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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.

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.

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.

Ozet : Gonadotropin serbestlestirici hormon (GnRH) agonisti ile oosit maturasyonunun tetiklendigi ve sonrasinda tum embriyolarin donduruldugu 27 yasindaki olguda luteal destek olmaksizin olusan spontan klinik gebelik sunulmustur. Polikistik over sendromu (PKOS) tanisiyla, oncesinde 3 sefer kontrollu ovaryan stimulasyon ve intrauterin inseminasyon uygulanmis olan hastaya GnRH antagonist protokolu ile intrasitoplasmik sperm enjeksiyonu tedavisi planlandi. Stimulasyonun 11. gununde ≥11 mm 25 adet folikul saptanmasi uzerine GnRH agonisti uygulanarak final oosit maturasyonu saglandi. Blastokist evresine kadar gelisim gosteren yuksek kalitedeki embriyolarin tumu vitrifiye edildi. Taze embriyo transferi planlanmamasi dolayisiyla hastaya luteal faz destegi verilmeyerek yedi gun sureyle cinsel iliski onerilmedi. Ancak, oosit toplanmasinin 5 hafta sonrasinda amenore yakinmasiyla tarafimiza tekrar basvuran hastaya yapilan transvajinal ultrasonografide fetal kalp atimi muspet spontan tekiz gebelik izlendi. Gunumuzde, GnRH agonistlerle tetikleme sonrasi luteal fazin nasil desteklenmesi gerektigine dair yogun tartismalar devam etmektedir. Bu bulgular, ovaryan stimulasyon sonrasi suprafizyolojik steroid seviyelerine ragmen, her hastanin korpus luteum fonksiyonlarinin devaminin farklilik gosterebilecegine isaret etmektedir. Dolayisiyla, PKOS ve beraberinde endojen luteinizan hormon aktivitesinin yuksek oldugu hastalar, korpus luteumun sinirli ancak luteal faz icin yeterli aktivitesinin devam edebilecegi bir alt grubu olusturuyor olabilir. Anahtar kelimeler: GnRH agonist tetikleme, luteal faz destegi, spontan gebelik SPONTANEOUS CLINICAL PREGNANCY FOLLOWING GNRH AGONIST TRIGGERING AND FREEZE ALL POLICY Abstract: We describe a 27 year-old patient undergoing follicle stimulation with gonadotrophin releasing hormone (GnRH) agonist and freeze-all approach, presented with spontaneous clinical pregnancy without supplementation of luteal phase. The patient had three attempts with controlled ovarian hyperstimulation and intrauterine insemination due to polycystic ovary syndrome (PCOS) before referring to our clinic for intracytoplasmic sperm injection. A GnRH antagonist protocol was assigned and ovarian stimulation commenced. After the detection of 25 follicles ≥11 mm, final oocyte maturation was triggered with GnRH agonist on the eleventh day of stimulation. Since freeze all approach was taken, no luteal phase support was administered. High quality blastocysts were vitrified. The couple was advised to refrain from sexual intercourse for seven days. The patient, however, presented with amenorrhea five weeks after the day of oocyte retrieval. A clinical pregnancy with fetal cardiac activity was determined on ultrasound examination. Currently, there is an ongoing debate on how best to counteract the negative impact of agonist triggering on the luteal phase. Our case demonstrates that corpus luteum functions might diverse despite supra-physiological sex steroids resulting from ovarian stimulation. Therefore, in case of PCOS consisting high endogenous LH activity, corpus luteum might be rescued and luteolysis might limit itself in such cycles shortly after implantation. Keywords: GnRH agonist trigger, luteal phase support, spontaneous conception

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.

OZET: Hucre siklusunun farkli asamalarinda oosit maturasyon aresti ile karsilasilabilir. Uremeye yardimci tedavi uygulamalarinda tum oositlerin mayozu tamamlayamamalari nadir olarak karsilasilan bir durumdur. Sundugumuz olguda, onceki tedavisinde matur oosit elde edemedigimiz bir vakada, GnRH agonisti (Triptorelin asetat 0.2 mg) ve standart doz hCG’yi (hCG 5000 IU) beraber uygulanarak matur oosit elde etmeye calistik. Buna karsin, “ikili tetikleme” ile yine oosit maturasyonunun metafaz-1 asamasinda duraksadigini saptadik. Her ne kadar olgumuzda “ikili tetikleme” stratejisi etkin olmamissa da, oosit maturasyon aresti farkli nedenlere bagli olabileceginden sonuclarimizin genellenmemesi daha uygun olabilir. Bu hususta, oosit maturasyon aresti ile karsilasilan her olgunun literaturde yer almasinin, yontemler basarisiz olsa dahi, uzun vadede problemin cozumune yonelik katki saglayabilecegini dusunmekteyiz. ANAHTAR KELIMELER: oosit maturasyon aresti, gonadotropin serbestlestirici hormon agonisti, ikili tetikleme DUAL TRIGGERING (GNRH AGONIST AND HCG) IN REPEATED TOTAL OOCYTE MATURATION ARREST ABSTRACT: Maturation arrest of human oocytes might occur at various stages of the cell cycle. A total failure of human oocytes to complete meiosis is rarely observed during assisted conception cycles. We describe here an infertile couple for whom all oocytes failed to mature during their previous in vitro fertilization treatment. Even with the use of dual triggering concept (Triptorelin asetat 0.2 mg plus hCG 5000 IU) oocyte maturation was again arrested at metaphase 1 stage in their next cycle. Since failure to resume meiosis might arise from different etiologies, we cannot conclude that “dual trigger” is not an alternative treatment option for the patients with history of recurrent oocyte maturation arrest. However, we do believe that our observation will guide future researchers. KEYWORDS: oocyte maturation arrest, gonadotrophin releasing hormone agonist, dual trigger

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.

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.

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.