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This retrospective cohort study determined the relative efficacy of blastocyst and cleavage-stage transfers in patients with differing numbers of zygotes. A total of 1116 women whose embryo transfers were planned independently of patient characteristics were included. Cleavage-stage (D3) and blastocyst-stage (D5) transfer outcomes were analyzed per number of zygotes. The D5 group included transfer cancellations as the intention-to-treat population. The effect of the embryo transfer date on the clinical outcomes (clinical pregnancy and implantation rates) was analyzed using multivariate logistic regression. Among the patients, 584 and 532 underwent D3 and D5 embryo transfers, respectively. The clinical pregnancy rates were significantly higher in D5 patients with ≥ 6 zygotes (25.7% vs 48.3%). The multivariate logistic regression analysis for clinical pregnancy did not show significant differences between the blastocyst and cleavage-stage transfers in patients with ≤ 5 zygotes (0.874 [0.635-1.204]). Compared to the cleavage-stage, blastocyst-stage transfers for patients with ≥ 6 zygotes resulted in a three-fold increase in clinical pregnancy rates (3.122 [1.797-5.425]). Blastocyst transfers were not inferior to cleavage-stage embryo transfers among patients with few zygotes and were preferable for patients with several zygotes.

Assisted reproduction is presumed to increase monozygotic twin rates, with the possible contribution of laboratory and medical interventions. Monozygotic dichorionic gestations are supposed to originate from the splitting of an embryo during the first four days of development, before blastocyst formation. Single embryo transfers could result in dichorionic pregnancies, currently explained by embryo splitting as described in the worldwide used medical textbooks, or concomitant conception. However, such splitting has never been observed in human in vitro fertilization, and downregulated frozen cycles could also produce multiple gestations. Several models of the possible origins of dichorionicity have been suggested. However, some possible underlying mechanisms observed from assisted reproduction seem to have been overlooked. In this review, we aimed to document the current knowledge, criticize the accepted dogma, and propose new insights into the origin of zygosity and chorionicity.

Research question: Does endometrial compaction, determined by both transvaginal (TVUS) and abdominal ultrasonography (AUS), improve reproductive outcomes in vitrified–warmed embryo transfer (FET) cycles, and is there a correlation between compaction and serum progesterone concentrations on day of embryo transfer? Design: Prospective observational cohort study at a single tertiary care IVF centre including 204 patients undergoing high-quality vitrified–warmed blastocyst transfer in a hormone replacement therapy (HRT) cycle. The change in endometrial thickness (EMT) between end of oestrogen-only phase and day of embryo transfer, as measured by sequential TVUS, was used to categorize endometrium as undergoing compaction (≥5% decrease), no change, or expansion (≥5% increase). EMT was also examined using AUS at the time of embryo transfer. Primary outcome measure was ongoing pregnancy rates. Results: Thirty-one cycles (15.2%) demonstrated compaction, whereas 123 (60.3%) expanded and 50 (24.5%) remained unchanged as measured by sequential TVUS. Ongoing pregnancy rates did not differ among cycles with compaction (58.1%), those with expansion (56.9%), and those with no change (60.0%; P=0.932). Furthermore, oestrogen, progesterone and oestrogen/progesterone concentrations on day of embryo transfer were comparable among all groups. Using AUS, endometrial compaction was seen in 46 cycles (22.5%), and there was a positive correlation between body mass index and AUS-measured EMT change (ρ = 0.161, P = 0.021). In the group with AUS-determined endometrial compaction, AUS measurements showed a significantly thinner EMT on day of embryo transfer (8.3 mm; interquartile range [IQR] [7.5; 9.2] versus 9.3 mm; IQR [8.4; 11.4], P < 0.001) and higher for EMT change (1.3 mm; IQR [0.8; 1.7] versus 0.1 mm; IQR [–1.1; 1.0], P < 0.001) compared with TVUS measurements. Conclusions: Endometrial compaction during HRT–FET does not predict ongoing pregnancy.

Objective The primary aim of this study is to investigate whether there are any minor sonographic uterine findings, not typical for adenomyosis, in endometriosis patients. The secondary objective is to determine the prevalence of sonographic features of adenomyosis in an infertile population with endometriosis. Study design The investigation was of 291 infertile women with endometriosis, either manifesting endometrioma (OMA) or diagnosed through laparoscopy, who were investigated for two‐dimensional transvaginal sonographic (2D-TVS) features of adenomyosis. These patients were grouped as either having endometriosis with adenomyosis (EwA,n = 121) or without adenomyosis (EwoA, n = 170). Additionally, patients without both endometriosis and 2D-TVS features of adenomyosis constituted the control group (n = 170). Results At least one 2D-TVS feature of adenomyosis was detected in 41.6 % (n = 121) of women with endometriosis. Asymmetrical myometrial thickening of uterine walls (57.9 %), hyperechogenic islands (47.1 %), and fan-shaped shadowing (46.9 %) were relatively more prevalent 2D-TVS findings among EwA patients. Multiple OMA (p = 0.038), OMA ≥ 4 cm (p = 0.034), and total OMA volumes were found to be higher (p = 0.004) in the EwA group. Additionally, uterine volumes were found to be 96.7 cm3, 73.0 cm3, and 64.2 cm3 in the EwA, EwoA, and control groups, respectively (EwA vs EwoA, p Conclusion A stepwise and statistically significant volume increase from the control group to the EwoA and then to the EwA group may reflect a spectrum of uterine involvement in endometriosis. This might indicate that many uterine endometriosis cases are still hidden from view, possibly demonstrating an "iceberg phenomenon".

Purpose This study analyzed the safety of myomectomy during the cesarean section (CS). Methods Pregnant women who underwent myomectomy during CS in a tertiary center between January 2015 and November 2019 were included in the study in Group A, and pregnant women who did not have myoma and who underwent only CS were included in the study in Group B. The following information was obtained from patient files in hospital archives and was then recorded and compared: age, gravidity, parity, gestational week, characteristics of the myomas (i.e., location, size, number, and type), duration of surgery, perioperative complications, need for blood transfusion, preoperative and postoperative hemoglobin (Hb) values, duration of surgery, and hospital stay duration. Results A total of 83 patients underwent CS plus myomectomy (Group A), and 80 patients (without myoma) underwent only CS (Group B).There were no statistically significant differences between the groups in terms of preoperative and postoperative Hb values or blood transfusion rates (p > 0.05). Hospitalization and surgery duration were significantly higher in the group that underwent CS myomectomy (p = 0.001 andp = 0.001, respectively). The mean myoma size was 8.3 +/- 4.1 cm in Group A. There was a statistically significant and inverse correlation between the size of the myoma and the delivery week (p = 0.035). There was a statistically significant and positive correlation between the myoma size and hospital stay (p = 0.01). Conclusion Myomectomy during CS is safe and can be applied regardless of the location, size, type, and number of myomas. However, to make myomectomy routine during CS, multi-center studies that include more cases are needed.

The aim of this study is to define a new method of manipulating the uterus during laparoscopic hysterectomy. A total laparoscopic hysterectomy (TLH) with the newly defined technique was performed in 29 patients between July 2016 and July 2017. In this new technique, the uterus was bound from uterine corpus and fundus like a bridle with polyester tape, to allow abdominal manipulation. The technique was successfully performed at the first attempt in 93.1% of cases. It was repeated in two cases (6.9%) since the polyester tape departed away from the uterus at the first attempt. The mean application time was 11.2 min. The vaginal manipulator was not required in any of the cases. There were no intraoperative complications. In conclusion, this method has the advantages of not requiring any vaginal manipulator, reducing the number of people required during operation, permitting a near maximum manipulation of the uterus in all three dimensions, and giving the control of these manipulations directly to the surgeon. On the other hand, the technique also has some inadequacies which should be discussed and improved on in the future. Impact of statement What is already known on this subject? In a laparoscopic hysterectomy, manipulation of the uterus is essential for anatomical dissection of the regions and completion of the operation without complications. An ideal uterine manipulator is defined as inexpensive, as convenient, fast and suitable for injecting solutions, removing the need for an assistant and most importantly offering the most suitable range of motion. In this study, we describe a new and different technique (rein technique) allowing the abdominal manipulation of the uterus in a laparoscopic hysterectomy and discuss the advantages and disadvantages of this method. What do the results of this study add? The procedure was easily accomplished in most patients. We did not need to use an extra uterine manipulator in any of the cases. What are the implications of these findings for clinical practice and/or further research? In conclusion, the rein technique of uterine manipulation is effective and safe.

The current study aimed to investigate the effects of luteal gonadotropin-releasing hormone (GnRH) antagonist pretreatment on the outcomes of diminished ovarian reserve (DOR) patients who were treated using a FSH/letrozole/GnRH antagonist (FLA) protocol. Thus, patients who had luteal GnRH antagonist pretreatment (AFLA) prior to stimulation were compared to patients who had the FLA protocol, only. An electronic database was used to identify patients and stimulation characteristics. Women who had a total antral follicle count (AFC) of 0.05). However, the AFLA group had significantly more metaphase-2 (MII) oocytes (p=0.009), a higher oocyte maturity rate (MII/total oocytes) (p=0.029), and a higher mature oocyte yield (MII/AFC) (p=0.020) with more cleaved embryos (p=0.036), and a significantly reduced number of canceled cycles (26.7% vs. 44.7%; p=0.048). The clinical pregnancy rate per cycle was 22.2% vs. 13.2% (p=0.195) in the AFLA and FLA groups, respectively. Interestingly, a subgroup analysis including ESHRE Bologna criteria poor responder patients showed that the luteal administration of GnRH antagonist resulted in better outcomes when compared with the FLA protocol alone. In conclusion, luteal GnRH antagonist pretreatment improves ovarian stimulation parameters and reproductive outcomes in poor ovarian reserve IVF patients.

Aim: To evaluate the effect of instant urinary catheterization on pregnancy rates in women who are on bed rest after embryo transfer (ET). Methods: This retrospective study included patients who underwent intracytoplasmic sperm injection (ICSI) treatment at the Akdeniz University Fertility Clinic between January 2015 and March 2016. All patients were advised bed rest for an hour after ET. The clinic's electronic database was screened to identify the uterine anatomy of the patients, transferred embryo quality, and urinary catheterization status. Only women with an anteverted and anteflexed uterus and cycles that resulted in high-quality blastocyst transfers were included in this analysis. Finally, 71 cycles with urinary catheterization and 81 cycles with no catheterization were analyzed. Results: The clinical (53.5 vs. 40.7%, p = 0.115) and ongoing pregnancy (43.7 vs. 35.8%, p = 0.323) rates were comparable between urinary catheterization and non-catheterization groups. Multivariate analysis by logistic regression including confounding factors revealed that urinary catheterization was independently associated with clinical pregnancy (OR 2.06, 95% CI 1.03-4.13, p = 0.041). However, no significant association was detected between catheterization and the clinically more relevant, ongoing pregnancy (OR 1.65, 95% CI 0.82-3.30, p = 0.160). Conclusion: Our preliminary findings on the use of instant urinary catheterization after ET are promising and justify further investigation in larger prospective studies.

Background Sigmoid vaginoplasty has carved a niche for itself in reconstructive genitoplasty. We describe the successful use of a robotically assisted sigmoid vaginoplasty in an adolescent girl with Mayer-Rokitansky-Kuster-Hauser syndrome. Case An 18-year-old girl was referred to our hospital with the complaint of primary amenorrhea. She was thoroughly evaluated and magnetic resonance imaging was done, which revealed absence of a vagina and uterus but bilateral normal ovaries. Because cytogenetic analysis was "normal 46,XX" karyotype, Mayer-Rokitansky-Kuster-Hauser syndrome was diagnosed. She was successfully managed by the use of robot-isolated sigmoid colon segment for vaginal replacement and robot-sewn colon-colon anastomosis. A follow-up was done at the 3rd and 6th months, which revealed a large capacious vagina even without self-dilatation. Conclusions The robotic approach is feasible and can produce satisfying postoperative outcomes and might be a minimally invasive technique in future vaginoplasty surgery.

Objective. To investigate in vitro fertilization (IVF) treatment outcomes of unilateral oocyte retrieval in patients with transvaginally inaccessible ovaries.Study Design. Ninety-two women who underwent unilateral oocyte retrieval were retrospectively matched for age, antral follicle count, and body mass index with 184 women who underwent bilateral oocyte retrieval. Each patient in bilateral oocyte retrieval group had the same number of cumulus oophorus complexes (COCs) from single ovary and had comparable number of follicles (±2) on contralateral site where follicular aspiration was performed.Results. The number of COCs, metaphase-2 oocytes, 2-pronuclei, and top-quality embryos was significantly lower in unilateral oocyte retrieval group. However, proportion of patients with an embryo transfer of at least one top-quality embryo was found to be comparable between unilateral and bilateral oocyte retrieval. Subsequently, clinical pregnancy and live birth rates were found to be similar between the groups. The ROC curve analysis revealed (AUC = 0.74, 95% CI 0.63–0.86,p=0.001) that retrieved COCs ≥ 5 from single ovary had sensitivity of 76.0% and specificity of 64.2% for occurrence of a clinical pregnancy.Conclusion. The patients with unilateral oocyte retrieval have reasonable chance of success with IVF. The retrieval of ≥5 COCs from accessible ovary might result in better treatment outcomes among these patients.

Aim: The aim of this study was to evaluate midurethral tissue characteristics in continent and stress urinary incontinent postmenopausal women by using transvaginal ultrasound gray-level histogram. Methods: Thirty-seven patients with stress urinary incontinence (SUI) and 77 patients without SUI were evaluated. Vaginal ultrasound gray-level histograms were performed by 2 gynecologists blinded to patients' SUI statuses. The mean gray-level (MGL) of ultrasound gray-level histogram, representing the echogenicity of a region of interest, was measured in the anterior and posterior midurethral wall along a vertical ultrasound beam. The difference in MGL between anterior and posterior (AP difference) midurethra was calculated. Results: The MGL value of SUI patients was found to be lower in posterior (p = 0.008) and higher in anterior midurethral region (p = 0.001) when compared with control group. In addition, the difference in MGL between anterior and posterior midurethra (AP difference) was found to be higher in SUI group (p < 0.001). Multivariate analysis by logistic regression including confounding factors revealed that AP difference was independently associated with presence of SUI (adjusted OR 1.14, 95% CI 1.08-1.20, p < 0.001). Intra- and inter-observer reproducibility was found to be high with intraclass correlation coefficient of 0.83 and 0.78, respectively. Conclusion: Postmenopausal SUI patients might have a distinct midurethral echogenicity pattern with the quantitative ultrasonography.

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 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.

Placental abruption is defined as ‘premature separation of normally implanted placenta from uterus, generally characterised by abdominal/pelvic pain, vaginal bleeding and uterine tenderness’. It co...

Our aim was to determine the effect of cervical dilatation at non-labour caesarean section on post-operative pain and maternal morbidity. This prospective, randomised, single-blinded trial was conducted from March 2013 to February 2014. In all, 199 patients were enrolled in the study: 102 in non-dilated group and 97 in cervical dilatation group. Based on Visual Analogue Scale, there were no significant differences between the two groups on post-operative 8th, 24th and 48th hour pain scores. We observed thinner endometrial cavity thickness, shorter operation time and shorter hospitalisation duration in cervical dilatation group. However, change in haemoglobin concentrations and puerperal fever rates were found to be comparable between the groups. In conclusion, intra-operative cervical dilatation does not seem to benefit in terms of post-operative pain, change in haemoglobin concentrations or puerperal fever.

PubMedID: 24435497 Objective: This study aimed at determining if tumor-free distance (TFD) from outermost layer of cervix predicts surgicopathologic factors and outcome in surgically treated cervical cancer patients. Materials and methods: One hundred sixteen surgically treated cervical squamous cell carcinomas between 1991 and 2010 with FIGO stage IB/2A were identified and reevaluated histologically regarding the TFD. TFD was defined as the distance between outermost layer of cervix and deepest cervical stromal invasion. Depth of invasion (DOI) and TFD were expressed as continuous variables and compared with traditional surgicopathologic variables and survival to determine their prognostic significance. Results: The mean DOI was 10.3 mm and the mean TFD was 4.2 mm. The most common stage was IB1 (60 patients, 51.7%). The mean number of removed pelvic lymph nodes was 32.2 (median 30; range 8-78). Positive pelvic lymph nodes were found in 27 (23%) of the patients. Sixty-eight patients had lymphovascular space involvement (LVSI). Sixty-eight patients (59%) received postoperative radiotherapy where the following items were present: tumor diameter >4 cm, positive lymph nodes, LVSI and positive surgical margins. With the median fol-low- up of 53 months (3-219 months); 14 patients had local and 13 patients had distant metastases (5 of the patients had both at the time of recurrence). With logistic regression analysis, TFD was a predictor of pelvic lymph involvement ( p=0.028) and LVSI (p=0.008) while DOI was a predictor of LVSI (p=0.044). In Cox regression analysis, increased TFD was associated with improved disease-free survival (DFS) (p=0.007). DFS curves (for TFD cut off value 2.5 mm) according to Kaplan-Meier were found to be statistically significant (log rank test=0.002). Conclusion: The results indicate that TFD is predictive of pelvic lymph node involvement, LVSI and patient outcome in surgically treated cervical cancer patients. However, prospective measurement of TFD is still necessary to determine its value in clinical practice. © Springer-Verlag 2014.

Objective To evaluate the prognostic value of tumor budding (TB) in endometrioid (EEC) and non-endometrioid endometrial cancers (NEEC) and to determine its correlation with expression of E-cadherin. Methods Ninety-five patients with primary endometrial carcinoma were examined statistically. All patients were diagnosed, treated, and given follow-up care at Dokuz Eylul University Faculty of Medicine. Tumor budding detected by either H&E-stained sections and anticytokeratin-staining C11. The tissue block with the largest invasive front was chosen for budding counting and immunostaining. E-cadherin expression was examined by immunohistochemistry using the primary antibodies against to it. Results Tumor budding was low-grade in 73 and high-grade in 22 cases. E-cadherin expression loss was identified in 48 patients. The high-grade TB was significantly higher in patients with advanced stage and deep myometrial invasion (p=0.032 and 0.018, respectively). E-Cadherin expression was significantly lower in NEECs than EECs (p=0.032). The negative expression of E-cadherin was associated with advanced stage and poor differentiation (p=0.001 and p=0.024, respectively). We determined that tumor budding adversely correlated with the presence of E-cadherin expression but not statistically significant. Based on the results of multivariate analysis, TB has an independent impact on cumulative overall survival. We found no statistically significant difference between E-cadherin expression and survival. Conclusions TB is associated with undifferentiated tumor, advanced stage and decreased postoperative survival in endometrial cancer. It might be a valuable prognostic clinicopathologic factor which can be applicable in routine examination.

This report describes the use of in vitro oocyte maturation in two patients with history of repeated oocyte maturation arrest (OMA) from in vitro fertilization. Based on these two cases, in vitro oocyte maturation from unstimulated cycles seems not an alternative treatment option for the patients with history of OMA. © 2011 Springer-Verlag.

Objectives To examine the effect of copper intrauterine device (Cu-IUD) on female sexual dysfunction (FSD) subtypes. Material and methods There were 159 sexually active women (ninety Cu-IUD users and sixty-nine women with no contraception) who attended the gynecology clinic for routine gynecologic control informed about the study and asked to fill Female Sexual Function Index (FSFI) and Beck Depression Inventory questionnaires. Results The prevalence of FSD was 41.1% ( n = 37) and 37.7% ( n = 26) in Cu-IUD users and control groups, respectively ( p > 0.05). In analyses of mean overall and subgroup scores of FSFI, significantly lower scores for arousal ( p = 0.021), lubrication ( p = 0.021), orgasm ( p = 0.040), pain ( p 0.001), and overall FSFI ( p = 0.031) were noted in Cu-IUD users. When the results for FSFI domains were considered for Cu-IUD users separately, the only difference to reach statistical significance, using a Bonferroni adjustment, was found to be the pain domain. Finally, we determined that Cu-IUD status made the strongest unique contribution to explaining the dependent variable pain in multiple logistic regression model (β = −0.26, p = 0.001). Conclusion Cu-IUD users have increased sexual pain compared to women with no contraception, which in turn possibly causes decreased sexual arousal, lubrication, and orgasm in these women.