine cavity for 7 days to prevent obstruction. The patient has been menstruating regularly since the operation. Menouria might be an early sign of congenital vesicouterine fistula. Resection of the fistulous tract with uterine preservation might be considered in patients with vaginal agenesis.

Robotic-assisted laparoscopic repair of symptomatic cesarean scar defect: a report of two cases.

BACKGROUND: Symptomatic cesarean scar defect is one of the commonly reported long-term complications of cesarean section. CASES: We present two cases of symptomatic cesarean scar defect treated conservatively by robotic-assisted laparoscopy at our institution. Both patients presented with hematocele, pelvic discomfort and secondary infertility. Transvaginal ultrasound revealed hematocele measuring 3.7 x 1.9 x 3.8 cm and 3.0 x 2.0 x 1.6 cm in the lower uterine segments, respectively. After surgery normal menses resumed in both patients, and their childbearing potential was preserved. The patients conceived 3 and 11 months after surgery, respectively. CONCLUSION: Recognition of cesarean scar defect is important in the explanation of certain menstrual disorders since surgical intervention can result in improvement of symptoms and prevent the related secondary obstetric and gynecologic complications. Robotic-assisted laparoscopic approach is a good minimally invasive alternative for the repair of cesarean scar defect.

Term delivery following transvaginal drainage of bilateral ovarian abscesses after oocyte retrieval: a case report.

BACKGROUND: Severe postovum retrieval complications such as tuboovarian abscess are rare. We present an early pelvic infection case following egg retrieval. CASE: A 31-year-old woman with unexplained infertility developed early pelvic infection subsequent to transvaginal oocyte retrieval (TVOR). Broad spectrum antibiotics were administered. Upon persistence of fever and ultrasonographic appearance of probable abscess, transvaginal ultrasound-guided drainage was performed on post-TVOR day 9 as well as posterior colpotomy and T-drain replacement into the cul de sac. Signs and symptoms of pelvic infection improved following drain replacement. Her beta-hCG was found to be positive in the following days. Drain was removed after 3 weeks. Her pregnancy follow-up was uncomplicated. She delivered a healthy baby vaginally at 38 gestational weeks. CONCLUSION: Early diagnosis with prompt administration of antibiotics and drainage may prevent poor pregnancy outcome in ovarian abscess patients subsequent to transvaginal oocyte retrieval.

Reconstruction of vaginal agenesis.

Vaginal ageneses are by no means rare anomalies. Complete Mullerian agenesis is the most common reason for vaginal agenesis requiring reconstruction. Patients usually present with pain, hematocolpos, or hematometra in puberty, and later with amenorrhea and dyspareunia. Detailed information is given here regarding etiologies, timing of surgery, and current treatment options for vaginal agenesis. Outcomes and short- and long-term complications of recent treatment options are also discussed.