SPEAKERS PRESENTATIONS

Transcription

SPEAKERS PRESENTATIONS
COURSE 1
GENETIC MEDICINE FOR
OBSTETRICS
PHYSICIAN COURSE
COURSE 3
OVULATION INDUCTION
COURSE
Coffee Break
COLPOSCOPY COURSE
LAPAROSCOPIC – ROBOTIC
SURGERY COURSE
Coffee Break
OVULATION INDUCTION
COURSE
Lunch
COLPOSCOPY COURSE
Lunch
Lunch
OBSTETRICS
PHYSICIAN COURSE
OVULATION INDUCTION
COURSE
Coffee Break
Coffee Break
OBSTETRICS
PHYSICIAN COURSE
Lunch
CELL FREE FETAL DNA AND
FIRST TRIMESTER SCREENING –
REASONABLE IMPLEMENTATION
AND COST BENEFIT ANALYSIS
COLPOSCOPY COURSE
OVULATION INDUCTION
COURSE
Coffee Break
Coffee Break
OVULATION INDUCTION
COURSE
CELL FREE FETAL DNA AND
FIRST TRIMESTER SCREENING –
REASONABLE IMPLEMENTATION
AND COST BENEFIT ANALYSIS
18:30 - 19:00
OPENING CEREMONY - SPEECHES / HALL 1
19:00 - 19:50
20:30
OPENING CONFERENCE
HALL 1
Surgical Gynecology - Quo Vadis?
Sara
SaraBrucker
Brucker
Future
Surgeons,
Future
Surgeries
and Future
Training Eğitim Camran
Geleceğin
Cerrahları,
Geleceğin
Cerrahisi,
ve Gelecekteki
CamranNezhat
Nezhat
WELCOME RECEPTION
Coffee Break
SURGERY COURSE
Coffee Break
SURGERY COURSE
COLPOSCOPY COURSE
Sara Brucker
Camran Nezhat
FIRST DAY (COURSE and OPENING)
GENETIC MEDICINE FOR OBSTETRICS
PHYSICIAN COURSE
COURSE 5
SURGERY COURSE
Coffee Break
Coffee Break
COURSE 4
May 11, 2016, Wednesday
08:30
09:30
10:00
10:30
10:45
11:00
11:15
11:30
11:45
12:00
12:15
12:30
12:45
13:00
13:15
13:30
13:45
14:00
14:15
14:30
14:45
15:00
15:15
15:30
15:45
16:00
16:15
16:30
16:45
17:00
17:15
17:30
17:45
18:00
18:15
COURSE 2
May 12, 2016, Thursday
HALL 1
HALL 2
HALL 3
HALL 4
HALL 5
HALL 1
KEYNOTE LECTURE
ANTENATAL
CARE
ORAL
PRESENTATION
ORAL
PRESENTATION
HALL 3
HALL 4
HALL 1
PELVIC FLOOR
AND BLADDER
DYSFUNCTION
HALL 3
ORAL
PRESENTATION
HIGH RISK
PREGNANCY
ENDOMETROISIS
ORAL
ORAL
- ADENOMYOZIS PRESENTATIONS PRESENTATIONS
THE RATIONAL OF
DRUG CONSUMPTION
Coffee Break
Coffee Break
Coffee Break
SATELLITE SYMPOSIUM
SATELLITE SYMPOSIUM
SATELLITE SYMPOSIUM
FETAL
CARDIOLOGY
ORAL
PRESENTATION
ORAL
PRESENTATION
LIVE SURGERY
VIDEO
PRESENTATION
ONCOLOGY
STEM CELLS,
MYOMAS AND
MENOPAUSE
ORAL
ORAL
PRESENTATIONS PRESENTATIONS
Lunch
Lunch
Lunch
SATELLITE SYMPOSIUM
SATELLITE SYMPOSIUM
SATELLITE SYMPOSIUM
Coffee Break
Coffee Break
Coffee Break
ENDOSCOPY
MYOMA ADENOMYOSIS
Coffee Break
OBSTETRICAL
ULTRASONOGRAPHY
AWARD
ORAL
WINNING
PRESENTATION
PRESENTATIONS
OBSTETRICS AND
GYNECOLOGY
INFERTILITY ART
ORAL
PRESENTATION
VIDEO
PRESENTATION
REPRODUCTIVE
MEDICINE
Coffee Break
LIVE SURGERY
BORROWED LIVES - ALİ POYRAZOĞLU
POSTPARTUM
HEMORRHAGE
ORAL
PRESENTATIONS
Coffee Break
ONCOLOGY
GYNECOLOGY
HALL 4
KEYNOTE LECTURE
KEYNOTE LECTURE
NEW
VIDEO
HORIZONS IN
ENDOMETRIOSIS
PRESENTATION
PERINATOLOGY
AND ART
HALL 2
INFERTILITY ART
Coffee Break
ORAL
PRESENTATION
IVF - COH
PROTOCOLS
GAMETES AND
EMBRYOS
ORAL
PRESENTATIONS
GALA CONCERT
PROGRAM at a GLANCE
ENDOMETRIOSIS
ONCOLOGY /
CERVIX
HALL 2
May 14, 2016, Saturday
May 12 - 14, 2016
08:30
08:40
08:50
09:00
09:10
09:20
09:30
09:40
09:50
10:00
10:10
10:20
10:30
10:40
10:50
11:00
11:10
11:20
11:30
11:40
11:50
12:00
12:10
12:20
12:30
12:40
12:50
13:00
13:10
13:20
13:30
13:40
13:50
14:00
14:10
14:20
14:30
14:40
14:50
15:00
15:10
15:20
15:30
15:40
15:50
16:00
16:10
16:20
16:30
16:40
16:50
17:00
17:10
17:20
17:30
17:40
17:50
18:00
18:10
18:20
20:30
May 13, 2016, Friday
OVULATION INDUCTION COURSE
GENETIC MEDICINE FOR OBSTETRICS PHYSICIAN COURSE
Course Chairs: Erkut Attar, Eray Çalışkan
Course Chair: L. Cem Demirel
COURSE 2 HALL
COURSE 1 HALL
09:30 - 10:30 INTRODUCTION INTO THE FIELD OF CLINICAL GENETICS
10:00 - 11:00 PHYSIOLOGY OF OVULATION
09:30 - 09:50
09:50 - 10:10
10:10 - 10:30
10:30 - 11:10
Basic genetics and cytogenetics
Gülleyla Arel Kılıç
Major forms of human inheritance: Mendelian and mitochondrial
Leyla Özer
Imprinted disorders and epigenetics in reproductive medicine L. Cem Demirel
10:30 - 10:50
10:50 - 11:10
11:10 - 11:30
Meiosis, early embryogenesis and chromosomal aneuploidies in early human
embryo development Gülleyla Arel Kılıç
Analysing blastomeres and trophectoderm – whole genomic technologies:
microarrays and next generation sequencing
Evrim Ünsal
DEVELOPING EMBRYO
10:00 - 10:10 Opening: Objectives and methodology of the course. Learning goals
Erkut Attar, Eray Çalışkan
10:10 - 10:30 Current knowledge of ovulation physiology and endocrinology of
menstrual cycle
Bahar Uslu
10:30 - 10:50 Ovulation induction and endometrium Yiğit Çakıroğlu
10:50 - 11:00 Discussion
11:00 - 11:20 Coffee Break
11:20 - 12:30 OVARIAN STIMULATION FOR NON IVF PATIENTS
Chromosomal causes of infertility + genes involved in male and female infertility
Yaman Sağlam
11:50 - 13:00 Lunch
11:20 - 11:40
11:40 - 12:00
12:00 - 12:20
12:20 - 12:30
Ovarian stimulation in hypogonadotrophic hypogonadizm
Erdal Sak
Ovarian stimulation in PCOS: Algorhytms
Kayhan Yakın
Ovarian stimulation in IUI
Mertihan Kurdoğlu
Discussion
12:30 - 13:30 Lunch
13:00 - 14:00 GENETIC COUNSELING (GC) AND GENETIC TESTING (GT) IN HUMAN
REPRODUCTION
13:30 - 14:40 OVARIAN STIMULATION IN IVF PATIENTS - I
13:00 - 13:20 Taking a family history for genetical causes of diseases and principles of
genetic counselling
Yasemin Alanay
13:20 - 13:40 Genetic counseling (GC) and genetic testing (GT) in families having a child
with unclarified mental retardation (MR), dysmorphism, developmental
delay, intrauterine or neonatal exitus
Hülya Kayserili
13:40 - 14:00 Genetic counseling (GC) and genetic testing (GT) in consanguineous marriages
Yasemin Alanay
14:00 - 14:20 CLINICAL GENETICS IN PERINATOLOGY
15:00 - 16:20 OVARIAN STIMULATION IN IVF PATIENTS - II
The use of arrays in invasive prenatal testing
Gülay Özgön
14:40 - 15:40 PGD – PGS
14:40 - 15:00
15:00 - 15:20
15:20 - 15:40
PGD for single gene disorders and monogenic PGD applications with special
considerations Evrim Ünsal
PGD for chromosomal abnormalities
Leyla Özer
PGS for improving IVF success
L. Cem Demirel
15:40 - 16:40 RECURRENT PREGNANCY LOSSES
15:40 - 16:00
16:00 - 16:20
16:20 - 16:40
Genetic counseling and genetic testing in RPL Gülay Özgön
How to best evaluate the fetus genetically, after intrauterine exitus to identify
genetic etiopathogenesis ?
Hülya Kayserili
PGS for recurrent pregnancy losses
Gülay Özgön
13:30 - 13:50
13:50 - 14:10
14:10 - 14:30
14:30 - 14:40
15:00 - 15:20
15:20 - 15:40
15:40 - 16:00
16:00 - 16:20
Prediction of ovarian stimulation: Algorhytms Ahmet Zeki Işık
Laboratory tests used before/in controlled ovarian stimulation
Murat Api
Personalized protocols for controlled ovarian stimulation Cem Atabekoğlu
Discussion
LH use in controlled ovarian hyperstimulation Yılmaz Güzel
Triggerng of ovulation by GnRH analogues: Current situation Ercan Baştu
Luteal phase support in GnRH analog triggering
Münire Erman Akar
Discussion
16:30 - 17:50 OVARIAN STIMULATION IN IVF PATIENTS - III
16:30 - 16:50 Adjuvant use before/in controlled ovarian hyperstimulation protocols
Fatma Ferda Verit
16:50 - 17:10 Controlled ovarian hyperstimulation protocols for preservation of
fertility (Cancer and age)
Mete Işıkoğlu
17:10 - 17:30 Freeze all
Kemal Özgür
17:30 - 17:50 Tartışma
17:50 - 18:00 Wraping up the day
COURSE PROGRAM
11:30 - 11:50 INFERTILITY
Coffee Break
CELL FREE FETAL DNA AND FIRST TRIMESTER
SCREENING – REASONABLE IMPLEMENTATION AND
COST BENEFIT ANALYSIS
Course Chairs: Emine Çetin, Yaprak Üstün
COLPOSCOPY COURSE
LAPAROSCOPIC – ROBOTIC SURGERY COURSE
COURSE 4 HALL
COURSE 5 HALL
Course Chairs: Kunter Yüce, M. Faruk Köse
COURSE 3 HALL
10:30 - 11:30
10:30 - 11:00
11:00 - 11:20
11:20 - 11:30
SESSION 1
Chair: Kunter Yüce
Epidemiology of HPV infections Ali Ayhan
Cervical cancer screening
Nejat Özgül
Discussion
16:00 - 18:15 SESSION 2
16:00 - 16:30
16:30 - 17:00
17:00 - 17:30
17:30 - 17:45
17:45 - 18:15
Early fetal Echocardiography Emine Çetin
Early Anomaly scan
Kai-Sven Heling
Multiple Pregnancies
Karl Oliver Kagan
Updates Invasive Testing
Emine Çetin
Discussion
13:30 - 14:30 Lunch
14:30 - 16:00 SESSION 3
Chair: Macit Arvas
14:30 - 14:50 Colposcopy of HSIL (ASC-H +) M. Faruk Köse
14:50 - 15:10 Colposcopy of invasive cervical cancer
Ali Haberal
15:10 - 15:30 Cytological and histological management of
premalignant cervical lesions Macit Arvas
15:30 - 15:50 Cryotherapy, LEEP and conization
Ahmet Barış Güzel
16:30 - 17:30 SESSION 4
Chair: Kunter Yüce
16:30 - 17:30 Interactive case studies
Kunter Yüce, Nejat Özgül
18:30 - 19:00
OPENING CEREMONY - SPEECHES / HALL 1
19:00 - 19:50
20:30
OPENING CONFERENCE
HALL 1
Surgical Gynecology - Quo Vadis?
Sara
SaraBrucker
Brucker
Future
Surgeons,
Future
Surgeries
and Future
Training Eğitim Camran
Geleceğin
Cerrahları,
Geleceğin
Cerrahisi,
ve Gelecekteki
CamranNezhat
Nezhat
WELCOME RECEPTION
08:30 - 09:00 Opening
U. Fırat Ortaç, Mete Güngör
09:00 - 09:15 Robotic systems, trocar entries and docking
Yakup Kumtepe
09:15 - 09:30 Robotic myomectomy
Kubilay Ertan
09:30 - 09:45 Robotic sacrocolpopexy
Gökhan Kılıç
09:45 - 10:00 Robotic deep endometriosis surgery
Ahmet Göçmen
10:45 - 12:00 SESSION 2
10:45 - 11:00 Robotic Hysterectomy
Fatih Güçer
11:00 - 11:15 Robotic single-port hysterectomy
Mete Güngör
11:15 - 11:30 Robotic lymphadenectomy M. Murat Naki
12:00 - 13:30 Lunch
13:30 - 15:00 SESSION 3
13:30 - 13:45 Laparoscopic trocar entry sites and
techniques
Salih Taşkın
13:45 - 14:00 Laparoscopic suture techniques
Gazi Yıldırım
14:00 - 14:15 Morcellation and tissue removal techniques in
laparoscopic surgery
Hüsnü Çelik
14:15 - 14:30 Laparoscopic myomectomy Kemal Özerkan
15:15 - 16:45 SESSION 4
15:15 - 15:30 Laparoscopic approach to adnexal masses
U. Fırat Ortaç
15:30 - 15:45 Laparoscopic hysterectomy
Mehmet Ali Vardar
15:45 - 16:00 Laparoscopic single-port hysterectomy
Polat Dursun
16:00 - 16:15 Laparoscopic lymphadenectomy
Çağatay Taşkıran
Sara Brucker
Camran Nezhat
COURSE PROGRAM
13:15 - 13:45 First Trimester screening and cell free fetal
DNA– where are we today and where will web
e tomorrow?
Karl Oliver Kagan
13:45 - 14:00 Implementation of cff DNA in Turkey
Yaprak Üstün
14:00 - 14:30 Maternal Serum Biochemistry – which
information do we gain other than trisomies
Karl Oliver Kagan
08:30 - 10:30 SESSION 1
13:15 - 15:45 SESSION 1
12:00 - 13:30 SESSION 2
Chairs: Nejat Özgül, Gökhan Tulunay
12:00 - 12:20 Colposcopy
Kunter Yüce
12:20 - 12:40 Normal cervical colposcopy
Hakan Ozan
12:40 - 13:00 Colposcopy of abnormal transformation zone
H. Gökhan Tulunay
13:00 - 13:20 Colposcopy of LSIL (+ ASC-US) Müfit C. Yenen
Course Chairs: U. Fırat Ortaç, Mete Güngör
SCIENTIFIC PROGRAM
HALL 1
HALL 2
KEYNOTE LECTURE
Hall 1
Targeting stem cells to treat uterine leiomyomas
Chair: Erkut Attar
08:30
- 09:00
09:00 - 10:20 ANTENATAL CARE
Chairs: Cansun Demir, Wolfgang Henrich
09:00 - 10:25 ONCOLOGY / CERVIX
Chairs: Sinan Özalp, Mete Güngör
09:00 - 09:20 Gestational diabetes: current diagnosis and
management
Cemil Yaman
09:00 - 09:15
Cervical screening programmes
Coşan Terek
09:15 - 09:30
National cervical cancer Screening program and its
current problems
Murat Gültekin
09:30 - 09:45
Management of low grade cervical preinvasive lesions
M. Murat Naki
09:20 - 09:40 Acute abdomen in pregnancy - Diagnosis and
management
Wolfgang Henrich
09:40 - 10:00 Laparoscopic abdominal cerclage for cervical
insufficiency
L. Cem Demirel
09:45 - 10:05 Early Cervical cancer – Sentinel or radical
lymphadenectomy
Peter Hillemanns
10:00 - 10:20
10:05 - 10:25
Vaccination in adults and pregnants
Serhat Ünal
HALL 3
Serdar Bulun
09:00 - 10:20 ORAL PRESENTATIONS
New insight in Pathophysiology of ovarian cancer:
Role of Fallopian tube and Endometriosis
Farr Nezhat
10:20 - 10:40
COFFEE BREAK
10:40
- 11:40
SATELLITE SYMPOSIUM
Hall 1
Chair: Dieter Maas
From past to present gonadotropins – An hCG story
Murat Sönmezer
11:40 - 13:00 ENDOMETRIOSIS
Chairs: Tommaso Falcone, Vedat Atay
11:40 - 13:00 FETAL CARDIOLOGY
Chairs: Rabih Chaoui, Candan İltemir Duvan
11:40 - 12:00
Epigenome, stem cells and sex steroids in
endometriosis: dangerous liaisons
Serdar Bulun
11:40 - 12:00
12:00 - 12:20
Management of advanced endometriosis in the
infertile patient
Tommaso Falcone
12:20 - 12:40
Oocyte quality in endometriosis patients
Thomas Ebner
12:20 - 12:40 Proper use of color Doppler in fetal
Echocardiography
Rabih Chaoui
12:40 - 13:00
Ideal IVF technology and protocol in IVF patient
with endometriosis
Ertan Sarıdoğan
12:40 - 13:00
Early Fetal Echocardiography
Emine Çetin
12:00 - 12:20 Parallel course of the great vessels –
differentialdiagnosis
Kai-Sven Heling
Conventional karyotyping and array CGH in fetal
cardiac abnormalities
Özlem Pata
13:00 - 14:00
LUNCH
14:00
- 15:00
SATELLITE SYMPOSIUM
Hall 1
Chairs: Kutay Biberoğlu, Cihat Ünlü
Endometriosis and pelvic pain: When to use medical treatment and when to do surgery
Speakers: Serdar Bulun, Fatih Şendağ, Erkut Attar
15:00 - 15:20
COFFEE BREAK
15:20 - 16:40 MYOMA - ADENOMYOSIS
Chairs: Michel Abou Abdallah, Cazip Üstün
15:20 - 17:00 OBSTETRICAL ULTRASONOGRAPHY
Chairs: Emine Yüksel, Yiğit Çakıroğlu
15:20 - 15:40
Multimodal treatment of uterine fibroid
Hans Rudolf Tinneberg
15:20 - 15:40
Minimally invasive fetal interventions
Christoph Berg
15:40 - 16:00
Adenomyosis: the main cause of infertility and
pain in patients with endometriosis!!?
The diagnostic and surgical approach
Jörg Keckstein
15:40 - 16:00
Anomalies of the upper extremities
Kai-Sven Heling
16:00 - 16:20
Anatomical myomectomies and hysterectomies
what is the news
Liselotte Mettler
16:00 - 16:20
Early examination of the fetal brain
Rabih Chaoui
16:20 - 16:40
Ultrasonography in twin pregnancy
Recep Has
16:20 - 16:40
Accidental diagnosis of uterine sarcoma: What to do?
Peter Mallmann
16:40 - 17:00
Ultrosonography: evaluation and importance of
“Soft Markers”
Cenk Sayın
16:40 - 17:00 COFFEE BREAK
17:00 - 18:00
LIVE SURGERY FROM ATLANTA
Hall 1
Chair: Ceana Nezhat
21:00 - 22:00
BORREWED LIVES - ALİ POYRAZOĞLU
15:20 - 16:40 AWARD WINNING PRESENTATIONS
16:40 - 17:00 COFFEE BREAK
Gerard Feuer
SCIENTIFIC PROGRAM
HALL 3
HALL 4
HALL 5
09:00 - 10:10 ORAL PRESENTATION
Chair: A. İrfan Kutlar
09:00 - 10:15 ORAL PRESENTATION
Chair: Abdulkadir Turgut
11:40 - 13:00 VIDEO PRESENTATIONS
Chairs: Yusuf Üstün, İlhan Şanverdi
09:00 - 09:05 OP- 001 / Neutrophil lymphocyte Ratio, Platelet lymphocyte Ratio and Mean Platelet Volume; which one is More Predictive in the Diagnosis of Pelvic Inflammatory Disease?
Kerem Doğa Seçkin
09:05 - 09:10 OP- 002 / Retrospective analysis of 114 cases treated cause dermoid cyst at the hospital of Zeynepkamil
Mesut Polat
09:10 - 09:15 OP- 003 / Is Xanthine oxidase activity in polycystic ovary syndrome associated with inflammatory and cardiovascular risk factors?
Hatice Isık
09:15 - 09:20 OP- 004 / Very Rare Etiology of Hemoperitoneum: Ovarian Fibroma
Mesut Köse
09:20 - 09:25 OP- 005 / Evaluation of Risk Factors for the Recurrence of Ovarian Endometriomas
Selçuk Selçuk
09:25 - 09:30 OP- 007 / Trends over years in approaches of hysterectomy for benign indications in a tertiary referral center
Hale Göksever Çelik
09:30 - 09:35 OP- 008 / Neutrophil / lymphocyte ratio as new-inflammatory biomarkers Primary ovarian insufficiency (POI) patients
Mehmet Sühha Bostancı
09:35 - 09:40 OP- 010 / An unruptured second trimester live tubal ectopic pregnancy which was misdiagnosed as abdominal pregnancy
Ozgur Ozdemir
09:40 - 09:45 OP- 011 / Treatment of Cervicitis; LEEP versus Cryotherapy
Mustafa Öztürk
09:45 - 09:50 OP- 012 / Differences in Contraceptive Method Preferences According to Demographic Characteristics: A City Case Study
Mustafa Öztürk
09:50 - 09:55 OP- 013 / Influence of the Type of Hysterectomy on Sexual and Psychological Condition
Meryem Kurek Eken
09:55 - 10:00 OP- 014 / Circulating SCUBE1 levels are elevated in lean glucose-
tolerant women with polycystic ovary syndrome
Onur Erol
10:00 - 10:05 OP- 015 / Lidocaine for pain control during IUD insertion
Burak Karadağ
10:05 - 10:10 OP- 016 / The impact of insulin resistance on clinical, hormonal and metabolic parameters in lean women with polycystic ovary syndrome
Gokce Anik Ilhan
09:00 - 09:05
09:05 - 09:10
09:10 - 09:15
OP-033 / Anti-müllerian hormone exhibits a great variation within menstruel cycle
Ümit Görkem
OP-034 / Bilateral Paratubal Cysts in an Adolescent
Meryem Kuru Pekcan
OP-035 / Carotid artery intima media thickness (CIMT) is statistically significantly increased in young PCOS patients - reflection of an increased cardiovascular disease risk at the very beginning of life
Gokce Anik Ilhan
09:15 - 09:20 OP-036 / The evaluation of temperament and quality of life in patients with polycystic ovary syndrome
Zeynep Özcan Dağ
09:20 - 09:25 OP-037 / Recurrent Pregnancy Loss is Associated With Increased Serum Growth Differentiation Factor 15 and C-Reactive Protein
Nagihan Sarı
09:25 - 09:30 OP-038 / Pregnancy,fibromyalgia syndrome and serotonin
Melahat Atasever
09:30 - 09:35 OP-039 / Mefanemic acid for bleeding and spotting with the levonorgestrel intrauterine system
Erhan Aktürk
09:35 - 09:40 OP-040 / Examination of effects on uterine and ovarian volumes of intrauterine system containing levonorgestrel
Hanifi Şahin
09:40 - 09:45 OP-041 / A rare-type of Endometriosis: Abdominal wall endometriosis
Fatih Mehmet Findik
09:45 - 09:50 OP-042 / How effective is the VG test (Vaginal Test), a novel diagnostic method for vaginal infections?
Sezin Ertürk Aksakal
09:50 - 09:55 OP-043 / Five years data about refugee services of Turkey’s biggest Government Woman Hospital
Esma Sarıkaya
09:55 - 10:00 OP-044 / Cytohistologic outcomes of patients with postcoital bleeding
Hasan Aykut Tuncer
10:00 - 10:05 OP-045 / ADAMTS-3, -13, -16, and -19 Levels in Patients With Habitual Abortion
Meryem Kuru Pekcan
10:05 - 10:10 OP-046 / The diagnostic accuracy of endometrial sampling in endometrial hyperplasia
Serdar Başaranoğlu
10:10 - 10:15 OP-048 / The predictive role of serum cystatin c levels in polycystic ovary syndrome in adolescents
Mehmet Çınar
09:00 - 09:15 VP-001 / Laparoscopic cerclage in the 12th week of gestation after radical trachelectomy and following IVF therapy
Gürkan Arikan
09:15 - 09:30 VP-002 / Laparoscopic management of an ectopic pregnancy in a lower segment cesarean section scar
Gürkan Arikan
09:30 - 09:45 VP-003 / Large uterus; Single port Hysterectomy
Suat Karataş
09:45 - 10:00 VP-004 / Laparoscopic Management Of Cesarean Scar Pregnancy
Sezen Bozkurt Koseoglu
10:00 - 10:15 VP-005 / Laparoscopic Surgery of A Case With Deep Pelvic Endometriosis
Burak Sezgin
10:20 - 10:40
COFFEE BREAK
10:20 - 10:40
Chair: Ahmet Barış Güzel
11:40 - 11:45 OP- 017 / The effects of IL-1A and IL-6 genes polymorphisms on gene expressions, hormonal and biochemical parameters in polycystic ovary syndrome
Mine İslimye Taskin
11:45 - 11:50 OP- 018 / Are the endometrial polyps related with chronic disease, and additional gynecological pathologies?
Öner Aynıoğlu
11:50 - 11:55 OP- 019 / Evaluation of endometrial receptivity by measuring HOXA-
10, HOXA-11, and LIF expression in patients with myoma uteri
Mustafa Kara
11:55 - 12:00 OP- 020 / Challenging differential diagnosis of a primary stromal mass, causing ovarian torsion in a postmenopausal woman
Refika Selimoğlu
COFFEE BREAK
Chair: Eray Çalışkan
11:40 - 11:45 OP-049 / A retrospective analysis of surgical site infections in gynecology
Şadıman Kıykaç Altınbaş
11:45 - 11:50 OP-050 / Two years follow-up of patients with abnormal uterine bleeding after insertion of the levonorgestrel-releasing intrauterine system
Numan Çim
11:50 - 11:55 OP-051 / Vitamin D deficiency in adolescent pregnancy and obstetric outcomes.
İsmail Burak Gültekin
11:55 - 12:00 OP-052 / Subcutaneous wound infiltration of ketamine is superior to bupivacaine in terms of pain perception and opioid consumption after cesarean section: a double-blinded randomized placebo controlled clinical trial
Hüseyin Aksoy
10:20 - 10:40
COFFEE BREAK
Chairs: Taner Usta, Mesut Polat
11:40 - 11:55 VP-006 / Coexistance of Lipoleiomyoma of the Uterus and Primary Ovarian Leiomyoma: Two Rare Entities in Same Individual
Elif Tekeli Yazıcı
11:55 - 12:10 VP-007 / Hybrid Natural Orificial Transluminal Endoscopic Surgery (Hybrid-NOTES) for an Ovarian Mass
Cihan Kaya
12:10 - 12:25 VP-008 / Laparoscopic myomectomy with temporary clipping of uterine and infundibulopelvic vessels
Cihan Kaya
12:25 - 12:40 VP-009 / Laparoscopic detortion of the ovary and bilateral ligamentopexis
Cihan Kaya
12:40 - 12:55 VP-010 / Laparoscopically Managed Cesarean Scar Pregnancy; A Case Report
Ozguc Takmaz
13:00 - 14:00
LUNCH
Chairs: M. Murat Naki, Kemal Özerkan
15:20 - 15:35 VP-011 / A Novel vaginal repair technique of apical prolapse and enterocele ensuring ureteral safety via vaginal ureteral dissection eliminating the need for intraoperative cystoscopy
Mehmet Sakinci
15:35 - 15:50 VP-012 / Hysteroscopically-assisted laparoscopic excision and repair of cesarean scar defect
Taner A Usta
15:50 - 16:05 VP-013 / Third trimester bilateral ovarian torsion in the presence of bilateral ovarian cysts: a case report
Tulay Ozlu
16:05 - 16:20 VP-014 / Robotic resection of vascular mesometrium in an early–stage cervical cancer patient
Tayfun Toptaş
16:40 - 17:00
COFFEE BREAK
12:00 - 12:05 OP- 021 / Does postmenopausal osteoporosis have an impact on thiol-disulphide homeostasis?
Vakkas Korkmaz
12:05 - 12:10 OP- 022 / Evaluation of neutrofil-lymphocyet ratio, platelet-lymphocte ratio, red cell distribution width-platelet ratio for the diagnosis of premature ovarian insufficiency
Gülşah İlhan
12:10 - 12:15 OP- 024 / The rate of peripartum hysterectomy in Kosovo
Astrit Malush Gashi
12:15 - 12:20 OP- 025 / Clinical Features and Histopathologic Outcomes of Presumed Benign Adnexial Masses in Postmenopausal Women
Burcu Kısa Karakaya
12:20 - 12:25 OP- 026 / Urologic complications of obstetrics and gynecological surgery
Aysel Uysal
12:25 - 12:30 OP- 027 / Serum anti-Müllerian hormone levels in euthyroid adolescent girls with Hashimoto’s thyroiditis: relationship to antioxidant status
Onur Erol
12:30 - 12:35 OP- 028 / Guess who pays the bill? Of course the most innocent
Funda Akpinar
12:35 - 12:40 OP- 029 / Vulvovaginal candidiasis: evaluation of management practices of obstetrician - gynecologists in Turkey
Ahmet Barış GÜZEL
12:40 - 12:45 OP- 030 / Surgical Approach to Pelvic Masses during the Infant and Adolescent Periods in the Çukurova Region of Turkey
Ahmet Barış GÜZEL
12:45 - 12:50 OP- 031 / Cystatin C, a promising metabolic risk marker in women with polycystic ovary syndrome
Gokce Anik Ilhan
12:50 - 12:55 OP- 032 / Manual Seperation with and without Betamethasone and Estrogen Creams in the Treatment of Prepubertal Labial Adhesions
İlhan Bahri Delibaş
13:00 - 14:00
LUNCH
15:20 - 16:45 AWARD WIN ABSTRACTS
Chairs: L. Cem Demirel, Gazi Yıldırım
15:20 - 15:25 Award opening speech
Cihat Ünlü
Best abstract award
15:25 - 15:45 OP-047 / A preliminary investigation on the use of Fourier Transform
Infrared Spectroscopy as a non-invasive diagnosis of
endometriosis
Pinar Calis
15:45 - 16:05
2nd best abstract award
OP- 006 / BRCA1 and BRCA2 sequence variations detected with next
generation sequencing in patients with premature ovarian insufficiency
Nafiye Yılmaz
16:05 - 16:25
3rd best abstract award
OP-211 / The effects of Etanercept and Cabergoline on endometriotic
implant, uterus and over in rat endometriosis model
Cihan Deniz Keleş
Dr. Aysun - Cihat Ünlü special reward
16:25 - 16:45 OP-218 / Mini-laparoscopic surgery for gynecological conditions
Servet Gençdal
16:45 - 17:00
COFFEE BREAK
12:00 - 12:05 OP-053 / Comparison of blood and urine nephrin levels in preeclampsia and intrauterine growth retardation
Ahter Tanay Tayyar
12:05 - 12:10 OP-054 / What is Frightening the Multiple Cesarean Section?
Hacer Uyanıkoğlu
12:10 - 12:15 OP-055 / The quality of sleep and the severity of depression in hyperemesis gravidarum
Mesut Köse
12:15 - 12:20 OP-056 / Is there a relationship between amniotic fluid cytokines levels and postterm pregnancy
Vakkas Korkmaz
12:20 - 12:25 OP-057 / Impairment of thiol disulphide homeostasis in preeclampsia
Vakkas Korkmaz
12:25 - 12:30 OP-058 / Evaluation of Maternal Hemorrhage in Placenta Accreta
Elif Ağaçayak
12:30 - 12:35 OP-059 / Evaluation of the relationship between methyltetrahydrofolate reductase (MTHFR) gene polymorphism, folate metabolism and homocysteine value in father-mather-child as a risk of Down’s Syndrome: a clinic study
Refika Selimoglu
12:35 - 12:40 OP-060 / Nifedipine increases foetoplacental perfusion
Ertugrul Karahanoglu
12:40 - 12:45 OP-061 / Can the gestational diabetes screening predict the preeclampsia?
Gonca Batmaz
12:45 -12:50 OP-062 / Obstetric outcomes of isolated oligohydramnios during early-term,
full-term and late-term periods and determination of optimal timing of delivery
Ertugrul Karahanoglu
12:50 - 12:55 OP-063 / Comparing neonatal respiratory morbidity in neonates delivered after 34 weeks of gestation with and without antenatal corticosteroid
Burcu Kısa Karakaya
12:55 - 13:00 OP-064 / Skin incision lengths in caesarean section
Mustafa Ulubay
13:00 - 14:00
LUNCH
Chair: Eren Akbaba
15:20 - 15:25
15:25 - 15:30
15:30 - 15:35
15:35 - 15:40
15:40 - 15:45
15:45 - 15:50
15:50 - 15:55
15:55 - 16:00
16:00 - 16:05
16:05 - 16:10
16:10 - 16:15
16:15 - 16:20
OP-065 / Ultrasound-guided versus classic surgical transversus abdominis plane block in obese patients following caesarean section: a prospective randomised study
Aykut Urfalıoğlu
OP-066 / Evaluation of the relationship between sTWEAK (TNF-related weak inducer of apoptosis ) levels and First Trimester Vaginal Bleeeding in Pregnant Women
Eren Akbaba
OP-067 / Comparison of systemic and local methotrexate treatments in cesarean
scar pregnancies:time to change conventional treatment and follow- up protocols
Semih Zeki Uludağ
OP-068 / YKL-40 immunoreactivity in Placenta Creta
İlay Gözükara
OP-069 / MR pelvimetry in women with sickle cell anemia and sickle cell trait
İlay Gözükara
OP-070 / How normal is ‘normal’? Validation of normal 75g OGTT results by neonatal outcomes
Gokce Anik Ilhan
OP-071 / Serum and Placental Levels of Milk Fat Globul Epidermal Growth Factor-8, Osteoprotegerin and Suppressor of Cytokine Signaling-3 Receptor in Pregnant Women with Preeclampsia, and Their Relation with Severity of Disease
Sevim Tuncer
OP-072 / What is The Ideal Cutoff in Screening for Gestational Diabetes Mellitus in Twin Pregnancies
Akın Usta
OP-073 / Evaluation of preeclampsia severity by examining the placenta with acoustic radiation force impulse elastography
Bircan Alan
OP-074 / The prognostic value of first-trimester cystatin C levels for gestational complications
Hatice Kansu Celik
OP-075 / Local resection may be a strong alternative to cesarean hysterectomy in conservative surgical management of placenta percreta
Erbil Karaman
OP-076 / Insulin resistance is associated with adverse maternal and fetal health outcome in non-GDM pregnants
Akın Usta
16:40 - 17:00
COFFEE BREAK
SCIENTIFIC PROGRAM
HALL 1
HALL 2
08:30 - 09:00
HALL 3
KEYNOTE LECTURE
Hall 1
Pregnancy as window for future health
Chair: Emine Çetin
Karl Oliver Kagan
09:00 - 10:20 ENDOMETRIOSIS
Chairs: Ceana Nezhat, Şahin Zeteroğlu
09:00 - 10:20 NEW HORIZONS IN PERINATOLOGY AND ART
Chairs: H. Taylan Öney, Esma Sarıkaya
09:00 - 10:20 PELVIC FLOOR AND BLADDER DYSFUNCTION
Chairs: Akın Sivaslıoğlu, Niyazi Aşkar
09:00 - 09:20
09:00 - 09:20
The current role of genetic sonography in the era
of NIPD
Fehmi Yazıcıoğlu
09:00 - 09:20
Management of apical prolapse
Fuat Demirci
09:20 - 09:40
Update on non-invasive prenatal testing a success Story
Wolfgang Holzgreve
09:20 - 09:40
Treatment of pelvic floor / sphincter ani muscle
disorders after vaginal delivery
Ralf Tunn
09:40 - 10:00
Maternal serum biochemistry - which information
do we gain other than trisomy ?
Karl Oliver Kagan
10:00 - 10:20
Understanding follicle growth in vitro: Are we
getting closer to obtaining mature oocytes from
in vitro grown follicles in humans?
Özgür Öktem
Surgical Management of endometriosis
Tommaso Falcone
09:20 - 09:40 Ultrasound mapping of DIE: an opportunity for
surgeons
Errico Zupi
09:40 - 10:00
Deep infiltrating endometriosis: the role of
diagnostics and individual surgery
Jörg Keckstein
10:00 - 10:20
Surgical strategies to combat the endometriosis
associated pelvic pain
Ceana Nezhat
09:40 - 10:00 To cut or not to cut- the damage done by
Episiotomy
Michael Stark
10:00 - 10:20 Conservative and surgical treatment of overactive
bladder
Ralf Tunn
10:20 - 10:40
COFFEE BREAK
10:40 - 11:40
SATELLITE SYMPOSIUM
Hall 1
Chairs: Cihat Ünlü, Yaprak Üstün
Progestagens used in endometrium and cycle control - Fatih Durmuşoğlu
A new strong and safe choice in combined oral contraception - Alfred Mueck
Progesterone only pills - Berna Dilbaz
11:40
- 12:40
LIVE SURGERY FROM FRANCE
Hall 1
Chair: Ceana Nezhat
12:40 - 13:40
COFFEE BREAK
Bruno Deval
13:40
- 14:40
SATELLITE SYMPOSIUM
Hall 1
Chair: Sezai Şahmay
Oral contraceptives and new trends “To which patient, which pill?”
Speakers: Cihat Ünlü, Bülent Urman, Faruk Buyru
14:40 - 14:50
COFFEE BREAK
14:50 - 16:10 ENDOSCOPY
Chairs: Farr Nezhat, Moşe Benhabib
14:50 - 16:10 OBSTETRICS AND GYNECOLOGY
Chairs: Cemal Ark, Ruşen Aytaç
14:50 - 15:50 INFERTILITY - ART
Chairs: Talip Gül, Niyazi Tuğ
14:50 - 15:10
Pelvic anatomy from a laparoscopic surgeon’s
point of view
Tommaso Falcone
14:50 - 15:10
Morcelation use in Minimally Invasive Gynecology
Gökhan Kılıç
15:10 - 15:30
Laparoscopic Supracervical Hysterectomy
should replace Endometrial Ablation in surgical
management of menorrhagia
Errico Zupi
15:10 - 15:30
The evidence based optimal Cesarean Section and
the results of its international application
Michael Stark
14:50 - 15:10 Updates in an embryology lab - a clinician’s
perspective
Ege Tavmergen Göker
15:30 - 15:50
New developments in robotic surgery
Kubilay Ertan
15:30 - 15:50
Thromboprophylaxis in obstetrics and gynecology
Yusuf Üstün
15:50 - 16:10
Complications of Robotic surgery
Farr Nezhat
15:50 - 16:10
Vitamin D and gynecological diseases
Rukset Attar
16:10 - 16:30
15:10 - 15:30
15:30 - 15:50
Achievement of fertility in Klinefelter syndrome
Kutay Biberoğlu
How to prevent OHSS
Bülent Gülekli
COFFEE BREAK
16:30 - 17:50 ONCOLOGY
Chairs: Ali Ayhan, Orhan Ünal
16:30 - 17:50 GYNECOLOGY
Chairs: Rıfat Gürsoy, Özay Oral
16:30 - 17:50 INFERTILITY - ART
Chair: Recai Pabuçcu
16:30 - 16:50
The role of robotic single port surgery in
gynecologic oncology
Mete Güngör
16:30 - 16:50 Treatment options for therapy resistant pelvic
pain
Hans Rudolf Tinneberg
16:30 - 16:50 Office hysteroscopy in infertility
Nafiye Yılmaz
16:50 - 17:10
Vulvar cancer – Sentinel, radical
lymphadenectomy and/or radiation therapy
Peter Hillemanns
16:50 - 17:10
Menopause: current trends
Fatih Durmuşoğlu
17:10 - 17:30
Current management of endometrial hyperplasias
Macit Arvas
17:10 - 17:30
Prolapse-hysterectomy and cystocele repair anatomical landmarks and
surgical technique
Ralf Tunn
17:30 - 17:50
Management of early stage endometrial cancer
Ali Ayhan
17:30 - 17:50 3D high definition vision systems in gyn
laparoscopy
Taner Usta
16:50 - 17:10
Advanced hysteroscopic procedures in infertility
Recai Pabuçcu
17:10 - 17:30
Utility of AMH in IVF practice
Bülent Tıraş
17:30 - 17:50
Which müllerian anomly to treat and how ?
Yılmaz Şahin
SCIENTIFIC PROGRAM
HALL 4
Chair: Yaprak Üstün
09:00 - 09:05
OP-077 / Agents used for cervical ripening: A cost effectiveness analysis among patients of high risk pregnancy in a teaching hospital
Funda Akpinar
09:05 - 09:10
OP-078 / Uterine Adhesions After Recurrent Pregnancy Loss or Spontaneous Abortion
Nurcan Yörük
09:10 - 09:15
OP-079 / Low Primary Cesarean Delivery Rates of a Secondary Health Center in a Seven Year Period
Hilal Sakallı
09:15 - 09:20
OP-080 / How Does Gelatin Sponge Affect Postoperative Morbidity of Women Delivering by Cesarean Section?
Alev Özer
09:20 - 09:25
OP-081 / Prophylactic hypogastric artery ligation in surgery for placental invasion disorders
Bülent Köstü
09:25 - 09:30
OP-082 / Assessment of the Cesarean Scar Pregnancies Diagnosed in a Tertiary Health Center in the Last Year
Alev Özer
09:30 - 09:35
OP-083 / Association between maternal vitamin D status in pregnant women and risk of gestational diabetes mellitus
Seda Ates
09:35 - 09:40
OP-084 / Patients Followed due to Severe Maternal Morbidity and Treatment Results
Hilal Uslu Yuvacı
09:40 - 09:45
OP-085 / Thiol Disulphides May be a Marker to Determine the Degree of Preeclampsia?
Hilal Uslu Yuvacı
09:45 - 09:50
OP-086 / Obstetric Relaparotomies
Fatih Mehmet Findik
09:50 - 09:55
OP-088 / Relationship between Fetuin-A levels and recurrent miscarriage
A. Seval Ozgu Erdinc
09:55 - 10:00
OP-089 / Emergency peripartum hysterectomy: a 10-year experience at a single center
Hüseyin Çağlayan Özcan
10:00 - 10:05
OP-090 / Placental vascularization and apoptosis in Type-1 DM and Gestational DM
Süleyman Akarsu
10:05 - 10:10
OP-091 / Intended vaginal birth after cesarean section, retrospective analysis of an eight years period from a single
perinatal center in Germany
Ö. Birol Durukan
10:10 - 10:15
OP-092 / Activation of STAT3 and TNFα in severe Pre-eclampsia
Cihan Toğrul
10:20 - 10:40
COFFEE BREAK
Chair: Hasan Volkan Kurtaran
14:50 - 14:55
OP-093 / Can anemia predict perinatal outcomes in pregnancy?
Aykut Özcan
14:55 - 15:00
OP-094 / Do adipokines have an association with gestational diabetes mellitus?
Ümit Görkem
15:00 - 15:05
OP-095 / Comparison of Short Term Perinatal Outcomes in Infants with Early Preterm Intrauterine Growth Restriction (IUGR) of Absent (or Reverse) and Normal End-Diastolic Umbilical Artery Blood Flow
Şafak Ozdemırcı
15:05 - 15:10
OP-096 / Low Circulating Levels of Cyclophilin A (CypA) in Women with Polycycstic Ovary Syndrome
Akın Usta
15:10 - 15:15
OP-097 / The effect of first trimester fasting glucose levels on pregnancy outcome
Esra Yasar Celik
15:15 - 15:20
OP-098 / Nause and Vomiting In Pregnancy is Associated With Increased Levels of Serum Growth differentiation factor 15
Nagihan Sarı
15:20 - 15:25
OP-099 / The evaluation of placental apoptosis in severe preeclampsia with auto-antibodies and pro-inflammatory cytokines
Niyazi Cenk Sayin
15:25 - 15:30
OP-100 / The effect of maternal obesity on the reliability of fetal biometric measurements
Burak Yücel
15:30 - 15:35
OP-101 / Intrahepatic Choletasis of Pregnancy is Associated with Higher Human Chorionic Gonadotrophin MoM Levels, Higher Incidence of Gestational Diabetes Mellitus and Insulin Requirement
Tuğba Ensari
15:35 - 15:40
OP-102 / New Screening Method for Prediction of Preterm Delivery in Singleton Pregnancies
Cagri Gulumser
15:40 - 15:45
OP-103 / Major determinants of newborn survival and duration of hospitalization at neonatal intensive care unit in pregnants with preterm premature rupture of membranes
Meryem Kurek Eken
15:45 - 15:50
OP-104 / Does awareness of gestational age during ultrasonographic fetal biometry affect the results: a preliminary intra-observer variability and agreement study
Hüseyin Aksoy
15:50 - 15:55
OP-105 / Amniotic Fluid Paraoxonase-1 Activity, Thyroid Hormone Concentrations and Oxidative Status in Neural Tube Defects
Muhammet Erdal Sak
15:55 - 16:00
OP-106 / The relationship between sonographic fetal thymus size and maternal obesity
Raziye Desdicioğlu
16:00 - 16:05
OP-107 / Comparison of first trimester uterine artery doppler parameters in hyperemesis gravidarum with normal pregnancy
Fatih Keskin
16:05 - 16:10
OP-108 / Accuracy of Ultrasonographic Fetal Weight Estimation: Association of Possible Confounding Factors
İlhan Bahri Delibaş
16:10 - 16:30
COFFEE BREAK
Chair: Ercan Baştu
16:30 -16:35
OP-109 / Relationship Between Cardiothoracic Ratio and Assesment of Brain Sparing in Intrauterin Growth Restriction
Burak Akselim
16:35 - 16:40
OP-110 / Non-Invasive Prenatal Testing For Fetal Chromosomal Abnormalities: Baskent University Experience
Cagri Gulumser
16:40 - 16:45
OP-111 / Prenatal Diagnosis of Fetal Urinary Anomalies and Antepartum Approach
Serdar Başaranoğlu
16:45 - 16:50
OP-112 / The Efficiency of First Trimester Screening Test in Dr. Sami Ulus Women Health and Research Hospital
İsmail Burak Gültekin
16:50 - 16:55
OP-113 / High Grade Servikal İntraepiteliyal Lezyonların Değerlendirilmesinde Kolposkopi Eşliğinde Yapılan Biyopsi ile Servikal Konizasyon Yöntemlerinin Karşılaştırılması
Adnan İncebıyık
16:55 - 17:00
OP-114 / Preoperative Differentiation between Malignant and Benign Ovarian Masses in Patients with Normal CA-125 Levels
Ali Ozgur Ersoy
17:00 - 17:05
OP-115 / Myometrial invasion in endometrial cancer patients: Can magnetic resonans imaging predict the myometrial invasion before surgery?
Funda Atalay
17:05 - 17:10
OP-116 / The utility of tumor markers and neutrophil lymphocyte ratio in patients with an intraoperative diagnosis of mucinous borderline ovarian tumor
Kerem Doğa Seçkin
17:10 - 17:15
OP-117 / The Determination Of Loneliness Levels Of Woman With Gynecological Cancer
Günnaz Şahin
17:15 - 17:20
OP-118 / Prognostic factors on endometrial cancer; how accurate ?
Kazibe Koyuncu
17:20 - 17:25
OP-119 / Colposcopic evaluation of pre and postmenapausal women with abnormal cervical cytologies
Keziban Doğan
17:25 - 17:30
OP-120 / Proteomic Analysis in Endometrial Cancer and Endometrial Hyperplasia Tissues by 2D-DIGE Technique
Yasin Ceylan
Chair: Eralp Başer
17:30 - 17:35
OP-121 / Final histological outcomes of patients with cervical intraepithelial neoplasia grades 2 and 3 and positive surgical margins following loop electrosurgical excision procedures
Hasan Aykut Tuncer
17:35 - 17:40
OP-122 / Lymph node metastasis predictors in endometrial cancer; nomogram constructed by clinical and pathologic risk factors
Yavuz Emre Şükür
17:40 - 17:45
OP-123 / Comparison of the Outcomes of Optimal Cytoreductive Surgery Achieved in Stage IIIC Serous Papillary Epithelial Ovarian Cancer at Different Centers: Is Experience Important?
Emine Karabuk
17:45 - 17:50
OP-124 / The Outcomes of Fertility-Sparing Surgery in Epithelial Ovarian Cancer
Emine Karabuk
17:50 - 17:55
OP-125 / Sentinel lymph node biopsy using florescent imaging technology / indocyanine green in endometrial cancer: early experiences with new laparoscopic system
Salih Taşkın
17:55 - 18:00
OP-126 / The efficacy of preoperative positron emission tomography-computed tomography (PET-CT) for detection of lymph node metastasis in endometrial cancer
Mustafa Tas
SCIENTIFIC PROGRAM
HALL 1
08:30 - 09:00
HALL 2
HALL 3
KEYNOTE LECTURE
Hall 1
New infertility treatments (IVA: in vitro activation) of patients with primary ovarian insufficiency (POI)
Chair: Peter Mallmann
Kazuhiro Kawamura
09:00 - 10:00 HIGH RISK PREGNANCY
Chairs: Wolfgang Holzgreve, Bülent Tandoğan
09:00 - 10:20 ENDOMETRIOSIS - ADENOMYOZIS
Chairs: Turan Çetin, Salim Erkaya
09:00 - 09:20
Diagnosis and operative strategies of abnormally
invasive placentation (AIP)
Wolfgang Henrich
09:00 - 09:20
09:20 - 09:40
Prediction and current management of preeclampsia
Rıza Madazlı
09:20 - 09:40 Adenomyosis and infertility: any clinical
relevance?
Gürkan Uncu
09:40 - 10:00
Cervical cerclage and pessary aplications in
preterm labour
Zeki Şahinoğlu
09:40 - 10:00
10:00 - 10:20 THE RATIONAL OF DRUG CONSUMPTION
M. Sühha Bostancı
How does endometriosis generate pelvic pain ?
Gazi Yıldırım
Evidence based management of endometriosis in 2016
Cihat Ünlü
10:00 - 10:20 The genetical basis of endometriosis
ethiopathogenesis
Mustafa Bahçeci
10:20 - 10:40
COFFEE BREAK
10:40
- 11:40
SATELLITE SYMPOSIUM
Hall 1
Chair: L. Cem Demirel
The future of prenatal tests - NIPT’s
Speaker: Carlos Simón
11:40 - 13:00 ONCOLOGY
Chairs: Macit Arvas, M. Faruk Köse
11:40 - 13:00 STEM CELLS, MYOMAS AND MENOPAUSE
Chairs: Sezai Şahmay, Karl-Heinz Broer
11:40 - 12:00
Hereditary cancer risk assessment and risk
reduction strategies
Banu Arun
11:40 - 12:00
Stem cells in obstetrics and oncology- how can we
counsel our patients?
Wolfgang Holzgreve
12:00 - 12:20
Nerve sparing approach in radical surgery
Çağatay Taşkıran
12:00 - 12:20
Induction of in vivo spermatogenesis with stem cells
Çiler Çelik Özenci
12:20 - 12:40
Management of early stage ovarian cancer
M. Faruk Köse
12:40 - 13:00
Organ sparing approaches in gynecologic oncology
U. Fırat Ortaç
12:20 - 12:40
12:40 - 13:00
Evidence based management of Leiomyomas for
Infertility in 2016
Sedat Kadanalı
Menopause hormone therapy and breast cancer
risk – role of estrogens and progestins
Ludwig Kiesel
13:00 - 14:00
LUNCH
14:00 - 15:00
SATELLITE SYMPOSIUM
Hall 1
How many oocytes do we need to maximize cumulative live birth rates? - LH use in ART - Hakan Yaralı
Impacts of progesterone levels to pregnancy rates - Bülent Urman
15:00 - 15:10
COFFEE BREAK
15:10 - 16:30 REPRODUCTIVE MEDICINE
Chairs: Erol Tavmergen, Eray Çalışkan
15:10 - 16:30 POSTPARTUM HEMORRHAGE
Chairs: Sema Sanisoğlu, Yaprak Üstün, Emine Çetin
15:10 - 15:30
Individualisation of the COH protocols in IVF
Gürkan Bozdağ
15:10 - 15:30
Maternal mortality due to postpartum
hemorrhage in Turkey
Yaprak Üstün
15:30 - 15:50
Does PGS increase IVF success?
Eray Çalışkan
15:30 - 15:50
Surgical strategies to combat postpartum
hemorrhage: a multidisciplinary team approach
Ateş Karateke
15:50 - 16:10
LH for COH: by LH or by hCG - Any difference ?
Erol Tavmergen
16:10 - 16:30
Current data in trophectoderm biopsy
Hakan Yaralı
15:50 - 16:10
Thromboembolism prophylaxis in pregnancy and
early postpartum period
İbrahim Bildirici
16:10 - 16:30
A new harmonized supplement during pregnancy
and lactation
P. Antonio Regidor
16:50 - 17:00
COFFEE BREAK
17:00 - 18:20 IVF - COH PROTOCOLS
Chairs: Bülent Urman, Murat Ulukuş
17:00 - 18:20 GAMETES AND EMBRYOS
Chairs: Dieter Maas, Melih Gündüz
17:00 - 17:20 Tailoring the IVF cycle with progesterone
monitorisation
Ercan Baştu
17:00 - 17:20 The successful IVF laboratory: basic aspects to be
considered
Markus Montag
17:20 - 17:40
17:20 - 17:40
Quantitative and qualitative grading of human
blastocysts and its association with neonatal outcome
Thomas Ebner
17:40 - 18:00
Aneuploidy in oocytes: general and humanspecific risk factors
Ursula Eichenlaub
18:00 - 18:20
Oocyte cryoconservation for fertility preservation
Dieter Maas
Dual triggering with GnRH agonist and hCG
Bülent Urman
17:40 - 18:00 Luteal phase support in GnRH agonist triggered
cycle
Hüseyin Görkemli
18:00 - 18:20
20:30
OHHS after GnRH agonist triggering
Barış Ata
GALA CONCERT
SCIENTIFIC PROGRAM
HALL 3
Chair: Murat Bakacak
09:00 - 09:05
09:05 - 09:10
09:10 - 09:15
09:15 - 09:20
09:20 - 09:25
09:25 - 09:30
09:30 - 09:35
09:35 - 09:40
09:40 - 09:45
09:45 - 09:50
09:50 - 09:55
09:55 - 10:00
10:00 - 10:05
10:05 - 10:10
10:10 - 10:15
10:15 - 10:20
Chair: Ömer Lütfü Tapusuz
OP-127 / A comparative study of FIGO 1988 versus 2009 staging for endometrial carcinoma
Ali Emre Tahaoglu
OP-128 / Impact of thrombophilic gene mutations on postoperative thrombosis risk in patients with malign and
benign gynecologic conditions: A prospective study
Aşkın Doğan
OP-129 / Questioning the efficacy of uterine factors to determine lymphatic spread in endometrioid endometrial
cancer: overtreatment is the main issue
Osman Turkmen
OP-130 / The impact of tumor size on predicting lymph node metastasis in endometrial carcinoma
Kadir Cetinkaya
OP-131 / The distribution of abnormal cervical cancer screening results in different age groups: A tertiary center experience
Ebru Ersoy
OP-132 / Cytoreductive Surgery in Advanced Stage Germ Cell Tumors of Ovary
Alper Karalok
OP-133 / Evaluation of patients with atypical squamous cells-cannot exclude high-grade squamous intraepithelial l
esion for histological diagnosis of cervical intraepithelial neoplasia of grade 2 or more severe disease
Hasan Aykut Tuncer
OP-134 / Isolated brain involvement in endometrium cancer from case report to meta-analysis: Different face of
neuro-invasion from endometrium cancer
Gunsu Kimyon Comert
OP-135 / Analyzing patients who are positive for high risk human papilloma virus other than types 16 and 18
Hasan Aykut Tuncer
OP-136 / Colposcopy-guided punch or loop biopsy for each grade of abnormal epithelial cytology
Hasan Aykut Tuncer
OP-137 / Area under the curve of estradiol monitorisation: A novel approach to evaluate detrimental effect of
estrogen exposure on implantation along the COH: A prospective data analyses
Tayfun Kutlu
OP-138 / Is there a relationship between ovarian reserve tests with depression and anxiety scales
Sündüz Özlem Altınkaya
OP-139 / Assessment of semen quality in patients with androgenetic alopecia in an infertility clinic
Emre Sinan Güngör
OP-140 / Functional assessment of mismatch repair in nuclear extracts and whole cell extracts obtained from
mouse and human blastocysts
Pinar Tulay
OP-141 / Differential parental BRCA1 expression in relation to human preimplantation embryo development
Pinar Tulay
OP-142 / Comparison of pregnancy rates between patients with and without local endometrial scratching before
intrauterine insemination
Ömer Erkan Yapça
10:20 - 10:40
COFFEE BREAK
Chair: Tayfun Kutlu
11:40 - 11:45
11:45 - 11:50
11:50 - 11:55
11:55 - 12:00
12:00 - 12:05
12:05 - 12:10
12:10 - 12:15
12:15 - 12:20
12:20 - 12:25
12:25 - 12:30
12:30 - 12:35
12:35 - 12:40
12:40 - 12:45
HALL 4
OP-143 / Evaluation of Endometrial Receptivity by Measuring HOXA-10, HOXA-11, and LIF Expression in Patients
with Polycystic Ovary Syndrome
Mustafa Kara
OP-144 / The role of premature ovarian failure awareness in female sexual functions and distress
Serdar Aydın
OP-145 / Non Invasive Prediction Of Implantation Window In Controlled Hyperstimulation Cycles:Can The Time
From The Menstrual Day At Embryo Transfer To Expected Menstrual Cycle Give A Clue ?”
İlhan Şanverdi
OP-146 / Seasonal variation of human sperm cells among 4422 semen samples: A retrospective study in Turkey
Runa Özelçi
OP-147 / Can Assisted Reproductive Therapy Indications Be Influential on Different Fetal Genders? Data From A
Tertiary Care Institution
Ebru Ersoy
OP-148 / Infertility associated with the Familial Mediterranean Fever
Eren Pek
OP-149 / Predicting Value Of Anti-Mullerian Hormone In Response To Clomiphene Citrate Used For Ovulation
Induction At Women Diagnosed With Unexplained Infertility
Bora Çoşkun
OP-150 / Does obesity really have any effect on ovarian reserve?
Ümit Görkem
OP-151 / The effect of vitamin D on ovarian reserve markers
Ümit Görkem
OP-152 / Does tenaculum use during intrauterine insemination effect pregnancy rate?
Ayla Sargın Oruç
OP-153 / A retrospective analysis of patients who underwent preimplantation genetic diagnosis due to single gene
defects: Our three years experience
Burak Yücel
OP-154 / Changing the protocol does not affect the outcome of in vitro fertilization in successive cycles
A. Seval Ozgu Erdinc
OP-155 / Impact of sperm morphology and progressively motile sperm count for pregnancy outcomes in
intrauterine insemination
Meryem Kuru Pekcan
09:00 - 09:05 OP-191 / Non-surgical management of unruptured cornual pregnancies: A case series
Görkem Tuncay
09:05 - 09:10 OP-192 / Heterotopic Cesarean Scar Pregnancy Following İn Vitro Fertilization
Cenk Soysal
09:10 - 09:15 OP-193 / Dermoid Cyst of The Round Ligament Misdiagnosed as Inguinal Hernia
Bülent Yirci
09:15 - 09:20
OP-194 / An extremely Rare Case of Vaginal Agenesis, Uterus Unicornis, Haematocolpos, Mental Retardation,
Bilateral Tarsal Syndactyly and camptodactyly; Possible Fraser Syndrome/ Ablepheron Macrostomia Syndrome, A Case From Pristina, Kosovo
Tuğba Ensari
09:20 - 09:25 OP-195 / Unsuccessful Outcome of Selective Embolisation in A Patient With Haematoma After Myomectomy
Bülent Yirci
09:25 - 09:30 OP-196 / Two novel mutations in the FRAS1 gene in Fraser Syndrome: Two case reports
Senem Yaman Tunç
09:30 - 09:35 OP-197 / The effect of dexpanthenol on ischemia/reperfusion-induced ovarian injury: biochemical and
histopathologic evaluation
Oya Soylu Karapınar
09:35 - 09:40 OP-198 / Comparison of low molecular weight heparin and rapamycine in an experimental uterine horn adhesion
model
Ahter Tanay Tayyar
09:40 - 09:45 OP-199 / Bevacizumab Exposure in Pregnant Rats Might Provide a Model to Study Human Preeclampsia
Metin Kaba
09:45 - 09:50 OP-200 / Does Vitamin D prevent ischemia-reperfusion injury of ovary on a rat model?
Vehbi Yavuz Tokgoz
09:50 - 09:55 OP-201 / Dose dependent protective effects of vardenafil on ischemia–reperfusion injury with biochemical and
histopathologic evaluation in rat ovary
Cihan Toğrul
09:55 - 10:00 OP-202 / Investigation of effects of vitamin D and mannitol in rat ovary induced by experimental ischemia/
reperfusion injury
Atilla Karateke
10:00 - 10:05 OP-203 / Investigation of the protective effects of amifostine against damage of hysterosalpingography on ovarian
tissue: a rat model
Sevim Tuncer
10:05 - 10:10 OP-205 / Effects of Quercetin and Surgicel® on Preventing Adhesions After Gynecological Surgery: A Rat Uterine
Horn Model
Gürhan Güney
10:10 - 10:15 OP-206 / Effect of Garlic Oil On Ovarian Reserve And Evaluation Of Serum Antioxidant Paramaters, A Rat Ovarian
Torsion Model
Cihan Kaya
10:20 - 10:40
COFFEE BREAK
Chair: M. Sühha Bostancı
11:40 - 11:45 OP-207 / Dose dependent protective effect of Tempol in experimental ovarian ischemia-reperfusion injury
Oya Soylu Karapınar
11:45 - 11:50 OP-208 / Comparison of the effects of bilateral total salpingectomy versus bilateral proximal tubal occlusion on
ovarian histopathology of rats: an experimental study
Sevim Tuncer
11:50 - 11:55 OP-209 / Oocyte Quality and Follicle Atresia are Changed in a Mouse Model of Fragile X Primary Ovarian
Insufficiency
Bahar Uslu
11:55 - 12:00 OP-210 / Effects of endocannabinoids on the isolated rabbit myometrium: An experimental invitro study
Ömer Lütfi Tapısız
12:00 - 12:05 OP-212 / Detrimental Effect Of Cystectomy On Ovarian Reserve: Endometrioma Vs. Other Types Of Ovarian Cysts, Time To
Reconsider Surgery For Endometriomas
Tayfun Kutlu
12:45 - 12:50
12:50 - 12:55
12:55 - 13:00
OP-156 / Does Pituitary Suppression Effect Live Birth Rate in Women with Hypo-gonadotrophic Hypogonadism
Undergoing Intra-Cytoplasmic Sperm Injection; a Multicenter Cohort Study
Sezcan Mumusoglu
OP-157 / Comparison of urodynamic parameters between intrafascial and extrafascial hysterectomy techniques
Recep Erin
OP-158 / Bilateral sacrospinous fixation without hysterectomy:18-month follow-up
Mehmet Baki Şentürk
13:00 - 14:00
LUNCH
Chair: Yılmaz Güzel
15:10 - 15:15 OP-159 / Posterior Vaginal Wall Cyst Masquerading as rectocele: A Diagnostic Dilemma
Hediye Dagdeviren
15:15 - 15:20 OP-160 / Effects of Tans-Obturator Tape outside-in versus inside-out procedure for stres urinary incontinence on
women’s sexual functions and quality of life: Results of a prospective randomized study
Bülent Arıcı
15:20 - 15:25 OP-161 / Creation of Neovagina in a Patient With Complete Uterovaginal Agenesis Using Peritoneum of Bladder, A
Case From Pristina, Kosovo
Mehmet Baki Şentürk
15:25 - 15:30 OP-162 / The Impact of Concurrent Pelvic Organ Prolapse Reconstructive Surgery on Midurethral Sling Procedure
Outcome
Buğra Çoşkun
15:30 - 15:35 OP-163 / Delayed Vaginal and Cesarean Delivery in a Twin Birth: A Case Report
Mustafa Ulubay
15:35 - 15:40 OP-164 / Recurrent Placenta Percreta in Patients Who Underwent Previous Uterus Sparing Surgery for Placenta
Percreta: An Unusual Case Report
Adnan İncebıyık
15:40 - 15:45 OP-165 / A rare cause of adnexal mass: Chondrosarcoma
Murat Dede
15:45 - 15:50 OP-166 / A Case Report: Genital Tuberculosis mimicing Ovarian Cancer
Murat Dede
15:50 - 15:55 OP-167 / Joubert Syndrome: Case Series
Hatice Akkaya
15:55 - 16:00 OP-168 / A rare cause of urinary retantion in women: Fowler’s syndrome
Hediye Dağdeviren
16:00 - 16:05 OP-169 / A Uterine carcinosarcoma case with high levels of AFP(alpha fetoprotein)
Hanifi Şahin
16:05 - 16:10 OP-170 / An extremely rare case of complicated appendicitis, in utero appendix with fistula formation
Mustafa Gazi Uçar
16:10 - 16:15 OP-171 / Subamniotic hematom: a rare reported condition
Ramazan Erda Pay
16:15 - 16:20 OP-172 / Squamo-transitional cervical cancer: A case report with unusual clinical findings
Georgios Gitas
16:20 - 16:25 OP-173 / Polyhydramnios and Pregnancy Complicated with Bartter’s Syndrome: A Case Report
Hasan Ulubaşoğlu
16:25 - 16:30 OP-174 / İntragestational Methotrexate Treatment Cesarean Of Scar Ectopic Pregnancy, A Case Report
Hasan Ulubaşoğlu
16:30 - 16:35 OP-175 / Hyperandrogenism of ovarian origin in postmenopausal woman: Is surgery reasonable for diagnosis and
treatment ?
Meltem Tekelioğlu
16:35 - 16:40 OP-176 / Unilateral Renal Ectopic Kidney During Paraaortic Lymphadenectomy: A Case Report
Mustafa Taş
16:40 - 16:45 OP-177 / Synchronous primary malignant tumors of female genital tract: A case report of endometrial
endometrioid adenocarcinoma coexisted with ovarian papillary serous adenocarcinoma
Osman Temizkan
16:45 - 16:50 OP-178 / carcinosarcoma of the fallopian tube: rare case
10:20 - 10:40
COFFEE BREAK
Chair: Erdal Sak
17:00 - 17:05
17:05 - 17:10
17:10 - 17:15
17:15 - 17:20
17:20 - 17:25
17:25 - 17:30
17:30 - 17:35
17:35 - 17:40
17:40 - 17:45
17:45 - 17:50
17:50 - 17:55
17:55 - 18:00
OP-179 / A Case of Endometrıal Cancer Presentıng with Acetebular Metastasis
OP-180 / A rare case of inguinal ovary in ovarian hyperstimulation
Ramazan Erda Pay
OP-181 / Ovarian hyper stimulation syndrome presented with isolated unilateral right side hydrothorax: two cases
and systematic review of the literature
Sezcan Mumusoglu
OP-182 / Extreme leukocytosis in obstetric patients
Hale Göksever Çelik
OP-183 / Uterine atony with generalized convulsion after intravenous oxytocin infusion (Water Intoxication)
Yüksel ışık
OP-184 / The Family With Bartsocas Papas Syndrome From Turkey
Rukiye Ada Bender
OP-185 / Ligneous inflammation of female genital tract and conjunctiva associated with plasminogen deficiency: A
Case report
Ebru Yüce
OP-186 / A Case of Glioma Arising in an Ovarian Mature Cystic Teratoma
Esra Tamburacı
OP-187 / Two cases of vanishing endometrial carcinoma
Ömer Erkan Yapça
OP-188 / Incarcerated retroverted gravid uterus misdiagnosed of recurrent urinary tract infection
Erhan Aktürk
OP-189 / Aspergillus in a cervico-vaginal smear of a postmenopausal female
Erhan Aktürk
OP-190 / Pelvic pain associated by levator ani syndrome and relieved with prilocaine injection
Erhan Aktürk
12:05 - 12:10 OP-213 / Risk of Occult Uterus Malignomas while Using Power Morcellation
Georgios Gitas
12:10 - 12:15 OP-214 / The review of our office hysteroscopy experiencies in perspective ‘’See and Treat’’ concept
Emine Demirel
12:15 - 12:20 OP-215 / Neuraltherapy for treatment of endometriosis
Pınar Yalçın Bahat
12:20 - 12:25 OP-216 / A Comparision Of Skin Elevation And Fascial Elevation in Veress Needle Closed Entry Method
Bülent Köstü
12:25 - 12:30 OP-217 / The Closed Laparoscopic Entry Method Of Increasing Intraabdominal Pressure With Supraumbilical
Compression
Bülent Köstü
12:30 - 12:35 OP-219 / Isolated tubal torsion: Succesful preoperative diagnosis with Ultrasound and management with
Laparoscopy of four cases
Rıza Dur
12:35 - 12:40 OP-220 / Laparoscopic sacrocolpopexy: a single center experience of two years
Fatih Çelik
12:40 - 12:45 OP-221 / Hyperthermic intraperitoneal chemotherapy after secondary cytoreduction in epithelial ovarian cancer: a
single-center experience
Fatema Alkhan
12:45 - 12:50 OP-222 / Pregnancy in cancer survivors; experience of a University Hospital in Turkey
Ebru Alıcı Davutoğlu
13:00 - 14:00
LUNCH
Acute abdomen in pregnancy - Diagnosis and management
Wolfgang Henrich, M.D.
Department of Obstetrics
Charité, Campus Virchow Klinikum, Campus Mitte, Berlin
Ultrasonography is the first choice in making a diagnosis of acute
abdomen in pregnancy because it is non-invasive for both the
mother and fetus. A large amount of information can be obtained
by this versatile tool, even by an obstetrician who should normally
be familiar with the most common features of abdominal diseases.
The diagnosis and important aspects in treating acute abdomen
tend to be delayed due to the physiological features of pregnancy
and the restrictions with X-ray and CT.
Diagnosis is often made more difficult during pregnancy due to the
deviation of organs caused by an enlarged uterus and relaxation.
Any delay of diagnosis may seriously deteriorate the condition.
Detailed questioning of the patient and physical examination by
palpation are essential in making a diagnosis and determining
proper treatment.
Some of the symptoms observed in acute abdomen are often similar
to digestive symptoms associated with pregnancy. Information on
associated symptoms, and descriptions of stools, as well as the
patient’s medical history are helpful for the differential diagnosis.
The major symptom of acute abdomen is abdominal pain. As a
first step, the causative disease should be determined on the basis
of the site and characteristics of the abdominal pain as well as
what the patient has eaten. Sudden, violent pain is characteristic
for tract perforation, mesenteric artery embolism, ureterolithiasis
and ovarian torsion.
The most common reasons for an acute abdomen are acute
appendicitis (70%), ileus (20%), torsion of an ovarian cyst (5%),
cholecystitis due to cholecystolithiasis (4%), acute pancreatitis and
ureterolithiasis.
Acute appendicitis starts with the pain and discomfort in the upper
abdomen, which is primarily localized in the lower right abdomen
and moves later upward, corresponding to the gestational age.
Acute appendicitis is suspected if a swollen appendix (short axis
diameter of 6mm) is imaged at the point that corresponds with the
tenderness. In this case, the inflammation is considered to have
reached or exceeded the phlegmonosa. When the layer structure
becomes obscure, gangrenous appendicitis is suspected.
If there is a post-surgical history (e.g. Appendectomy) and severe
vomiting, ileus can be suspected. Characteristic ultrasonography
findings of simple ileus include dilated intestinal tract and full
intestinal image as well as intestinal folds.
Bloody stools may indicate ischemic colitis or mesenteric artery
embolism. Tarry stools suggest the perforation of a duodenal ulcer.
Acute cholecystitis and acute pancreatitis frequently occur after
eating fatty foods. Similar symptoms may have occurred several
times in the past. Gallbladder and duct stones might lead to
Cholecystitis. Stones are visible with typical echo features.
One of the severe complications by delayed treatment of
cholecystitis due to gallbladder stones is the development of
pancreatitis, which can lead to severe maternal complications.
In the absence of cholecystitis acute pancreatitis can be due to
metabolic disorders which might appear the first time during the
pregnancy.
Ovarian torsion can be detected by an ovarian cyst which is close
to the lateral uterine wall and just below the abdominal wall. In
detailed examination, the torsion of the adnexal vessels can be
detected by Color Doppler ultrasound.
The lecture will show a case series of the most common
diseases, responsible for an acute abdomen in pregnancy and the
corresponding ultrasound features. Recommendations will be
given for operative and conservative management strategies.
Oocyte quality in endometriosis patients
Thomas Ebner, M.D.
Kepler University, Kinderwunsch Zentrum, Linz, Austria
It was planned to describe detailed oocyte morphology in
endometriosis patients, compare it with an endometriosis-negative
control group, and evaluate its possible association with ART and
treatment outcome. Therefore, oocyte quality of all endometriosis
patients presenting at the Kinderwunsch Zentrum Linz was
prospectively assessed. Decision making process with respect to
embryo or blastocyst transfer was based on routine criteria but not
on oocyte morphology. Study group (with endometriosis) as well
as control group consisted of 129 IVF/ICSI cycles. Patients were
matched according to AMH, female age, previous treatment cycles,
and method of fertilization. A total of 23 patients each were treated
with conventional IVF. Endometriosis was staged according to
the revised ASRM guidelines of 1997. With respect to oocyte
morphology in ICSI it was focussed on intra- and extracytoplasmic
dysmorphisms. Patients with endometriosis had a significantly
lower rate of mature oocytes as well as morphologically normal
oocytes. In particular, brownish oocytes and the presence of
refractile bodies were found to be increased. Endometriosis
stage IV had significantly worse quality oocytes than stages I-III.
Fertilization was significantly reduced in conventional IVF but not
ICSI. Most likely due to lower fertilization rates in endometriosis
III-IV as compared to I-II. No difference was observed with respect
to rates of implantation, clinical pregnancy, miscarriage, live birth,
and malformation. Neonatal outcome was comparable between
endometriosis positive and negative groups. Based on the present
data, IVF should not be first choice treatment option in moderate
to severe endometriosis (III-IV). Once fertilized, no impairment
of further preimplantation embryo development and pregnancy
outcome right up to healthy live birth rate has to be expected.
Anatomical hysterectomy, what are the news?
Liselotte Mettler, M.D.
University Hospitals of Schleswig-Holstein, Campus Kiel
Department of Obstetrics & Gynecology
In gynaecologic endoscopic surgery, endoscopic hysterectomies
are performed since 1990 and have reached as well with single port
entry as well as with multiple port entry or with robotic assistance
an acceptable success rate with few side effects.
For TLH the patient is prepared in Trendelenburg position and
by vaginal access the uterine manipulator is placed. In addition
a transurethral pelvic catheter (Folley catheter) is situated. The
arms of the patient are naturally fixed along the body to give for
the first and second surgeon optimal space for surgery. The first
surgeon stands on the left side of the patient, the second surgeon
on the right side. An assistant is sitting between the legs of the
patient and can manipulate the uterus with the uterine manipulator.
The operation starts by positioning the Verress canula which is
later being replaced by the 10 mm optic trocar. After introducing
the HDTV video optic, an exploration of the entire abdominal
cavity, literally focussing on the minor pelvis is performed. The
bladder, the rectum, the pelvic vessels, the ureters are identified
and demonstrated.
As first step the round ligament is coagulated and separated near the
pelvic side wall. Afterwards the peritoneum is further incised. The
anterior leaf of the broad ligament is opened up to the bladder fold
and the bladder is pushed downwards. Now the posterior leaf of
the broad ligament is demonstrated and the ureters are lateralized.
After that the retro peritoneal space is explored. The course of the
ureters is demonstrated and the exit of the uterine artery from the
iliac artery is visualized. The crossing point of the uterine artery
and the ureter is demonstrated and the uterine artery is coagulated.
The bladder piller is identified, coagulated and separated. This
is followed by the separation of the ovary and the tube from the
uterus. If the adnexas, after sufficient distance of the ureters have
to be dissected with the uterus, the infundibulopelvic ligament is
coagulated and the mesosalpinx and the mesovar is separated in
direction of the fenestration. The fenestration reveals to be a good
orientation point. Now the main parametrium is dissected in small
steps down to the vaginal vault. The presentation and preparation
of the uterine vessel bundles is performed which after coagulation
is separated with a scissor. The same procedure is performed
contralaterally.
The uterus can be moved with a manipulator cranial and to the
contralateral side. Thus the tension of the tissue is evident which
lateralizes the bladder and the distal ureters. The uterus then is
separated from the vagina with the monopolar hook following the
upper part of the ceramic cup of the manipulator. The uterus is then
extracted through the vagina or positioned into the vagina to keep
the pneumoperitoneum. In cases of large benign uteri an additional
electromorcellator 10 mm – 12 mm is carefully dissecting the
material which is then extracted through the abdominal wall.
The sacrouterine ligament can be attached to the posterior wall
as decensus prophylaxis McCall Suture. The peritoneum is closed
with a continuous Vicrly Suture 3 x 0. Finally suction irrigation
with Ringers lactate. In order to prevent a Douglascele we apply a
fixation of the sacrouterine ligaments according to Van Herendael.
Laparoscopic Radical Hysterectomy (LRH) in cases of malignancy
of the cervix uterus or ovaries depends on disease related
alterations already existing at the surgical procedure. However,
more radicality means dissection and demonstration of anatomical
structures and always includes the resection of the uterus and
adnexas, its vascular supply and the parametria as well as the upper
third of the vagina.
The correct indication for the selected procedure of hysterectomy in
accordance with the wish of the patient depends on the knowledge
of the individual surgeon and his current possibilities. A detailed
evaluation of 1.200 cases of TLH is presented.
Accidental diagnosis of uterine sarcoma: What to do?
Peter Mallmann, M.D.
Cologne
In most patients uterine fibroids are treated by laparoscopy. Based
on a legal action in the United States there is a debate about the
potential risk of incorrect treatment if histological examination
detects an uterine sarcoma instead uterine fibroids. The incidence
of uterine sarcoma standardized for age in 2010 was between 1,3
to 2.02 for every 100.000 women. In pre-operative diagnostic
it is not possible to differentiate a myoma from a sarcoma, this
can only be done post-operatively during the histo-pathological
work-up. So in most cases the diagnosis of uterine sarcoma is
done accidentally. The most commonly used approach for surgical
treatment of uterine fibroids is a laparoscopic approach by myoma
enucleation, subtotal or total hysterectomy in combination with
morcellation. The co-incidental finding of uterine sarcomas
therefore occurs most commonly with this approach. The most
common histological type after surgical treatment of presumed
uterine fibroids are leiomyosarcoma, followed by endometrial
stroma sarcoma and undifferentiated endometrial stroma sarcoma.
After the accidental diagnosis of uterine sarcoma it is urgently
necessary that these patients are treated by surgery in accordance
with the current oncological guidelines. This includes a total
hysterectomy, in cases of a previous supra cervical hysterectomy
the cervix has to be removed, in most cases combined with a
bilateral adnexectomy. Is is not necessary to remove pelvic and
para-aortic lymph nodes which are not enlarged. After morcellation
a dissemination of malignant tissue can not be rolled out. This may
worsen the patient`s prognosis. The current available data are not
sufficient to arrive at a definite conclusion which would allow an
estimate of the deterioration of the prognosis for the individual
patient and to determine whether an adjuvant therapy is necessary.
In patients with uterine carcinosarcoma an adjuvant chemotherapy
with cisplatin/iphosphamid can be discussed. Using an adjuvant
radiotherapy of the pelvic area the risk of local recurrence can be
reduced. In uterine carcinosarcoma a chemotherapy with cisplatin,
doxorubicin and iphosphamid or docetaxel and gemcitabin may
lead to an increased progression-free survival. Endometrial stroma
sarcoma and an adjuvant endocrine therapy using MPA is used.
In undifferentiated endometrial sarcoma with positive receptor
content an adjuvant endocrine therapy can be discussed. There
are no studies available concerning the benefit of all adjuvant
procedures in patients with an accidental diagnosis of uterine
sarcoma after morcellation. As in cases of accidental diagnosis of
sarcoma the prognosis of the patient is bad, the patients must be
provided with all information about the risks.
Cervical screening programmes
Coşan Terek, M.D.
Ege University Faculty of Medicine, Department of Obstetrics and Gynecology
Bornova, Izmir, Turkey
Most cases of cervical cancer occur in women who were either
never screened or were screened inadequately. National public
health measures are critical to build a nationwide screening
program for cervical cancer.
Natural history of cervical neoplasia
Infection with oncogenic (high-risk) HPV is a necessary bu not
sufficient factor for the development of cervical neoplasia. Only a
small fraction of women harboring oncogenic HPV will develop a
significant abnormality. Persistent infection at 1 year and 2 years
after intial infection predicts subsequent risk of cervical neoplasia
regardless of age. HPV genotype (HPV 16 and HPV 18) is the most
important determinant of persistence and progression. Cigarette
smoking, compromised immune system and HIV infection are
the cofactors that increase the likelihood of persistent HPV
infection. Most young women (especially under 21 years) have an
effective immune response that clears the infection in an average
of 8 months. Concomitant with infection resolution, most cervical
neoplasia also will resolve spontaneously in this population. HPV
infection detected in women over 30 years is more likely to reflect
persistent infection.
Cervical cytology screening techniques
In liquid-based technique exfoliated cells form the transformation
zone are transferred to a vial of liquid preservative. In conventional
method exfoliated cells from the transformation zone are
transferred directly to a slide and fixed. Liquid-based method has
the advantage of allowing a single specimen to perform cytology,
HPV testing and testing for gonorrhea and chlamydial infection.
There is no difference in sensitivity or specifity for the detection
of CIN between conventional and liquid-based techniques. Both
methods are acceptable for screening.
HPV testing
The tests assess exfoliated cervical cells for the presence of subsets
of the 15-18 high-risk HPV genotypes. The test kits should be
validated and meet spesific criteria for clinical performance. The
indications for HPV testing are:
1.Determination of need for colposcopy in women with an ASCUS cytology result (reflex testing)
2.Use as an adjunct to cytology for cervical cancer screening in
women aged 30-65 years (cotesting)
3.One HPV test (Cobas HPV test) is FDA approved in 2014 for
primary cervical cancer screening. FDA accepted the indication
for its use for primary screening in women starting at age 25 years.
Rescreening after a negative test should occur no sooner than every
3 years. Positive specimens undergo HPV genotyping. If specimen
is positive for HPV 16 or HPV 18 colposcopy is performed. If
specimen is negative for HPV 16 and HPV 18, cytology testing is
performed on the specimen and if results are abnormal, colposcopy
is performed.
When should screening begin?
Cervical cancer screening should begin at age 21 years. Earlier
onset of screening increases anxiety and unnecessary excision and
ablation of cervix. Women younger than 21 years should not be
screened regardless of the age of sexual intiation or the presence of
other behavior-related risk factors.
What tests should be performed for screening?
Women aged 21-29 years should be tested with cervical cytology
alone in every 3 years. Cotesting should not be performed in
women younger than 30 years.
For women aged 30-65 years cotesting with cytology and HPV
testing ever 5 years is preferred; screening with cytology alone
every 3 years is acceptable. It is important to educate patients
about the nature of cervical cancer screening, its limitations and
the rationale for prolonging the screening interval. Screening by
any modality should be discontinued after age 65 years in women
with evidence of adequate negative prior screening test results and
no history of cervical intraepithelial neoplsia (CIN) 2 or higher. In
women who have had a hysterectomy with removal of the cervix
(total hysterectomy) and have never had CIN 2 or higher, routine
cytology screening and HPV testing should be discontinued.
How should ASC-US cytology and negative HPV test results
be managed?
HPV testing is a very effective method of triage for an ASC-US
cytology result. Women have a low risk of CIN 3 and recommended
that they have cotesting in 3 years rather than 5 years. If their 3-year
cotest results are negative women can return to routine screening.
How should cytology-negative, HPV-positive cotest results be
managed?
There are two ways:
1.Repeat cotesting in 12 months. If the repeat cervical cytology
test result is ASC-US or the HPV test result is still positive, the
patient should be referred to colposcopy; otherwise, cotesting in 3
years is indicated.
2.Immediate HPV genotype-specific testing for HPV 16 and HPV
18 is performed. Women with positive test results for either HPV
genotype are referred for colposcopy. If negative, repeat cotesting
is performed in 12 months.
More frequent cervical cancer screening is indicated in the
following situations:
1.HIV infection
2.Immuno-compromised women (solid organ transplant)
3.Diethylstilbestrol exposure in utero
4.Previous treatment for CIN2, CIN3 or cancer
Reference
Cervical Cancer Screening and Prevention ACOG Practice Bulletin
number 157, 2016
National cervical cancer Screening program and its current
problems
Murat Gültekin, M.D.
Cervical cancer is the third frequent cancer for woman following
breast cancer and colorectal cancer Thanks to long term successful
applications of cervical smear screenings, in many countries
morbidity and mortality in cervical cancer decreased more than
% 70.
Cervical cancer which can be treated with screening and early
diagnosis, is one of the rare causes of deaths due to cancer. It is
possible to say that, any women who regularly go to screening will
not die due to cervical cancer. Thus World Health Organization
(WHO) suggests screening for cervical cancer in all countries.
Screening method and screening internals may differ in countries .
Definite suggestion is the screening of a woman once in a life time
between the ages of 30-65 with an appropriate screening method
for cervical cancer
Why is Cervical Cancer Important?
• Cervical cancer is a preventable disease.
• Cervical cancer can be % 100 treated with early diagnosis.
• Deaths due to cervical cancer can totally be prevented.
• It is possible to say, a woman, who is applied cervical screening
will not die due to cervical cancer.
• Cervical cancer is a disease of which pathogenesis is completely
enlightened.
• Cervical cancer has a carcinogenesis (transferring into cancer)
duration of 10-20 years and in this period it is possible to identify
the facts that may turn into cancer.
• The number of women dying due to cervical cancer is inversely
proportional with development level of that country in terms of
health services and importance attributed to women in such society.
National Screening Problems in Turkey
• Large target population (15 Million)
• Lack of manpower (technician, expert)
• Frequent positional changes in manpower
• Lack of awareness (medical staff and population)
• Geographical limitations (large surface area, seasonal
difficulties, transport difficulties)
• Quality control
Why HPV for Turkey
• High Negative Predictive Value
• Higher sensitivity
• Manpower advantage
• Central quality control
• Low HPV positivity (low prevalence)
• Shortening the time to final diagnosis
• Self-testing ability for future
• A new test for a New Awareness Restart
• Central tender cost due to high target population
Today, it is known that, cervical cancer is % 99.9 caused by HPV
(Human Popilloma Virus). Turkey implemented HPV DNA testing
as a primary screen for cervical cancer in mid-2014. The program
is organised and all ladies over 30 years of age are screened for
13 High Risk HPV types via HC2. The ones with positive results
are further analyzed after DNA extraction for HPV genotypes
for epidemiological purposes together with reflex cytology
evaluations. All analysis is done in a central MEGA HPV laboratory
implemented in Ankara. Daily, >5,000 samples are analyzed and
the results are reported within 10 days of collecting the sample.
A specialized population based software is used to evaluate and
monitor all steps from sample collection and transport to reporting
results, showing the progress through each step of this 10 day
process. Untill now, almost 1.5 million ladies have been screened
with HPV DNA testing and no samples have been lost or mixed
up. The software also gives a national HPV Map, with genotypes
across the whole country for epidemiological monitoring.
This is a unique and a first nationally organised and implemented
HPV based screening program in the world.
Early Cervical cancer – Sentinel or radical lymphadenectomy
Peter Hillemanns, M.D.
Hannover, Germany
Radical lymphadenectomy has been an essential part in the
surgical treatment of cervical cancer. Lymphadenectomy provides
an accurate prognosis and directs the use of adjuvant therapy.
However, limited data support a therapeutic benefit of radical
lymphadenectomy. Instead, it increases operative time, the risk
for lower extremity lymphedema in up to 10% and lymphocele
formation which may become symptomatic and even infected.
For early cervical cancer, sentinel lymph node (SLN) mapping
has emerged as a possible alternative: it seems to have the ability
to accurately stage patients while reducing the number of lymph
nodes removed, the operative time, and morbidity. Traditional
methods for SLN detection are blue dyes and radioactive tracers.
Diagnostic accuracy is the single most important parameter of the
sentinel procedure and should be as high as possible in order to
become a reliable alternative to standard lymph node dissection.
For breast cancer, application of only one tracer radio-colloid is
state of the art. However, in cervical cancer detection rates are
higher when a combined tracer technique is used. About 20%
of SLN’s may be missed if only one tracer is used. Using the
combined technique of blue dye and technetium-99 tracers in early
stage cervical cancer, sensitivity of SLN biopsy achieves about
90% which is similar compared to breast cancer.
The cervix is a midline organ with bilateral lymphatic drainage.
Therefore, SLN for cervical cancers must be identified in both
hemipelvices which is still a challenge: bilateral SLN detection
yielded a lower detection rate (60%) compared to ‘at least one SLN’
(91%), or ‘per hemi-pelvis’ (74%) approach. We prefer a complete
bilateral pelvic lymph node dissection whenever the SLN is not
bilaterally detected. A side-specific LND is an alternative option
which will lead to a residual false negative risk of 0.4% instead of
0.08% (Tax et al, 2015). We could further improve the detection
by using SPECT/CT instead of lymphscintigraphy, preoperatively
(Klapdor et al, 2014).
Subgroup analyses in patients with early stage disease showed a
bilateral detection rate of 87% and 83% in patients with a tumor
diameter of 2 cm and 4 cm when using a double tracer technique
(Tax et al, 2015). In the German AGO Uterus 3 study, the detection
rate of pelvic SLN was 88.6% with a sensitivity of 77.4% for
metastatic pelvic nodes which was lower than 90%, the predefined
noninferiority margin. The sensitivity in women with tumors less
than 2 cm was 90.9% with a negative predictive value of 99.1%,
thus achieving an acceptable accuracy (Altgassen et al, 2008).
Therefore, the German S3 guideline for Cervical Cancer Diagnosis
and Treatment 2014 restricts its recommendation for SLN mapping
to tumor less than 2 cm (2014).
Ultrastaging with serial sectioning and use of immunohistochemistry
for cytokeratins or p16 leads to the highest diagnostic accuracy by
detecting SLN metastases in 80% of early stage cervical cancer
patients in whom the SLN was negative on frozen section or H&E
analysis. Even detection of isolated tumor cells by ultrastaging has
clinical relevance. One step further, we could show the clinical
relevance of detecting Human Papilloma Virus (HPV) mRNA in
sentinel nodes (Durst et al, 2015).
In the review by Tax et al., a subgroup with ultrastaging achieved a
sensitivity of 99.6% and 99.9% NPV if the following prerequisites
were met: bilateral SLN detection, no suspicious lymph nodes on
pre-operative imaging or during surgery, a primary tumor diameter
of up to 4 cm and ultrastaging. These criteria reduce the residual
risk on occult metastases to 0.08%. In contrast, in melanoma, breast
and vulvar cancer a residual risk of 3%, 0–10% and 2% on occult
metastasis has been used as an acceptable cut-off point to abandon
complete lymph node dissection. On the basis of these results
and the must of ultrastaging , they recommend not to perform a
complete PLND in these patients.
However, the current mapping techniques with the non-visible
technetium, the need for detection via an expensive endoscopic
intraoperative gamma probe and the problem of blue dye in
patients with adipose tissue asks for an improvement in our current
SLN mapping techniques. An alternative is indocyanine green
(ICG) which is a fluorophobe that fluoresces within the nearinfrared spectrum. It can be injected immediately before surgery.
The false-negative rate is very low with high sensitivity and
negative predictive value. In our experience, however, it leads to a
fluorescence slowly climbing the lymphatic vessels via pelvis up to
the paraaortic regions. Therefore, it may have a reduced specificity
and, thus, the consequence of more SLN´s to be excised compared
to the conventional techniques. A limitation of ICG is the necessity
of performing near-infrared (NIR) imaging intraoperatively, which
requires additional equipment. NIR imaging is available on the
robotic Si/Xi and Storz surgical platforms. It also is available for
other laparoscopic and open cases using commercially obtainable
equipment. Future studies will show whether ICG mapping replace
radioactive and blue tracers.
Literature
(2014) S3-Leitlinie Diagnostik, Therapie und Nachsorge
der
Patientin
mit
Zervixkarzinom
(Langversion).
Leitlinienprogramm Onkologie. Leitlinienprogramm Onkologie
der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen
Fachgesellschaften e. V. (AWMF), Deutschen Krebsgesellschaft e.
V. (DKG) und Deutschen Krebshilfe e. V. (DKH). Vol. AWMFRegisternummer 032/033OL.
Altgassen C, Hertel H, Brandstadt A, Kohler C, Durst M, Schneider
A (2008) Multicenter validation study of the sentinel lymph node
concept in cervical cancer: AGO Study Group. J Clin Oncol 26:
2943-2951
Durst M, Hoyer H, Altgassen C, Greinke C, Hafner N, Fishta A,
Gajda M, Mahnert U, Hillemanns P, Dimpfl T, Lenhard M, Petry
KU, Runnebaum IB, Schneider A (2015) Prognostic value of HPVmRNA in sentinel lymph nodes of cervical cancer patients with
pN0-status. Oncotarget 6: 23015-23025
Klapdor R, Mucke J, Schneider M, Langer F, Gratz KF, Hillemanns
P, Hertel H (2014) Value and advantages of preoperative sentinel
lymph node imaging with SPECT/CT in cervical cancer. Int J
Gynecol Cancer 24: 295-302
Tax C, Rovers MM, de Graaf C, Zusterzeel PL, Bekkers RL (2015)
The sentinel node procedure in early stage cervical cancer, taking
the next step; a diagnostic review. Gynecol Oncol 139: 559-567
Conventional karyotyping and array CGH in fetal cardiac
abnormalities
Özlem Pata, M.D.
Congenital heart disease is the most common cause of noninfectious
neonatal mortality, affecting up to 1% of newborns. Most of the
CHD may be treated by surgical repair or palliation with a good
outcome. However the prognosis depends on the presence of
chromosomal or extra cardiac malformations.
The frequency of chromosomal abnormalities in infants with
congenital heart defects has been estimated as 5-15 % from
postnatal data. On the other hand the frequency of abnormal
karyotype in fetuses has been reported in the range of 30-40% ().
Comparing infants and fetuses this higher rate is mainly due to an
increased perinatal mortality in fetuses with aneuploidy.
Cytogenetic fetal karyotyping used to be the gold standard of
prenatal genetic testing. Karyotyping is able to detect aneuploidy
and large chromosomal rearrangements. The most known
chromosomal anomalies associated with CHD are trisomy 21,
18 and 22q11. Furthermore, fetuses with CHD carry residual risk
of additional genetic anomalies including micro deletion, micro
duplication syndromes or single gene disorders such as Williams
–Beuren, Noonan or Alagille syndrome..
Some cardiac defects are more commonly associated with
chromosomal abnormalities such as endocardial cushion defect,
tetralogy of Fallot. On the other hand, transposition of great
vessel or heterotaxy syndrome is not usually associated with
chromosomal abnormalities. However, ıt is exhibited that the risk
of non-iatrogenic neurological impairment is increased even in
isolated CHD. For all we know, it might be that these abnormalities
deemed as isolated contain genetic abnormalities, which we fail
to determine by conventional techniques and this results with
neurologic deficit that shall affect our decision as well as the
famıly’s decision in prenatal consultation.
Array comparative genomic hybridization (aCGH) is a molecular
cytogenetic technique that is able to detect the presence of
clinically significant copy number variants (CNVs) within the
genome that are not detected by routine fetal karyotyping. There
have been many studies on the use of aCGH to identify clinically
significant CNAs in prenatal diagnosis of fetuses with abnormal
ultrasound findings. Especially considering congenital cardiac
abnormalities, ıf karyotyping and 22q11 analysis by FISH normal,
using aCGH has additional value, detecting pathogenic CNVs
in 7.0%. Even transposition of the great arteries and heterotaxy,
which are not considered to be not associated with chromosomal
anomalies detected by karyotyping, were found to have pathogenic
aCGH results. On the other side we might come across variants
of unknown significant in aCGH, which holds true in 3.4% of the
cases with CHD. The detection of VOUS could lead to challenges
in counseling and parental anxiety.
Consequently; although we normally expect isolated CHD with
normal karyotype aCGH is able to give, additional information.
References
1- Abuhamad A., Chaoui R. Genetic Aspects of Congenital
Heart Defects. In A practical guide to Fetal Echocardiography:
Normal and Abnormal Hearts. Second Edition LWW.
2- Jansen F.A.R, Blumenfeld YJ, Fisher A, Cobben JM, Odibo
AO, Borrel A, Haak MC. Array comparative genomic
hybridization and fetal congenital heart defects: a systematic
review and meta-analysis. Ultrasound Obstet Gynecol
2015;45:27-35
3- Shaffer LG, Rosenfeld JA, Dabell MP, Coppinger J et al.
Detection rates of clinically significant genpmic alterations
by microarray analysis for specific anomalies detected by
ultrasound. Prenatal Diagnosis2012, 32,986-995.
4- Wapner RJ, Martin JL, Levy B, Ballif BC et al. Chromosoaml
microarray versus karyotyping for prenatal diagnosis. N Engl
J Med 2012;367:2175-2184
5- Donnely JC, Platt LD, Rebarber A, Zachary J, Grobman WA,
Wapner RJ. Association of copy number variants with specific
ultrasonographically detected fetal anomalies. Obstet Gynecol
2014;124:83-90
Minimally invasive fetal interventions
Christoph Berg, M.D.
Minimally invasive fetal interventions encompass the multiple
treatment options in complicated monochorionic pregnancies,
tracheal occlusion to promote lung growth in diaphragmatic hernia,
ablation of the feeding vessel in fetal tumors and bronchopulmonary
sequestration and shunting for megacystis and thoracal effusions.
Although few interventions have proven their feasibility in RCT’s,
most fetal interventions are still experimental.
The superiority of laser therapy over amniodrainge in TTTS has
been demonstrated in a RCT over ten years ago. In recent years
the operative method has evolved with the application of the
Solomon technique that reduced postoperative TAP sequences and
recurrence of TTTS in a RCT.
TRAP sequence diagnosed in the first trimester has an overall
mortality of >70%. The TRAPIST RCT Trial is on the way to
assess the feasibility of first trimester intervention by intrafetal
Laser.
Laser therapy for sIUGR has shown to be associated with a high
rate of complications and a high rate of IUFD of the IUGR twin.
Contemporary studies have demonstrated a significantly better
outcome for the AGA twin after cord coagulation in the IUGR
twin.
Tracheal occlusion in diaphragmatic hernia for severe (<25% O/E
LHR) lung hypoplasia has demonstrated significantly improved
outcomes in a RCT. The TOTAL trial investigates, whether these
results can be extended to moderate lung hypoplasia in congenital
diaphragmatic hernia.
Intrafetal laser ablation of the feeding vessels is associated
with poor outcomes in sacrococcygeal teratoma. In contrast,
bronchopulmonary sequestration with massive pleural effusion can
be successfully treated with intrafetal laser in most of the cases.
Second trimester shunting of megacystis in LUTO, although
associated with an improved overall survival, results in less than
30% normal renal function after birth. New intrauterine devices
for vesicoamniotic shunting have a significantly reduced size
and are therefore candidates for application in the first trimester.
Preliminary data suggest that first trimester shunting for megacystis
might be able to preserve renal function in a significant proportion
of cases.
Although new minimally intrauterine invasive techniques have
shown promising results in initial non-comparative studies, RCT’s
are warranted in order to assess the true value of these treatment
options. Due to the rarity of the targeted diseases multinational
trials will be of outmost importance.
Progestagens used in endometrium and cycle control
Fatih Durmuşoğlu, M.D.
It is well known that the endometrium is one of the most sensitive
target organs for sex steroids, with oestrogens being potent
stimulators of the proliferative activity and progesterone limiting
this activity and transforming the oestrogenprimed cells into a
structure functionally prepared for nidation.Due to the interactions
between oestrogens and progestogens, the topic ‘endometrium
and hormonal contraceptives’ is at.the same time fascinating
and multifaceted. Therefore, by necessity the discussion needs
to be restricted to the effect of contraceptive progestogens when
given alone. Within this context two subjects seem to have
special relevance: on the one hand, the effects induced on the
endometrium by either the systemic administration, or the local
delivery, of contraceptive progestogens and on the other hand,
the consequences that progestogens, when given alone, have in
determining menstrual bleeding patterns .
A proper evaluation of the effects that synthetic progestogens,
administered alone, have on the endometrium must take into account
several factors: first and foremost, the route of administration,
and specifically whether the steroid is delivered locally, or
systemically; second, the duration and timing of treatment; third,
the presence or absence of an endogenous oestrogen priming;
and fourth,the peculiar biochemical characteristics of each of
the different molecules utilized clinically.A good example of the
importance of timing has been provided recently by Xing et al.
(1983) who showed that progesterone, administered by vaginal
delivery at a rate of 1.4 mg/24 h, from cycle day 2 to day 6, does
not influence endometrial appearance on day 6, whereas, if it is
delivered from day 7 to day 11, the endometrial appearance on day
11 is significantly altered.It seems therefore that the endometrium
can only respond to progesterone when a sufficient number of
specific receptors have been induced by the oestrogen priming
(Baulieu et al., 1980).
Combination oral contraceptives demonstrate the effects of both
exogenous estrogen and progestin, with a dominant progestinonly effect “pill endometrium” depending on the length of use
of the combined oral contraceptive (COC). Progestins in the first
few cycles of use induce secretory differentiation, with coexistent
proliferative and secretory features. The progestin down-regulates
the estrogen receptor after several cycles and a “classic pill
endometrium” occurs, composed of quiescent, atrophic glandular
epithelium against a background of tortuous glands similar to
secretory phase. The use of progestin-only methods such as
injections or implants early on induces stromal cells with plump
pink cytoplasm and distinct cell borders, known as decidualization,
that are similar to changes seen in early pregnancy , but atrophy of
both glands and stroma occur with continued use.
The 19-nor steroids with progestational biologic activity used in
COC initially result in hyperinvoluted glands in an inert stroma.
There are no consistent histologic features that allow differentiation
between the endometrial and vascular effects of the various 19-nor
steroids . The 17-alphaacetoxyprogesterone derivatives, when used
alone, tend to produce similar but less prominent progestational
effects than those of the combined 19-nor steroids with ethinyl
estradiol estrogen.
Exogenous hormones used as contraceptives induce histologic
changes with effects on endometrial glandular and stromal
architecture, blood vessels and cytology that differ from those that
occur during the menstrual ovarian cycle . The common histologic
findings with prolonged use of combined oral contraception
are atrophy of both glands and stroma and spiral arteriole
underdevelopment. There are few morphologic differences between
effects of individual progestogenic agents. Injectable contraception
with depot medroxyprogesterone induces endometrial changes that
include atrophic glands in a background of predecidualized stroma.
Intrauterine devices releasing levonorgestrel induce atrophic
glands in a background of decidualized stroma and suppression
of spiral artery formation with thin-walled dilated vessels. The
prominence of such features depends on proximity of the affected
endometrium to the device. The IVR with levonorgestrel induces
variable secretory and suppressed histologic features that appear
to correspond with the hormone profile during treatment. A
common feature of all progestin-only contraceptives is the effects
on vasculature, in which underdevelopment of spiral arterioles
and dilated, thin-walled vessels may contribute to the irregular
bleeding common with such contraceptives.
The role of new progesterones in gynecology
ütreatment of menstrual bleeding problems
ütreatment of endometriosis
ütreatment of premenstrual syndrome
üin hormone replacement therapy
Vulvar cancer – Sentinel, radical lymphadenectomy and/or radiation
therapy
Peter Hillemanns, M.D.
Hannover, Germany
Vulvar cancer is a rare disease, however, associated with an
increase over the last two decades. Treatment of early-stage vulvar
cancer has undergone major modifications during the last 10 years.
These modifications aimed to reduce treatment-related morbidity
by restricting excision size and introduction of sentinel lymph
node technique, without compromising survival rates.
The multicenter observational study GROINSS-V investigated the
safety of omitting inguinofemoral lymphadenectomy in patients
with a negative sentinel node (Van der Zee et al, 2008). This study,
together with the German Multicenter AGO Study Group and the
GOG-173 have set sentinel node mapping in vulvar cancer as
the standard of care based on adequate detection rate and reduced
morbidity compared with inguinofemoral lymphadenectomy
(Hampl et al, 2008; Levenback et al, 2012). Patients with unifocal
squamous cell carcinomas smaller than 4 cm and no suspicious
groin nodes on palpation were eligible for the sentinel node
procedure.
GROINSS-V showed a groin recurrence rate after a negative
sentinel node of 2.3%. In GOG 178, the false-negative predictive
value was 2.0 % in women with tumors smaller than 4 cm. In our
German study, the false-negative rate was slightly higher with 5.3%.
Treatment-related morbidity was significantly lower in patients
who had undergone sentinel node biopsy only, with a reduction
in frequency of lymphedema of the legs. One of the prerequisites
of vulvar sentinel dissection is the preoperative SLN marking, the
lymphoscintigraphy (LSG) and its correlation with intraoperative
SLN detection. In our actual study we could show that single
photon emission computed tomography with CT (SPECT/CT)
for sentinel lymph node (SLN) detection in vulvar cancer leads to
higher SLN identification compared to LSG (Klapdor et al, 2015).
Currently, some controversies remain, such as the treatment of the
contralateral groin in case of unilateral metastatic sentinel node.
Another actual German study presented a retrospective analysis
of 33 patients with a unilateral metastatic sentinel node (Woelber
et al, 2016). No contralateral nonsentinel node metastases were
found. The other five patients underwent ipsilateral inguinofemoral
lymphadenectomy. No groin recurrences in the contralateral groin
were observed in these patients, but three of the five received
postoperative radiotherapy to the groins, which may have sterilized
microscopic disease. This supports the omission of inguinofemoral
lymphadenectomy in case of a metastatic unilateral sentinel node
and a negative sentinel node in the contralateral groin. Indocyanine
green (ICG) fluorescence is a new option for SLN detection (Fig 1).
Women with node-positive vulvar cancer have a high risk for
disease recurrence. Indication criteria for adjuvant radiotherapy
are controversial. In the German AGO-CaRE-1 study (Mahner,
2015), 447 of 1249 patients (35.8%) with primary squamous-cell
vulvar cancer treated at 29 gynecologic cancer centers had lymph
node metastases (Mahner et al, 2015).We observed that adjuvant
radiotherapy was associated with improved prognosis in nodepositive patients, however, for patients with only one positive
lymph node, this was not statistically significant. The outcome
after adjuvant radiotherapy remained poor compared with nodenegative patients. Adjuvant chemoradiation could be a possible
strategy to improve therapy because it is superior to radiotherapy
alone in other squamous cell carcinomas but at the expense of
significant side effects.
Fig. 1 Indocyanine green (ICG) fluorescence positive sentinel
inguinal lymph node.
Hampl M, Hantschmann P, Michels W, Hillemanns P (2008)
Validation of the accuracy of the sentinel lymph node procedure
in patients with vulvar cancer: results of a multicenter study in
Germany. Gynecol Oncol 111: 282-288
Klapdor R, Langer F, Gratz KF, Hillemanns P, Hertel H (2015)
SPECT/CT for SLN dissection in vulvar cancer: Improved SLN
detection and dissection by preoperative three-dimensional
anatomical localisation. Gynecol Oncol 138: 590-596
Levenback CF, Ali S, Coleman RL, Gold MA, Fowler JM, Judson
PL, Bell MC, De Geest K, Spirtos NM, Potkul RK, Leitao MM,
Jr., Bakkum-Gamez JN, Rossi EC, Lentz SS, Burke JJ, 2nd, Van
Le L, Trimble CL (2012) Lymphatic mapping and sentinel lymph
node biopsy in women with squamous cell carcinoma of the vulva:
a gynecologic oncology group study. J Clin Oncol 30: 3786-3791
Mahner S, Jueckstock J, Hilpert F, Neuser P, Harter P, de Gregorio
N, Hasenburg A, Sehouli J, Habermann A, Hillemanns P, Fuerst S,
Strauss HG, Baumann K, Thiel F, Mustea A, Meier W, du Bois A,
Griebel LF, Woelber L (2015) Adjuvant therapy in lymph nodepositive vulvar cancer: the AGO-CaRE-1 study. J Natl Cancer Inst
107
Van der Zee AG, Oonk MH, De Hullu JA, Ansink AC, Vergote
I, Verheijen RH, Maggioni A, Gaarenstroom KN, Baldwin PJ,
Van Dorst EB, Van der Velden J, Hermans RH, van der Putten H,
Drouin P, Schneider A, Sluiter WJ (2008) Sentinel node dissection
is safe in the treatment of early-stage vulvar cancer. J Clin Oncol
26: 884-889
Woelber L, Eulenburg C, Grimm D, Trillsch F, Bohlmann I,
Burandt E, Dieckmann J, Klutmann S, Schmalfeldt B, Mahner S,
Prieske K (2016) The Risk of Contralateral Non-sentinel Metastasis
in Patients with Primary Vulvar Cancer and Unilaterally Positive
Sentinel Node. Ann Surg Oncol
The current role of genetic sonography in the era of NIPD
Fehmi Yazıcıoğlu, M.D.
Even in the era of cell free DNA analysis in the maternal serum,
100% sensitivity for the diagnosis of trisomy 21 can be achieved
only by karyotyping. But invasive diagnostic procedures necessary
for fetal karyotyping have serious complications like fetal loss
in 1/100-1/1000 . This prevents us from employing invasive
technics as mass screen procedures. Beginning with maternal age
various methods including first and second trimester biochemical
screening, 11-13.6 week, 18-22 week (genetic sonogram) fetal
scan have been implemented to identify high risk cases in various
stages of pregnancy . The aim was to use invasive technics in a
high risk group to lower the fetal loss rate without compromising
overall sensitivity. cfDNA in the maternal serum, with an overall
sensitivity of >99% and a false positive rate of<0.01% is the most
efficient screening tool. But the relatively high cost of this method
prevents it from becoming the primary screening tool for trisomy
21. In many parts of the world new algorythms were developed
to identify a group with an intermediate risk (1/50-1/3000) and
recommend cfDNA to this limited group only. Thus an efficient
screening strategy with high sensitivity but much lower cost is
aimed. In almost all these models the primary screening tool is
either first trimester screening(FTS) or a combination of FTS with
second trimester biochemical tests.
Genetic sonogram(GS) is usually part of a detailled fetal
anatomical scan at 16-20 weeks and simply used to identify high
risk fetuses depending on ultrasonographic markers of trisomy 21.
Beginning with simple nuchal fold thickness , GS has evolved to
include many new markers from aberrant right subclavian artery
to prenasal thickness etc. A recent metaanalysis have found it to
be a very efficient method in modifiying the risk of trisomy 21. A
negative GS was calculated to have a negative likelihood ratio of
0.12 meaning to lower the pretest risk by factor 8.3. The addition
of GS to FTS and or quadruple test usually resulted in better
sensitivity reaching 98% at its best.
Despite many reports claiming higher efficiency if FTS is followed
by GS, none of the low cost models attempted to incorporate GS
into the risk modifying process .
By using extended GS as a second step after FTS to select women
for cfDNA testing one can at least theoretically:
1. Lower the overall screening costs by41%
2. Have higherDR for other significant karyotype abnormalities
and structural defects
3. Better risk estimation for bad obstetric prognosis
4. And still have high DR for Trisomy 21 (96.98%)
Genetic sonography;
•
•
•
Has probably no meaning in NIPT positive women
Strongly recommended in NIPT lab failures
Not recommended in NIPT negative cases, but almost all
NIPT false negatives were detected by a positive FTS or GS/
•
•
detailled anatomic scan
Historically has been used quite succesfully for risk
modification in high/intermediate risk groups
Still appears to be a reasoanable tool for selection of high risk
cases in a group of intermediate risk women
Update on non-invasive prenatal testing - a success Story
Wolfgang Holzgreve, M.D.
Medical Director and CEO, University Medical Center Bonn, Germany
Since every invasive procedure such as amniocentesis and CVS
is associated with a risk of up to 1% for loosing the pregnancy,
it is an old dream to have a risk-free procedure available for the
same indications. Originally from 20 years ago the efforts were
concentrated on identifying fetal cells such as lymphocytes,
trophoblast cells and especially nucleated erythrocytes in the
circulation of pregnant women, but this approach did not produce
results which were reliable enough for prenatal diagnosis. The
work with fetal cells in the maternal circulation, however, revealed
fascinating new insights into the importance of michrochimerism
of some women´s diseases as well as the etiology of preeclampsia.
When it was found by Dennis Lo et al. In 1997 that cell-free DNA
from the fetus is present in the blood of pregnant women it became
possible to identify the Rhesus factor non-invasively, to identify
the y-chromosome as an approach to X-linked diseases and to
diagnose autosomal dominant diseases if the mutation came from
the paternal side and compund heterozygotes in couples at risk for
autosomal recessive diseases such as beta thalassemia.
Recently the non-invasive diagnosis of aneuploidies was performed
in more than a hundred thousand pregnancies, and the accuracy
has been proven to be in the range of 99% for trisomy 21, and
very good also for trisomies 18 and 13. There are issues still to
be resolved regarding the patent situation and the performance,
but the most important requirement for offering this lonf desired
technology in clinicl practice is that it is embedded in the proper
councelling which clearly outlines the chances and restrictions,
the limitations but also the excellent performance in experienced
hands.
In the future it will be possible to diagnose the whole genome noninvasively, and this non-invasive diagnostic approach therefore
become a paradigma shift in prenatal diagnosis after 25 years of
sometimes frustrating but finally very successful research.
323 words
Learnig objectives
1. What are the approaches to identify fetal material in the
circulation of pregnant women?
2. Is the identification of the rhesus factor possible ?
3. What is the accuracy of the detection of fetal trismomy 21
from maternal blood?
References:
Holzgreve W, Hahn S, Zhong XY, LapaireO, Hösli I, Tercanli S,
Miny P: Genetic communication between fetus and mother: shortand long-term consequences. Am J Obstet Gynecol 2007; 196 (4):
372-81
Palomaki G, Deciu C, Kloza EM et al: DNA sequencing of
maternal plasma reliably identifies trisomy 18 and trisomy 13 as
well as Down syndrome. An International Collaborative Study.
Genet Med 2012; 14 (3): 296-305
The evidence based optimal Cesarean Section and the results of its
international application
Michael Stark, M.D.
New European Surgical Academy (NESA), Berlin, Germany
As most abdominal operations are gradually replaced by
endoscopic, robotic and natural orifice surgeries, Caesarean Section
will remain one of the only abdominal operations. Therefore it is
of utmost importance to constantly evaluate the different steps for
its necessity and for the optimal way of performance as tradition
should not be served as an excuse.
The modified Joel-Cohen method results in a shorter incision to
delivery time and lower rate of febrile morbidity when compared
to the traditional Pfannenstiel incision.
Opening peritoneum using bi-digital stretching rather than sharp
instruments proved to be safer. The uterus should be opened in the
lower segment, after pushing the bladder down in order to prevent
damage to the myometrium where more muscle tissues exist above
the bladder. Exteriorization of the uterus makes stitching easier
and avoids unnecessary bleeding. Suturing the uterus with one
layer only results in stronger scars and reduced pain, because the
more stitching material left behind, more foreign body reaction
might weaken the scar.
Leaving both peritoneum layers open reduces adhesions and results
in reduced need for painkillers and closure should be avoided in all
other surgical disciplines as well, including endoscopy.
The fascia being sutured continuously with first knot underneath
the fascia prevents irritation in the sub-cutis, and, by a righthanded surgeon, suturing from the right to the left, proved to be
ergonomic.
Since the introduction of this modified and simplified method,
it has been evaluated by scores of peer-reviewed publications
from different countries. Without exception, all showed various
advantages of this method: shorter operation time, shorter
hospitalization, quicker mobilization, less blood loss, lower rate
of febrile morbidity, lower costs, and shorter need for painkillers.
Only 10 instruments and three sutures are needed, which simplifies
the workload of nurses. In order to standardize this operation, it
is important to use constantly the same needles and instruments.
Big needle is necessary for the uterus, as fewer steps are done and
therefore less foreign body reaction. A special sutures kit has been
developed which enables standardization of this procedure.
This operation is recommended as a universal routine method for
Caesarean section and its principles should apply to all surgical
disciplines.
Thromboprophylaxis in obstetrics and gynecology
Yusuf Üstün, M.D.
Pulmonary embolism (PE) and deep vein thrombosis (DVT)
are the two components of a single disease called venous
thromboembolism (VTE). Pregnant women have an increased risk
(4–5 fold) of developing a VTE, in comparison to non-pregnant
women due to hypercoagulability, increased venous stasis,
decreased venous outflow and compression of the inferior vena
cava and pelvic veins by the enlarging uterus.
at prophylactic doses as early as four to six hours after vaginal
delivery and 6 to 12 hours after cesarean delivery unless there
was significant bleeding, although for most patients we wait 6 to
12 hours after vaginal delivery and 12 to 24 hours after cesarean.
Many anticoagulants (eg, heparins, warfarin) can be used during
breastfeeding because they do not accumulate in breast milk
A subset of pregnant patients requires anticoagulation during
pregnancy and/or in the postpartum period, including women at
high risk of deep vein thrombosis and women with prosthetic heart
valves, atrial fibrillation, cerebral venous sinus thrombosis, left
ventricular dysfunction, and some women with fetal loss.
Regardless of risk for VTE, minimize immobilization and
dehydration. Routine laboratory thrombophilia screening of
pregnant women is not recommended. If anticoagulation is
required peripartum a multidisciplinary team approach is essential.
Develop a plan for the peripartum management of anticoagulation
(prophylactic or therapeutic). Determine dose of prophylaxis
(standard, intermediate or therapeutic) based on the assessment of
an individual’s risk for VTE.
A LMW heparin is the preferred anticoagulant for most pregnant
women. This is largely because available evidence has shown
these agents to be effective and safe for the fetus. LMW heparins
do not cross the placenta and do not cause fetal anticoagulation.
A systematic review of studies of the use of LMW heparin for
prevention or treatment of VTE in pregnancy concluded that LMW
heparin was both safe and effective (64 studies, 2777 pregnancies).
Rates of venous and arterial thrombosis were 0.8 and 0.5 percent,
respectively, and rates of significant bleeding (2 percent), skin
reactions (1.8 percent), and osteoporotic fractures (0.04 percent)
were acceptably low.
Unfractionated heparin is an acceptable and less expensive
alternative to LMW heparin. It may be more appropriate than
LMW heparin during stages of the pregnancy when rapid temporal
control of anticoagulation is required (eg, near the time of delivery,
if surgery is required). Unfractionated heparin is also preferred over
LMW heparin in patients with severe renal insufficiency because
LMW heparin metabolism is exclusively renal, while metabolism
of unfractionated heparin is renal and hepatic. It does not cross
the placenta, and available evidence has not indicated any harmful
effects on the fetus.
Non-heparin anticoagulants are generally not used during pregnancy
unless there is a contraindication to heparins (eg, heparin-induced
thrombocytopenia) or an inability to use injections.
Anticoagulation is reinstituted following delivery in most patients
who were receiving an anticoagulant during pregnancy; additional
patients may initiate anticoagulation postpartum for VTE
prophylaxis. Unfractionated or LMW heparin can be resumed
The use of thromboprophylaxis for patients undergoing gynecologic
surgery
The most highly re garded guidelines regarding perioperative
thromboprophylaxis are published by the American College
of Chest Physicians (ACCP). Based on the ACCP guidelines,
surgical patients are classified into risk categories. Use of
thromboprophylaxis is then guided by the risk category.
Issues in gynecologic surgery patients that may increase the
risk of thromboembolism include pregnancy, use of hormonal
contraceptives or postmenopausal hormone therapy, and
gynecologic malignancy. These factors are included in the risk
classification.
The ACCP guidelines differ somewhat from the guidelines
from the American College of Obstetricians and Gynecologists
(ACOG). Both guidelines define a minor procedure as lasting
less than 30 minutes, however, the ACCP differentiates between
open and laparoscopic surgery, effectively classifying all entirely
laparoscopic procedures as minor (regardless of duration or
complexity). The ACOG guidelines divide patients into risk
categories according to duration of surgery, age cut-offs (<40 years,
40 to 60 years, and >60 years), and individual VTE risk factors that
are either not evidence-based or are based on data which are 25
or more years old. Regarding laparoscopic surgery, some of the
considerations are that abdominal wall tissue trauma is decreased
with a laparoscopic approach, but activation of the coagulation
system is similar to laparotomy. In addition, laparoscopic
procedures may be as long or longer than open surgeries, and the
use of pneumoperitoneum and reverse Trendelenburg contribute
to venous stasis and, possibly, thrombosis. However, patients
regain mobility more rapidly after laparoscopy compared with
laparotomy.
There are no high-quality studies which have addressed the
question of thromboprophylaxis for gynecologic laparoscopy. In a
retrospective study of over 10,000 women after hysterectomy, the
rate of women who received thromboprophylaxis varied somewhat
for those undergoing a laparoscopic, abdominal, or vaginal
procedure (22, 38, or 47 percent, respectively); the incidence of
VTE for the three procedures did not differ significantly (0.3, 0.2
or 0.2 percent). Malignancy was not significantly associated with
an increased risk of VTE, but this was likely because there were
only six VTE events.
REFERENCES
Queensland Clinical Guideline: VTE prophylaxis in pregnancy
and the puerperium. October 2014.
Greer IA, Nelson-Piercy C. Low-molecular-weight heparins for
thromboprophylaxis and treatment of venous thromboembolism in
pregnancy: a systematic review of safety and efficacy. Blood 2005;
106:401.
Reducing the risk of venous thromboembolism during pregnancy
and the puerperium. RCOG, April 2015.
Howie PW. Anticoagulants in pregnancy. Clin Obstet Gynaecol
1986; 13:349.
Rutherford SE, Phelan JP. Thromboembolic disease in pregnancy.
Clin Perinatol 1986; 13:719.
Ginsberg JS, Kowalchuk G, Hirsh J, et al. Heparin therapy during
pregnancy. Risks to the fetus and mother. Arch Intern Med 1989;
149:2233
Guyatt GH, Akl EA, Crowther M, et al. Executive summary:
Antithrombotic Therapy and Prevention of Thrombosis, 9th ed:
American College of Chest Physicians Evidence-Based Clinical
Practice Guidelines. Chest 2012; 141:7S.
Bates SM, Greer IA, Middeldorp S, et al. VTE, thrombophilia,
antithrombotic therapy, and pregnancy: Antithrombotic Therapy
and Prevention of Thrombosis, 9th ed: American College of Chest
Physicians Evidence-Based Clinical Practice Guidelines. Chest
2012; 141:e691S.
Elsaigh E, Thachil J, Nash MJ, et al. The use of fondaparinux in
pregnancy. Br J Haematol 2015; 168:762.
Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in
nonorthopedic surgical patients: Antithrombotic Therapy and
Prevention of Thrombosis, 9th ed: American College of Chest
Physicians Evidence-Based Clinical Practice Guidelines. Chest
2012; 141:e227S.
Clarke-Pearson DL, Abaid LN. Prevention of venous
thromboembolic events after gynecologic surgery. Obstet Gynecol
2012; 119:155.
Committee on Practice Bulletins--Gynecology, American College
of Obstetricians and Gynecologists. ACOG Practice Bulletin No.
84: Prevention of deep vein thrombosis and pulmonary embolism.
Obstet Gynecol 2007; 110:429.
Mäkinen J, Johansson J, Tomás C, et al. Morbidity of 10 110
hysterectomies by type of approach. Hum Reprod 2001; 16:1473.
Menopause: current trends
Fatih Durmuşoğlu, M.D.
ü
Both physicians and the lay public do not address
postmenopausal hormone therapy as an ordinary medication.
ü
The benefits of hormone therapy are very subjective
(vasomotor symptoms) or preventive in nature (fractures)
ü
The potential risks involve serious, frightening diseases
(breast cancer, stroke)
ü
Perception-wise, in the post-WHI era, risks are overvalued and generalized to the whole postmenopausal population
and to all forms of hormone therapy
ü
Vast amounts of information exist. People tend to
be selective and pick pieces of it according to their beliefs and
personal experience; thus an overall perspective may be missing.
Key points in taking a medical history and examination
ü
Symptoms and their impact on quality of life, menstrual
history including age and type of menopause (natural or iatrogenic)
and contraception .
ü
Family or personal history should include that of breast,
ovarian, endometrial and colon cancer; venous thromboembolism,
migraine, and risk factors for osteoporosis, diabetes, hypertension,
heart disease and stroke
Diagnosis of menopausal status
ü
In women over 45 years irregular or absent menstruation
especially in the presence of vasomotor symptoms is diagnostic of
the menopause and in the vast majority of women no investigations
are required
ü
In younger women with suspected premature ovarian
failure or early menopause serial follicle-stimulating hormone
(FSH) measurements should be undertaken.
ü
In menstruating women, measurement of FSH should
be performed at the beginning of the follicular phase (days 2–5
of the cycle) to avoid ovulation- induced elevations of FSH.
Measurement of thyroid stimulating hormone (TSH) and prolactin
are also helpful in investigating menstrual irregularity.
Screening for diseases in later life and forecasting menopause
ü
Women should be encouraged to participate in national
screening programmes for cervical, breast and colon cancer.
ü
Risk of osteoporosis; FRAX can be used for people aged
between 40 and 90 years, either with or without measuring bone
mineral density.
ü
Assessment of cardiovascular risk and 10-year risk of a
myocardial infarction could be also advisable,
ü
To forecast the age of menopause with AMH measurements
is controversial and should only be undertaken in at risk women
ü
In general pelvic assessment (examination and ultrasound)
in asymptomatic women should be restricted to those at high risk
of endometrial or ovarian cancer
Management of hot flushes with and without estrogen
ü
The most effective treatment for menopausal vasomotor
symptoms is menopausal hormone therapy (MHT) with systemic
estrogen
ü
The two main routes of administration are oral and
transdermal (patches and gels)
ü
Most progestogens are given orally, norethisterone and
levonorgestrel are available in transdermal patches combined
with estradiol
ü
Levonorgestrel can be delivered directly to the uterus
with an intrauterine device
ü
Approved by the US Food and Drug administration in
2013 and the European Union in 2014 a new development is the
use of the selective estrogen modulator bazedoxifene instead of a
progestogen combined with conjugated estrogen
Symptom control;
ü
Symptom control is used to determine the minimum
required dose for each woman
ü
In women with POF, systemic estrogen-based MHT
is recommended at least until the average age of the natural
menopause, unless it is contraindicated
Genitourinary syndrome of menopause(GSM)
ü
GSM is defined as a collection of symptoms and signs
associated with a decrease in estrogen and other sex steroids
involving changes to the labia majora/minora, clitoris, vestibule/
introitus, vagina, urethra and bladder.
ü
There is no need to add a progestogen for endometrial
protection when topical estrogens are used in the recommended
doses. Breast cancer ???
ü
Approved in both the US and Europe the orally
administered selective estrogen receptor modulator ospemifene is
a new treatment option for women - The most common side effects
are hot flushes Conserving the skeleton and musculoskeletal health
ü
Both randomised (WHI) and observational studies show
that MHTreduce the risk of osteoporotic fracture but estrogendeficient bone loss will resume on stopping therapy.
ü
Estrogen-based therapy is the treatment of choice for
women under the age of 60 or within 10 years of menopause .
Global Consensus Statement on Menopausal Hormone Therapy
l
MHT is the most effective treatment for vasomotor
symptoms associated with menopause at any age, but benefits are
more likely to outweigh risks for symptomatic women before the
age of 60 years or within 10 years after menopause
l
Randomized clinical trials and observational data
as wellas meta-analyses provide evidence that standard-dose
estrogen-alone MHT may decrease coronary heart disease and allcause mortality in women younger than 60 years of age and within
10 years of menopause.
l
Data on estrogen plus progestogen MHT in this population
show a similar trend for mortality but in most randomized clinical
trials no significant increase or decrease in coronary heart disease
has been found.
l
Local low-dose estrogen therapy is preferred for women
whose symptoms are limited to vaginal dryness or associated
discomfort with intercourse.
l
Estrogen as a single systemic agent is appropriate in
women after hysterectomy but additional progestogen is required
in the presence of a uterus.
l
The option of MHT is an individual decision in terms
of quality of life and health priorities as well as personal risk
factors such as age, time since menopause and the risk of venous
thromboembolism, stroke, ischemic heart disease and breast
cancer.
l
The risk of venous thromboembolism and ischemic stroke
increases with oral MHT but the absolute risk is rare below age 60
years. Observational studies point to a lower risk with transdermal
therapy.
l
The risk of breast cancer in women over 50 years
associated with MHT is a complex issue.
l
The increased risk of breast cancer is primarily associated
with the addition of a progestogen to estrogen therapy and related
to the duration of use.
l
The risk of breast cancer attributable to MHT is small and
the risk decreases after treatment is stopped.
l
The dose and duration of MHT should be consistent with
treatment goals and safety issues and should be individualized.
l
In women with premature ovarian insuffi ciency, systemic
MHT is recommended at least until the average age of the natural
menopause.
l
The use of custom-compounded bioidentical hormone
therapy is not recommended.
l
Current safety data do not support the use of MHT in
breast cancer survivors.
Prolapse-hysterectomy and cystocele repair - anatomical landmarks
and surgical technique
Ralf Tunn, M.D.
Berlin
Vaginal vault suspension during hysterectomy for prolapse is both
a therapy for apical insufficiency and helps prevent recurrence.
Numerous techniques exist, with different anatomical results
and differing complications. The description of the different
approaches together with a description of the vaginal vault
suspension technique used at the Department for Urogynaecology
at St. Hedwig Hospital Berlin, Germany could serve as a basis for
reassessment and for recommendations by scientific associations
regarding general standards.
The key anatomical structures in vaginal vault suspension
procedures are the uterosacral ligaments, the rotund ligaments and
the retro-vesical and pre-rectal peritoneum. High peritonisation is
done to reduce the pressure gradient between the abdomen and the
vaginal apex.
The suspension technique described here was first developed at the
Gynaecological Department of the Charité, Humboldt University
of Berlin. Developed byWalter Stoeckel, continued by Helmut
Kraatz and Wolfgang Fischer and adapted to take advantage of the
most recent suture materials, this technique was implemented in
general clinical practice at the Department for Urogynaecology
of St. Hedwig Hospital in 2009. The modificationswere done
primarily with the aim of leaving less suture material in situ,
causing less injury to tissue and to create a suspension which more
closely resembles the female physiology. The basic principles of
the original technique were retained. The needle is initially left
in place at the end of the ligature of the uterosacral ligaments
and adnexa with the rotund ligaments. To carry out vaginal vault
suspension using a vaginal approach, the herniated bowel is
repositioned out of the rectouterine pouch. The bladder peritoneum
is mobilised and taken approximately 2 cm above the level of the
incision site, the pre-rectal peritoneum is mobilised and taken at
the start of the pre-rectal adipose tissue, the rotund ligaments and
the uterosacral ligaments are included separately. The peritoneum
is closed using purse-string
sutures as defined by high peritonisation with including the
mentioned structures; the peritoneum at the pelvic wall is only
included vapidly to prevent ligature of the ureters. The cul-de sac
pouch is obliterated through adaptation of the bladder peritoneum
and rectal peritoneum. Excess peritoneum is adapted to the
anterior endopelvic fascia to stabilise the anterior vaginal apex.
The vaginal corners are taken at the level of the paracolpium and
the previously shortened rotund and uterosacral ligaments are
sutured to the vaginal corners using the sutures mentioned above.
This repositions the base of the vagina up to the level of the middle
third of the vagina. It also acts as a tamponade for vascular stumps
and parametria, preventing secondary bleeding and extensive
haematoma formation. The authors are of the opinion that high
peritonisation using purse-string sutures including all mentioned
structures and suturing of the uterosacral and rotund ligaments to
the base of the vagina results in the even distribution of abdominal
pressure and symmetrical suspension of the vaginal vault. This
procedure provides both therapy and prevention. (Geburtsh
Frauenheilk 2012; 72:1099–1106).
Following technique is recommended for cystocele repair:
During vaginal hysterectomy the pubocervical fascia is separated
off the anterior cervical wall. It is neccessary to reestablish the
apical fixation. Therefore pubocervical fascia is connected to the
suture closing the peritoneum and, ideally, attached to the apical
edge of puborectal fascia.
Successfull reunification of those structures is reducing the risc
of recurrence of cystocele in the proximal part of anterior vaginal
wall (Ap, POP-Q).
After identifying the bladder pillars (as bilateral proximal
structures containing blood vessels) it is crucial to readaptate them
anatomical correctly. The hereby provided support already leads
to reponation of cystocele. This step is followed by transverse
single stitch suture of the visceral part of the fascia in a flat angle
bilaterally to the centre line.
This is performed up to the level of bladder neck. If each stitch
reaches the ATFP as lateral boarder and includes little of parietal
part of the subvesical fascia (as the structure containing blood
vessels) a subtle bleeding prevention is achieved.
Transition zone of fascia into the urogenital diaphragm is marking
the bladder neck region. In order to prevent Trigonocele the final
suture is set at this point.
Excessive and thinned vaginal wall is resected until exposure of
both layers of the vaginal wall (lamina muscularis vaginae and
vaginal epithelium). It is crucial to include both layers into the
suture which finally is closing the colpotomy.
3D high definition vision systems in gyn laparoscopy
Taner Usta, M.D.
Bagcilar Training and Research Hospital, Istanbul, Turkey
Fast technological innovation and patient demand for minimally
invasive surgery both pose pressure on surgeons for learning new
minimally invasive techniques including advanced laparoscopy
and robotic surgery. All of these developments allow safer
surgeries and aim to provide comfort for both patients and
surgeons. However, obtaining laparoscopic surgery skills takes
more time than open surgery considering the learning curves.
The most important limitation of conventional laparoscopy is
the lack of a sense of depth because of a 2-dimensional (2D) flat
view of the surgical field [1]. Laparoscopists are forced to rely
on monocular information to get the 3-dimensional (3D) sense of
open surgery. Vision defect associated with lack of depth in 2D
laparoscopic vision systems (LVSs) led the way of developing
3D LVSs. Providing the third dimension is considered important
for the further development of minimally invasive surgery [2].
Although a laparoscopic 3D display was reported to be useful over
three decades ago, 3D systems have not been used widely [3,4].
The aim of this presentation is to describe the potential advantages
and disadvantages of 3D high-definition laparoscopic surgery
for gynaecology. Although there are controversial publications
on the first-generation 3D high-definition laparoscopic surgery,
it is reported that, thanks to the technological advancements,
learning curve and operation time have been reduced with new
generation systems and that there are less error margins. With the
new-generation 3D high-definition LVSs, both inexperienced and
experienced surgeons reduce their time of operation. With newgeneration 3D LVSs, nausea, dizziness or eye fatigue reported
with the old-generation 3D LVSs are not observed or are rarely
observed. 3D high-definition LVSs can be considered as a good
interim solution between the 2D system and the robotic system
because it does not have any consumables, it is reusable, it
provides good image quality, it does not occupy large spaces in the
operation rooms and it is affordable.
FIGURE 1. The surgical team perform 3D laparoscopic surgery,
wearing polarized glasses.
References
1. Usta TA, Karacan T, Naki MM, et al. Comparison of
3-dimensional versus 2-dimensional laparoscopic vision system
in total laparoscopic hysterectomy: a retrospective study. Arch
Gynecol Obstet 2014; 290:705–709.
2. Wilhelm D, Reiser S, Kohn N, et al. Comparative evaluation
of HD 2D/3D && laparoscopic monitors and benchmarking to
a theoretically ideal 3D pseudo display: even well experienced
laparoscopists perform better with 3D. Surg Endosc 2014;
28:2387–2397.
3. Usta TA, Ozkaynak A, Kovalak E, et al. An
assessmentofthenewgeneration && three-dimensional high
definition laparoscopic vision system on surgical skills: a
randomized prospective study. Surg Endosc 2014.
4. Kyriazis I, Ozsoy M, Kallidonis P, et al. Integrating threedimensional vision in laparoscopy: the learning curve of an expert.
J Endourol 2014.
Treatment of pelvic floor / sphincter ani muscle disorders after
vaginal delivery
Ralf Tunn, M.D.
Berlin
First choice therapy of pelvic floor disorder following vaginal
delivery is behaviourial therapy consisting of awareness and reeducation of muscle, as well as electrical stimulation of the pelvic
floor muscle.
An avulsion of the puborectalis muscle – which is an detachment
of the muscle from the pubic bone - cannot be reconstructed
successfully via surgery.
The repair of third- and fourth-degree tears should be conducted by
an appropriately trained clinician or by a trainee under supervision
and has to be divided into a primary repair immediately after
delivery and a secondary repair months or years later.
The primary repair should take place in an operating theatre under
regional or general anaesthesia.
The torn anorectal mucosa should be repaired edge to edge with
atraumatic sutures preferably denier 3-0.
torn internal anal sphincter (IAS) can be identified it is advisable
to repair this separately with interrupted favoured atraumatic 3-0
sutures.
pair of a full thickness external anal sphincter (EAS) tear either an
overlapping or an end-to-end method can be used with equivalent
outcomes.
For partial thickness (all 3a and some 3b) tears an end-to-end
technique should be used.
Important issues concerning the perioperative management:
broad-spectrum antibiotics (e.g. 2nd generation cephalosporin)
is recommended following repair of OASIS to reduce the risk of
postoperative infections and wound dehiscence. Furthermore use
of postoperative laxatives is recommended for pain relief.
Women should be advised that physiotherapy following repair of
obstetric anal sphincter injuries (OASIS) could be beneficial. We
recommend a combination with electrical stimulation.
Women who experienced obstetric anal sphincter repair should
be reviewed 6–12 weeks postpartum. Wherever possible, review
should be conducted by clinicians with a special interest in OASIS.
If a woman is experiencing incontinence or pain at follow-up,
referral to a specialist, gynaecologist or colorectal surgeon should
be considered.
Regarding subsequent deliveries no definite recommendation can
be given up to date. Women should be counselled in respect to
symptoms of fecal incontinence and also the estimated birth weight
should be taken into account.
In the process of informed consent building available studies
with partially contradicting conclusions should be discussed
and Caesarian section as an option can be offered. In general a
restrictive use of (mediolateral) episiotomy is endorsed.
To cut or not to cut - the damage done by Episiotomy
Michael Stark, M.D.
New European Surgical Academy (NESA), Berlin, Germany
Although the human body is designed in a way which enables
natural child birth without any intervention, many obstetricians
are using episiotomies in a great percentage and sometimes even
routinely with the misguided rationale that doing so prevents
extended tears and will enhance delivery of a healthy baby.
These assumptions were found in many studies to be absolutely
incorrect. The episiotomy has proven not to prevent extended
tears; on the contrary, it has been shown that 3rd and 4th degree
lacerations are more frequent when episiotomies are being done.
At the same time, episiotomy is the cause for unnecessary pain
and bleeding which prevents the mother from looking after her
newborn.
In many countries, deliveries done by obstetricians result in a
much a higher rate of episiotomies as with midwives and private
obstetricians are doing many unnecessary episiotomies. In one
study it was shown that women attending private physicians had a
7-fold increased risk having an episiotomy!
Suturing episiotomy, when necessary (episiorraphy), is performed
traditionally in 3 layers, there is no unique, evidence-based way
to do it. Some are using single stitches and some continuous.
In order to optimize and simplify episiorraphy, a randomized
prospective study was done, showing that a 2 layer episiorraphy,
namely suturing the deep layers and the skin only continuously,
leaving the vaginal wall unsutured, resulted in a lower rate of
hemotomatas, less pain and better anatomical healing.
We highly recommend to deliver women with protection of the
perineum, avoiding episiotomy but in case episiotomy is necessary,
to use the 2 layer method with continuous suturing.
Conservative and surgical treatment of overactive bladder
Ralf Tunn, M.D.
Berlin
Overactive bladder is a prevalent and often distressing condition
that has a significant negative effect on the quality of life of those
affected. It contributes to the huge burden of incontinence on NHS
resources. Effective treatment is available; however, most patients
will never admit their problems, seek advice or be identified.
Pelvic floor exercises are more effective in subjective and objective
outcomes with biofeedback or verbal feedback. Transvaginal
electrical stimulation demonstrates subjective improvement in
overactive bladder symptoms and urodynamic parameters.
Weight loss with diet and exercise, caffeine reduction, 25-50%
reduction in fluid intake, and pelvic floor muscle exercises with
verbal instruction and or biofeedback were all efficacious.
Antimuscarinics and β3-adrenoceptor agonists are the two major
classes of oral pharmacotherapy and have similar efficacy for
treating the symptoms of OAB especially in elderly women.
Trospium, oxybutynin, fesoterodine, and darifenacin all have
unique properties that may confer certain advantages in the elderly
population. The hydrophilicity and quaternary amine structure of
trospium may limit its ability to cross the blood-brain barrier and
thus minimize impact on cognition in the elderly. In its oral form,
oxybutynin may have the most significant effect on cognition;
however, the transdermal preparations may be favorable in the
elderly population due to the ability to avoid first-pass metabolism
and its limited antimuscarinic adverse effects. Fesoterodine may
be the most extensively studied OAB medication in the elderly
population. Darifenacin has a strong affinity for the M3 receptor
in the bladder, while having a weak affinity for the M1 receptor
commonly found in the brain (Drugs aging 2015 Oct;32:809-19).
Mirabegron relaxes the detrusor muscle directly via a beta3
adrenoceptor agonist. Mirabegron improves daily incontinence
episodes, nocturia, number of daily voids, and urine volume per
void.
Improvement in persistence and compliance with OAB
pharmacotherapy is a hot topic in OAB treatment and should be an
important goal in the treatment of OAB.
Botulinum toxin A improves urge incontinence episodes, urgency,
frequency, quality of life, nocturia, and urodynamic testing
parameters.
Acupuncture improves quality of life and urodynamic testing
parameters.
Extracorporeal magnetic stimulation improves urodynamic
parameters.
Short-term posterior tibial nerve stimulation is more efficacious
than pelvic floor muscle training exercises and behavioral therapy
for improving: urgency, urinary incontinence episodes, daily voids,
volume per void, and overall quality of life.
Sacral neuromodulation is more efficacious than antimuscarinic
treatment for subjective improvement of overactive bladder
and quality of life (Am J Obstet Gynecol 2016, Epub ahead of
print).
Multiple therapies, including physical therapy, behavioral therapy,
transvaginal electrical stimulation, botulinum toxin A, acupuncture,
magnetic stimulation, antimuscarinic treatment, mirabegron,
posterior tibial nerve stimulation, sacral neuromodulation are
efficacious in the treatment of overactive bladder.
Achievement of fertility in Klinefelter syndrome
Kutay Biberoğlu, M.D.
Reproductive Endocrinology and Infertility Unit, Ankara Private IVF Center, Ankara
Klinefelter syndrome (KS) is one of the most common forms
of chromosomal aneuoploidy in humans and and its reported
incidence is 0.1-0.2% in the general population. The frequency of
KS has been reported to increase up to 0.7% of oligozoospermic
and 11% of azoospermic men. Approximately 85% of the patients
with KS have 47,XXY karyotype and the remaining has XXY/
XY mosaic pattern. The recent progress in Assisted Reproduction
Technologies (ART) and the introduction of intracytoplasmic
sperm injection (ICSI) with ejaculated or testicular spermatozoa
has provided the opportunity to become biological fathers of these
hopeless men. As there is no reliable predictor for sperm recovery
(SR) and there is a lack of adequate consensus on the management
of these patients, further studies and contributions are still needed
to find better treatment options.
In our case series of 83 men with KS underwent 88 TESE cycles at
the Ankara Private IVF Center, Ankara, Turkey. Only 6 of them had
mosaic Klinefelter syndrome. The physical examination revealed
atrophic testes by palpation in all. Of the patients, 8 (9%) preferred
to have an initial diagnostic TESE procedure and the remaining 75
underwent simultaneous fresh TESE-ICSI cycles. Conventionaland micro-TESE procedures were performed in 48 and 40 of the
cycles, respectively. Unilateral and bilateral TESE were performed
in 20, and in 63 men, respectively.
Spermatozoa were recovered with a rate of 39.8 %/TESE of 88
TESE procedures and a rate of 42.1%/patient in 83 men with KS.
None of the clinical parameters including age, serum FSH levels,
mosaicism, TESE technique, number of testicular fragments
analysed and previous biopsy report were predictive of successful
testicular SR. A younger age, lower FSH level and shorter infertility
duration were detected in men with positive spermatozoa, but all
were statistically non-significant. The SR rates were similar in
conventional (45.8%) and micro-TESE groups (32.5%). When
only 68 bilateral TESE procedures were considered, SR rates were
34.2% with conventional and 16.6% with micro-TESE techniques
and the difference was also not significant. Furthermore, the
number of testicular samples required were statistically less in
conventional as opposed to micro-TESE techniques (12.5+3.6 vs
14.6+3.7, p 0.023). Among 23 men with previous sperm positive
and negative testicular biopsy or TESE reports, spermatozoa
were recovered in 30% and 38.4%, respectively, in their current
TESE procedures. Of these, 5 cases underwent a second repeat
TESE after a first spermatozoa positive TESE in our center, and no
spermatozoa were found in four of them.
Cryopreservation of spermatozoa was utilized in 15 out of 35
sperm recovered patients (%42.8); 3 after diagnostic and 12 after
fresh TESE-ICSI procedures. One out of 3 patients who underwent
a diagnostic TESE with recovered spermatozoa did not apply for
an IVF cycle and 44 OPU cycles were carried out in the remaining
34 sperm recovered couples, 32 of which ended up with fresh
sperm injection cycles and the other 12 with cryo-preserved /
thawed testicular spermatozoa / ICSI cycles.
A total of 41 embryo transfer cycles (30 with fresh, 10 with
cryopreserved / thawed spermatozoa ICSI embryos and 1
cryopreserved / thawed embryo cycle) were carried out and 23
pregnancies were achieved (57%) including 22 clinical, (14
singletons, 5 twins, 2 triplets and 1 quadruplet), and 1 biochemical.
The clinical pregnancy rate per embryo transfer was 53.6%
(22/41). The multiple pregnancy rate was 36.4 %, with a twin
rate of 22.7 %, triplet 9.1 % and quadruplet of 4.6 %. Thorough
genetic evaluation revealed AZFa deletion, AZFa,c deletion,
and Kartagener syndrome, respectively in 3 men with KS. No
spermatozoa was found in two cases with AZF deletions. The man
with Kartagener syndrome fathered a healthy boy following the
TESE/ICSI cycle. Although preimplantation genetic diagnosis
(PGD) was offered, all declined except one (pregnancy was not
achieved following the transfer of 1 with normal genetic testing,
out of 6 embryos), due to the financial burden and/or denial of the
idea of selecting embryos according to their chromosomes, due to
ethical and religious reasons.
We found no association between male age, FSH serum levels
and SR rate in our patient population. a total of 23 patients with
a previous biopsy or TESE result had a TESE procedure and
spermatozoa were available in 3 of 10 patients with a prior positive
result and 5 of 13 patients with a previous negative result (30% vs.
38.4%), without any difference. Interestingly, in 4 out of 5 cases
with a first positive TESE result in our center, we were unable to
find spermatozoa in the consequent TESE. This indicates that not
only the existence of spermatozoa in a previous biopsy or TESE but
also many other factors including the amount of the spermatozoa
found, the extensiveness of the surgery and the number of pieces
taken in the first TESE may affect the success of the second TESE
procedure. Despite the previous reports suggesting the superiority
of micro-TESE, in our hands conventional technique was not
inferior to micro-TESE in relation to sperm recovery (45.5% vs.
32.5%) in our study. Furthermore, the number of testicular tissue
samples were significantly less with conventional technique than
with micro-TESE (12.5±3.6 versus 14.6±3.7, p 0.023).
In the present study, the clinical pregnancy/ ET rate of 53.6%,
including a fertilization rate of 51.6% [(the total fertilization
failure rate of 7% (3/43 ICSI cycles)] were comparable with the
results in the medical literature. Comparable fertilization rates of
52.7% with fresh and 48.3% with cryopreserved-thawed testicular
spermatozoa were observed in the present study.
In conclusion, ART performance using testicular spermatozoa
obtained from azoospermic men with KS is quite successful and
comparable to that of the patients with nonobstructive azoospermia
due to other causes. Both conventional and micro-TESE for SR
are successful in these patients and there is no predictive value of
any clinical or laboratory marker for sperm retrieval, except TESE
itself. As simultaneous TESE-ICSI cycles expose couples to an
emotional and financial burden, and since similar pregnancy rates
are reported with cryopreserved-thawed testicular spermatozoa
compared to fresh samples, a diagnostic TESE may be the first
choice until better predictors are available.
Which müllerian anomly to treat and how ?
Yılmaz Şahin, M.D.
Erciyes University, School of Medicine, Dep. of Obstetrics and Gynecology, Kayseri
Anomalies caused by total or partial agenesis of one or both
Müllerian ducts: Total: Rokitansky syndrome, Partial: Unicornuate
uterus.
Anomalies caused by the total or partial absence of fusion: Total:
Didelphys uterus, Partial: Bicornuate (bicollis and unicollis) uterus.
Anomalies caused by total or partial lack of reabsorption of the
septum between the Müllerian ducts: Total: Septate, Partial: Subseptate uterus.
Anomalies caused by a lack of later development: Hypoplastic
uterus, T-shaped uterus.
Segmentary defects and combinations.
Reproductive outcomes
Congenital uterine anomalies have been associated with an
increased incidence of infertility, recurrent abortion, IUGR,
fetal malposition (breech or transverse), premature rupture of
membranes, abruptio placentae, hemorrhage, operative delivery,
preterm labor, fetal death and retained placenta.
Prevalence
The prevalence of uterine malformations diagnosed by optimal
tests was 5.5% in general unselected population, 8% in unexplained
infertile women, 13.3% in those with recurrent miscarriage, and
even 24.5% in those with miscarriage and infertility1. Prevalence
of different types: Arcuate: 18%, Septate: 34.9%, Bicornuate:
26%, Unicornuate: 9.6%, Didelphys: 8.2%, Agenesis: 2.9%.
Diagnostic methods
The diagnostic potential of gynecological examination, HSG,
two-dimensional ultrasound (2D US), hysterosalpingo- contrastsonography (HyCoSy), three-dimensional (3D) US, magnetic
resonance imaging (MRI), hysteroscopy (HSC) and, finally,
endoscopic evaluation including both laparoscopy (LSC) and
HSC to provide objective and measurable information for the
anatomical status of the vagina, cervix, uterine cavity, uterine
wall, external contour of the uterus and other peritoneal structures
is critically evaluated. 3D USG may be more accurate than MRI.
2D US or 3D US: The shape and the dimensions of the uterine
cavity, the uterine wall and external uterine contour should be
recorded at the longitudinal and transverse planes. In order to
assess the configuration of the uterine cavity, it is important to
perform the study during the secretory phase (day 21 to 25) of
the menstrual cycle when the endometrium is thicker and most
echogenic, and the uterine cavity can be clearly differentiated from
the surrounding myometrium . In patients with female genital
anomalies, investigation of the urinary tract is also recommended
as mandatory.
The ESHRE/ESGE classification system
The ESHRE/ESGE classification system of female genital tract
congenital anomalies is presented in Fig 12.
Figure 1. ESHRE/ESGE classification of uterine anomalies:
schematic representation (Class U2: internal indentation >50%
of the uterine wall thickness and external contour straight or with
indentation <50%, Class U3: external indentation >50% of the
uterine wall thickness, Class U3b: width of the fundal indentation
at the midline >150% of the uterine wall thickness).
Treatment
Septate uterus: Hysteroscopic metroplasty: During the early
proliferation phase after accessing the endometrial cavity or
cavities and visualizing each tubal ostium, septum is cut starting
from proximal part, equidistant between anterior and posterior
uterine walls until the optimal uterine cavity shape.
Unicornuate uterus: Removal of uterine horns is indicated in the
event that they contain functional endometrium.
Bicornuate and didelphic uteri: Metroplasty for bicornuate and
didelphic uteri remains controversial, although may be indicated
for patients with repeatedly poor outcomes.
T-shaped uteri: Incisions are made on the uterine walls to expand
dysmorphic uteri3.
Term delivery rates in patients with untreated uterine malformations
are only 50%. After hysteroscopic septum resection live birth rate
is 85%4.
References
1. Paradisi R, Barzanti R, Fabbri R.
The techniques and outcomes of hysteroscopic metroplasty.
Curr Opin Obstet Gynecol. 2014;26:295-301
2. Grimbizis GF, Gordts S, Sardo AZ, et all. The ESHRE/
ESGE consensus on the classification of female genital tract
congenital anomalies. Hum Reprod 2013: 28:2032-44.
3. Sardo ADS, Florio P, Nazzaro G, Spinelli M, et all.
Hysteroscopic outpatient metroplasty to expand dysmorphic
uteri (HOME-DU technique): a pilot study. RBM Online
2015: 30: 166–74
4. Grimbizis GF1, Camus M, Tarlatzis BC, Bontis JN, Devroey
P. Clinical implications of uterine malformations and
hysteroscopic treatment results. Hum Reprod Update. 2001:
2:161-74.
Diagnosis and operative strategies of abnormally invasive
placentation (AIP)
Wolfgang Henrich, M.D.
Department of Obstetrics
Charité, Campus Virchow Klinikum, Campus Mitte, Berlin
Placental implantation disorders result in abnormal adherence of
the placental villi to the maternal myometrium. This is the result of
a partial or complete lack of the maternal decidua which leads to
direct contact between the chorion frondosum and the myometrium.
Depending on the extension and invasion depth of the placenta, a
differentiation is made between placenta accreta (invasion to the
internal myometrium wall), placenta increta (invasion into the
myometrium), and placenta percreta (invasion to the uterine serosa
or beyond the uterus).
Predisposing factors include previous cesarean section, curettage,
submucosal myoma, or myoma nucleation, endometritis, and
placental separation disorders in the patient history. Implantation
disorders and thus postpartal placental separation occur in approx.
1:1000 births. As a result of increasing cesarean delivery rates, a
drastic increase in the number of cases with placental implantation
disorders can be expected. Approx. 20 % of cases are connected
with placenta previa.
Diagnosis
All pregnant women with an increased risk for implantation
disorders should undergo antenatal placental implantation
evaluation.
Antenatal diagnosis of a placental implantation disorder is made
sonographically on the basis of a lack of boundary between the
placenta and myometrium possibly with defined lacuna imaging.
This occurs most frequently in the anterior lower uterine segment.
The visualization of a sudden change in myometrium diameter
with some myometrium layers of less than 1 - 2 mm can be helpful
for the suspected diagnosis even without lacunas.
In addition to the B-image of the thin or missing myometrium
layer, color Doppler sonography can illustrate the presence of an
implantation disorder with increased vessel perfusion.
The lower uterine segment near the cervix, low placental infiltration
under the bladder, and possible cervical invasion in the case of
placenta previa can be sonographically examined more accurately
transvaginally than transabdominally.A full bladder provides an
ideal acoustic window and the bladder wall is unfolded.
Although more rare than an anterior implantation disorder, a
posterior disorder, e. g. after myoma nucleation or curettage, is
also possible. This is more difficult to visualize due to the worse
acoustic window without the bladder or with the fetus as a line-ofsight obstruction.
3D sonography allows spatial representation of the finding. This is
useful for the exclusion of growth of the placenta into surrounding
structures, e. g. the bladder.
In these cases, the diagnostic value of MRI is not conclusive and
is the object of current research. Due to high-resolution ultrasound
images for the diagnosis of implantation disorders, MRI does not
seem to provide a significant gain. In the case of an implantation
disorder in the region of the rear wall or side wall, MRI is a useful
supplementary diagnostic method.
An intrapartal diagnosis is the result of a lack of placental
separation after a vaginal birth. Color Doppler sonography can
help differentiate between a prolonged placental period without
a placental implantation disorder and the presence of placenta
accreta. In the case of placenta accreta, a persistent blood flow
between the placenta attachment surface and the myometrium is
identifiable. During a caesarian section, placenta tissue cutting
through the uterine serosa with large-bore subserosal vessels and
lacunas can indicate an implantation disorder.
Management of placental implantation disorders
The management of placental implantation disorders depends on
the time of diagnosis and the birth method.
Procedure in the case of antenatal diagnosis
In the case of antenatal diagnosis of an advanced implantation
disorder (placenta increta, percreta), a cesarean section must
always be performed: the following procedure is possible for the
primary cesarean section:
1. Comprehensive findings: cesarean section hysterectomy without
previous attempt at placental separation if possible.
2.Focal findings: Partial uterine wall resection without removal of
the uterus with locally restricted implantation disorder.
3.Focal intracavitary Z-sutures to stop small areas of bleeding.
4.Conservative approach: Fetal delivery with avoidance of the
placental attachment location (e. g., cross incision of the fundus
after longitudinal laparotomy in the case of low anterior placenta
percreta) and leaving of the placenta in utero.
In the case of a conservative approach without removal of the
placenta, the umbilical cord is cut using an absorbable thread after
fetal delivery without further manipulation of the placenta. With
simultaneous administration of typical uterotonics, the uterotomy
is closed in two layers with simple interrupted sutures. As a rule,
it can take several weeks for the placenta to separate and be
expelled. In the case of postoperative bleeding without removal of
the placenta, the bleeding can be stopped via uterine embolization
or insertion of a balloon catheter into the internal iliac artery. If a
two-phase hysterectomy must be performed due to bleeding, the
operation morbidity and the need for transfusion are significantly
lower due to the partial involution of the uterus.
Procedure in the case of intrapartal diagnosis
If the placenta does not separate after a vaginal birth and bleeding
occurs, manual placenta separation possibly with subsequent
curettage is necessary. These measures should be performed with
intraoperative ultrasound control to prevent complications such as
perforations or the lack of removal of placenta remnants. In the
case of invasive increta placenta parts without increased bleeding, a
conservative approach without removal of the placenta parts is also
possible after vaginal birth. The placenta is either spontaneously
expelled or is removed in a second operation after a time interval
(even weeks later) with regular outpatient sonographic monitoring.
In the case of persistent significant bleeding from the placental
bed, uterine embolization is an alternative treatment option.
Hysterectomy is the option in the case of non controllable bleeding.
Hereditary cancer risk assessment and risk reduction strategies
Banu Arun, M.D.
About 10 % of breast cancer are related to germline mutations in
high penetrance genes. 85% of these include mutations in BRCA1
and BRCA 2 genes.
The rest relate to mutations in other hereditary genes such as
p53, PTEN, ATM, PALB2. Identification of hereditary factors in
a patient with breast cancer is important as it has implications on
treatment as well as family members.
Indications for BRCA testing include personal history of breast
cancer age less than 45 years, triple negative breast cancer age
less than 60 years, high grade ovarian cancer, male breast cancer,
amongst others. The availability of next generation sequencing
made panel testing available where multiple hereditary genes can
be tested at the same time. Indications for panel testing depends on
that person personal and family history of cancer. Risk management
options include preventive surgeries, chemoprevention and
screening.
Individualisation of the COH protocols in IVF
Gürkan Bozdağ, M.D.
Obviously, there is no protocol that will fit all and hence controlled
ovarian hyperstimulation (COH) with gonadotropin dosing should
be individualized. There have been efforts to match a patient with
the most optimum COH protocol using hormonal, functional and
genetic biomarkers. The goals of iCOH include; 1) optimize oocyte
number for achieving highest live birth rate, 2) avoid excessive
response and 3) decrease treatment burden.
For many years, increasing the number of available oocytes has
been assumed to be essential in an assisted reproduction technology
(ART) cycles. However, there is a non-linear relationship between
the number of oocytes and live birth rates in IVF. The live birth rate
depicts a plateau or even declines after a certain number of oocytes
are harvested. Furthermore, increase in the number of oocytes
harvested is clearly associated with increased risk of ovarian
hyperstimulation syndrome (OHSS) and potential detrimental
effect on endometrial receptivity. Hence, the “best” COH protocol
should attain the “optimum” number of oocytes whilst minimizing
the risks and treatment burden. According to available data, the
optimum number of oocyte retrieved should be 10 to 15 in an ART
cycle. Below and beyond those numbers the success rates per cycle
might be comprised.
Although female age is the most important predictor of live-birth
rate (LBR) in IVF, prediction of optimum ovarian response based
on ovarian reserve tests is essential for iCOH and gonadotropin
dosing. Although advanced female age is clearly linked to
declining fertility, it does not affect all women equally. Hence,
the chronological age might not be as valuable a predictor of
fertility as their “biological age” which is defined by hormonal
and functional biomarkers, such as serum anti-Müllerian hormone
(AMH) levels and bilateral antral follicle count (AFC). Genetic
biomarkers, although currently are of limited value may well be
the best predictive tool to individualize treatment in the future.
However, after all, when patients are stratified according to
ovarian reserve, achieving the highest LBR, maintaining safety
and decreasing treatment burden appears to be the respective main
goals in normal, hyper and poor ovarian reponders.
Dual triggering with GnRH agonist and hCG
Bülent Urman, M.D.
Koc University School of Medicine, Department of Obstetrics and Gynecology
Assisted Reproduction Unit, American Hospital, Istanbul
There is an optimal balance of ART. Success rates are increased
with the increasing number of oocytes retrieved. However, the
same is also associated with an increased risk of OHSS. GnRH
agonist triggering in an antagonist cycle has been shown to decrease
OHHS to negligible levels in overstimulated patients and thus
has been adopted as an alternative for final follicular maturation.
Agonist triggering does not compromise oocyte yield or quality.
Furthermore, oocyte maturation and embryo quality may be
favorably affected. Dual triggering may be implemented in two
different ways. One is the administration of GnrH agonist together
with a low dose of hCG in overstimulated cycles and the other is
the administration of GnRH agonist together with a conventional
dose of hCG in normally stimulated cycles. Dual triggering in
high responders but with serum estradiol < 4000 pg/mL was shown
to improve implantation and pregnancy rates without increasing
the incidence of clinically significant OHSS when compared to
analog triggering. The addition of a low dose of hCG may improve
the luteal phase which has been shown to be defective in analog
triggered cycles. There is evidence in the literature showing
lower conception rates despite intensive luteal phase support in
patients who have estradiol levels < 4000 pg/mL compared with
patients overstimulated to a higher degree. Dual trigger has also
been shown to better than agonist trigger combined with low dose
hCG supplementation of the luteal phase but equivalent to analog
trigger combined with intensified luteal support. Dual trigger
has also been used in normal responders with significant increase
in live birth rates compared to conventional hCG trigger. The
theory behind the beneficial effect of preovulatory administration
of an GnRH is that it could displace the GnRH antagonist from
endometrial GnRH receptors as well as from receptors in other
gonadotropin-producing cells, thus enabling proper postreceptor
actions for implantation. Another advantage of triggering with a
GnRH agonist for oocyte maturation is the simultaneous induction
of a midcycle FSH surge that is similar to the hormone surge in
a natural cycle. Animal studies have confirmed the role of FSH
in promoting the formation of luteinizing hormone (LH) receptor
sites in rat granulosa cells. The increase in LH receptors is crucial
for preparing the maturing follicle for an LH surge that triggers
the events of ovulation and subsequent luteinization of the
granulosa cells. Furthermore, FSH has been shown to promote the
resumption of oocyte meiosis and cumulus expansion in animal
models. FSH administration concomitant with hCG has been
shown to improve oocyte competence in terms of higher oocyte
recovery and fertilization rates. In summary dual trigger can be
used in all cycles stimulated with GnRH antagonists. However,
more data and robust randomized clinical trials are needed prior to
reaching definitive conclusions.
Stem cells in obstetrics and oncology - how can we counsel
our patients?
Wolfgang Holzgreve, M.D.
Medical Director and CEO, University Medical Center Bonn, Germany
Umbilical cord blood is rich in hematopoietic stem cells. At
birth, it can be collected, HLA-typed and stored. Cord blood is
successfully used since over 10 years as source of transplantation
of hematopoietic stem cells, in addition to bone marrow and
mobilized peripheral blood stem cells. Allogeneic transplantations
are performed between HLA-identical siblings and from HLAmatched unrelated donors. Most recipients of cord blood are
children with leukemia or genetic disorders, but also increasingly
adolescents and adults. Based on the promising results, cord
blood banks with cryopreserved, HLA-typed cord blood samples
from anonymous donors are set up worldwide, ready to be used
as allogeneic stem cell graft. Additionally, so-called “private”
cord blood banks were set up, providing the possibility to store
cord blood at birth from healthy children with no affected family
member for a possible autologous stem cell transplantation in the
future if the child later develops a disease such as leukemia. To
date, there is no established indication for an autologous cord blood
transplantation. Nevertheless, the plasticity and multipotency of
adult stem cells, which has been discovered recently, could lead
to a possible autologous use of cord blood stem cells for different
indications in regenerative medicines (cell- and organ replacement
/ regeneration). So far, however, this remains speculative.
Prenatal in-utero stem cell transplantation is promising therapeutic
option for genetic disorders, which is now at the edge of moving
from preclinical research into clinical application. The first clinical
experience shows that some form of severe immunodeficiency
can be treated successfully in-utero. No therapeutic success has
been achieved in genetic disorders which do not severely affect the
immune system, due to immunologic rejection and hematopoietic
competition between donor and host cells. Therefore, new
strategies are being developed, including graft modification,
prenatal conditioning of the fetus, postnatal re-transplantation after
prenatal induction of immune tolerance, and fetal gene therapy
using autologous fetal stem cells. The use of non-hematopoietic
(e.g. mesenchymal) or pluripotent stem cells will probably lead
to an expansion of the spectrum of indications. Simultaneously,
ethical implications, in particular regarding fetal gene therapy and
the use of pluripotent stem cells must be addressed.
Induction of in vivo spermatogenesis with stem cells
Çiler Çelik Özenci, M.D.
The testis is a complex organ and constant spermatogenesis is
supported by a highly robust stem cell system. The production of
spermatozoa relies on a pool of spermatogonial stem cells (SSCs)
which are formed in infancy and throughout adult life will either
self-renew or differentiate, in order to maintain a stem cell reserve
while providing cells to the spermatogenic cycle. Morphological
analyses in the 1960s established the basis of stem cell research
together with mammalian spermatogenesis. Our understanding of
spermatogenic stem cells started from the 1990s when functional
analyses included post-transplantation colony formation, in vitro
spermatogonial culture with persisting stem cell activity, in vivo
lineage tracing, and live imaging, and also lines of moleculargenetic analyses. Although still needs further investigation,
molecules that regulate the balance between self-renewal and
differentiation recently identified have greatly expanded our
understanding of SSC self-renewal and differentiation utilizing
transplantation assays and in vitro culture systems.
In some patients, spermatogenesis is severely diminished in which
germ cells are completely lacking or present in an immature form,
which results in sterility. For fatherhood, assisted reproduction
techniques need mature germ cells, thus the differentiation of
preexisting immature germ cells or the production of sperm from
somatic cells is the promising technology that remains largely
experimental and still requires extensive research. Each technique
offers a different approach to the improvement of germ-lineage
genetic manipulation and restoration of fertility. The content of
this talk will cover the development of the techniques available
from in vitro culture systems to in vivo bioassays by providing
current information and address ethical and biosafety issues, such
as gamete epigenetic status, ploidy, and chromatin integrity.
Maternal mortality due to postpartum hemorrhage in Turkey
Yaprak Üstün, M.D.
Zekai Tahir Burak Woman’s Health Training and Research Hospital
Maternal mortality and stillbirth are significant adverse outcomes
in developed countries and especially in developing countries (1).
Table 1 depicts maternal mortality ratio of Turkey between 2007
and 2015. Postpartum hemorrhage (PPH) has long been known
to be the one major cause of maternal mortality and is clinically
defined as blood loss greater than or equal to 500 mL. Turkey
National Maternal Mortality Study 2005 (2) revealed that almost
one quarter of maternal deaths occurred due to hemorrhage. Death
from PPH was 18.2 % in 2012 and 15.3 % in 2015 in Turkey.
While PPH remains one of the major cause of maternal mortality,
its relative contribution as a proportion of all deaths has decreased
over the years.
Majority of PPH cases are due to uterine atony. Other causes
of PPH include retention of the placenta, lacerations or tears of
the cervix, vagina, or perineum, abruption of placenta, morbidly
adherent placenta and uterine rupture.
Death from PPH depends largely on access to timely and competent
obstetric care. Exact diagnosis is important in order to commence
appropriate interventions.
To act decisively in the face of severe, ongoing hemorrhage is
essential.
In cases of uterine atony unresponsive to massage and uterotonics,
uterine tamponade using a balloon or packs can be used effectively.
Balloons are generally the preferred method because they are more
effective, quicker to insert, and allow continued assessment of
hemorrhage. In cases of ineffective tamponade, reinsertion of the
balloon or packing or B-Lynch suturization should be avoided, and
the doctor should proceed with laparotomy (3,4).
Insufficient or slow replacement of blood and clotting components
in the patient with massive ongoing hemorrhage may lead to
maternal death.
Management of placenta accreta adequately is also an important
point (3).
Any patient with placental previa and one or more cesarean
deliveries should be evaluated for the presence of placental
adherence anomalies and delivered in a tertiary care medical center
under elective conditions.
Table 1: Maternal mortality ratio of Turkey
Year
MMR in 100.00 live births
2015
13.7
2014
15.2
2013
15.9
2012
15.4
2011
15.5
2010
16.4
2009
18.4
2008
19.4
2007
21.2
References
Khan KS, Wojdyla D, Say L, Gulmezoglu AM, Van Look P. WHO
systematic review of causes of maternal deaths. Lancet 2006; 367:
1066–74.
Turkey National Maternal Mortality Study; 2005.
Steven C. Strategies for Reducing Maternal Mortality. Semin
Perinatol 2012; 36:42-47.
Haeri S, Dildy GA 3rd. Maternal mortality from hemorrhage.
Semin Perinatol. 2012;36:48-55.
Thromboembolism prophylaxis in pregnancy and early postpartum
period
İbrahim Bildirici, M.D.
Venous Thromboembolic Disease (VTE) prevention in pregnancy
and postpartum period
Pregnancy and the puerperium are risk factors for the development
of VTE. This risk is thought to be due to venous stasis of the
lower extremities, endothelial injury and the hypercoagulable state
that occurs during pregnancy. The incidence VTE is increased
throughout all trimesters of pregnancy but is highest during
the postpartum period. Factors that may further augment the
risk include a prior history of VTE, hospitalization for an acute
illness or cesarean delivery, and the presence of an inherited
thrombophilia (eg, factor V Leiden mutation prothrombin gene
mutation, antithrombin III, protein C, or protein S deficiencies).
Although pregnancy and the puerperium are risk factors for the
development of VTE, the vast majority of pregnant women do
not require thromboprophylaxis. However, thromboprophylaxis is
typically targeted at those who are considered to be at greatest risk
for the development of VTE during the antepartum and postpartum
periods.
2013 American College of Obstetricians and Gynecologists
(ACOG) guidelines on the selection criteria for antepartum
pharmacologic thromboprophylaxis during pregnancy is shown
below
Data are insufficient to support routine outpatient pharmacologic
thromboprophylaxis for most pregnant women. Pharmacologic
prophylaxis may be considered in patients with a history of a single
idiopathic, pregnancy-associated or estrogen-associated VTE, and
in those with a history of multiple VTEs, regardless of the cause.
Pharmacologic prophylaxis is also considered for patients with a
known thrombophilia and in those with persistent risk factors and
a prior history of VTE.
Pregnant women who have had a prior VTE related to a high
estrogen state (eg, prior pregnancy or estrogen-related VTE) are
considered candidates for thromboprophylaxis because these risk
factors are likely to increase the chances of recurrent VTE during
pregnancy. In contrast, those women in whom a transient risk
factor for prior VTE (eg, trauma, immobility, surgery) is identified,
the likelihood of recurrence is presumed to be lower. Thus, clinical
surveillance is preferred over pharmacologic thromboprophylaxis
for those without persistent risk factors, unless multiple VTEs
have occurred.
Women who are already receiving anticoagulant therapy should
have the need for ongoing therapeutic anticoagulation reassessed
at the beginning of the pregnancy. If it is determined that
therapeutic anticoagulation is necessary, women who are receiving
oral anticoagulation (direct thrombin and factor Xa inhibitors
and warfarin) should have their anticoagulant regimen converted
to a heparin-based regimen.
All postpartum women should be subjected to vigilant clinical
surveillance for the signs and symptoms of VTE. Pharmacologic
thromboprophylaxis can be administered to a select population of
postpartum women considered at high risk for VTE.
The decision to administer postpartum pharmacologic
thromboprophylaxis should be individualized for each patient with
careful assessment of the benefits and harms.
Data are insufficient to support routine outpatient pharmacologic
thromboprophylaxis for most women in the postpartum period.
Pharmacologic prophylaxis may be considered in patients with
a history of prior VTE (single or multiple) regardless of the
provoking factor (transient or persistent, inherited thrombophilia)
and in a subset of patients with inherited thrombophilia without a
personal or family history of VTE
The rationale for the use of thromboprophylaxis in the postpartum
period is similar to that provided for the antepartum period.
However, the threshold for anticoagulation is lowered in the
postpartum setting largely because the risk of VTE is increased,
and the potential for the more serious adverse effects of
anticoagulation, including placental hemorrhage, spinal hematoma
and fetal hemorrhage, is no longer a consideration. Compared with
the antepartum period, VTE, especially pulmonary embolism,
is two to five times more common in the puerperium with some
epidemiologic evidence suggesting persistent risk for six weeks
beyond delivery.
Pharmacologic prophylaxis — In contrast to anticoagulation of
nonpregnant women, the choice of anticoagulant during pregnancy
needs to take into account fetal safety and maternal peripartum
issues (eg, unpredictable onset of labor, use of neuraxial
anesthesia for management of labor pain). Heparins are used for
most pregnant women because they do not cross the placenta and
do not anticoagulate the fetus. Low molecular weight heparin
(LMWH)-based regimens are generally preferred.Unfractionated
heparin is preferred over LMWH in patients with severe renal
insufficiency (eg, creatinine clearance <30 mL/min), because
LMWH metabolism is exclusively renal, while metabolism of
unfractionated heparin is renal and hepatic.
Heparins can be administered during pregnancy at different doses
depending upon the risk of thromboembolism and desired degree
of anticoagulation.
• Prophylactic dose anticoagulation refers to the use of low doses
of anticoagulants (eg, enoxaparin 40 mg subcutaneously once
daily), which aims to reduce the risk of thromboembolism while
minimizing bleeding complications
• Intermediate dose anticoagulation refers to the adjustment
of prophylactic dose anticoagulation with weight gain during
pregnancy (eg, enoxaparin 40 mg subcutaneously twice daily)
• Therapeutic dose anticoagulation refers to the use of anticoagulants
at doses typically reserved for treatment of thromboembolic disease
(eg, enoxaparin 1 mg/kgsubcutaneously twice daily). Despite the
nomenclature, therapeutic dosing may be used prophylactically
(ie, to prevent thromboembolism).
When LMWH is administered for VTE prophylaxis in a patient
without a thrombophilia, prophylactic or intermediate doses are
used. Therapeutic dosing is used when prophylactic or intermediate
dosing is thought to be insufficient for thromboembolism
prophylaxis in some patients at very high risk of thromboembolism.
Mechanical prophylaxis — The efficacy of mechanical
thromboprophylaxis (eg, frequent left-lateral decubitus positioning
during late pregnancy, graduated elastic compression stockings,
and pneumatic compression devices) during pregnancy or the
puerperium is unknown because there is a paucity of evidence.
In a study of 10 pregnant women, venous Doppler ultrasound
demonstrated that graduated compression stockings increased
femoral vein flow velocity during late pregnancy. Nonetheless, the
use of mechanical prophylaxis following cesarean section and for
hospitalized women during pregnancy is considered safe.
SUMMARY AND RECOMMENDATIONS
• The risk of venous thromboembolism (VTE) is increased in
all trimesters of pregnancy, especially the postpartum period.
Although most women do not require thromboprophylaxis, those
who are considered to be at greatest risk are generally targeted for
VTE prevention.
• For most non-hospitalized pregnant women, we suggest
observation rather than pharmacologic prophylaxis for VTE
(Grade 2C). We suggest antepartum pharmacologic prophylaxis
for patients with a history of a single idiopathic, pregnancy-
associated or estrogen-associated VTE, and in those with a
history of multiple VTEs, regardless of the cause (Grade 2C).
Pharmacologic prophylaxis is also considered for patients with a
known thrombophilia and a history of VTE and for patients with
certain “high risk” thrombophilias plus a family history of VTE.
• For most postpartum women, we suggest observation rather
than pharmacologic prophylaxis for VTE (Grade 2C). We suggest
postpartum pharmacologic prophylaxis in patients with a history of
prior VTE (single or multiple) regardless of the provoking factor
(transient or persistent, inherited thrombophilia) and in a subset of
patients with inherited thrombophilia without a personal history of
VTE (Grade 2C).
• For most pregnant women who are hospitalized antenatally
for non-delivery reasons, the same criteria for pharmacologic
thromboprophylaxis is used as in the outpatient setting.
Select women who do not meet the criteria for outpatient
thromboprophylaxis may benefit from thromboprophylaxis during
an acute hospitalization.
• For women who undergo a cesarean section and have no additional
risk factors for VTE, it is suggested to use early ambulation
or the use of mechanical devices rather than pharmacologic
thromboprophylaxis (Grade 2C). For women who undergo a
cesarean section and have additional risk factors for VTE, the use
of both pharmacologic and mechanical thromboprophylaxis is
suggested (Grade 2C).
• For women in whom the decision is made to administer
pharmacologic prophylaxis, heparin-based regimens are safer than
oral anticoagulants. low molecular weight heparin use is suugested
rather than unfractionated heparin provided the patient does
not have renal insufficiency (eg, creatinine clearance <30 mL/
min) (Grade 2C). Heparin regimens are typically administered
during pregnancy at different doses depending upon the risk
of thromboembolism and desired degree of anticoagulation
(prophylactic, intermediate, therapeutic)
• Antepartum pharmacologic thromboprophylaxis should
be continued until delivery. It is suggested that postpartum
pharmacologic thromboprophylaxis be continued for six weeks to
three months. Following cesarean section, thromboprophylaxis is
continued until the patient is ambulatory.
The successful IVF laboratory: basic aspects to be considered
Markus Montag, M.D.
ilabcomm GmbH, Sankt Augustin, Germany
When it comes to the success of an IVF laboratory, every single
step in the procedure chain has to be considered as being a
source for impacting the outcome. Among these one can identify
certain basics that are frequently found during troubleshooting in
laboratories.
A major source of impaired success is improper handling of
gametes and embryos at wrong conditions. Although temperature
is considered as an important factor, not every laboratory can
deliver a documentation of the temperature profile that oocytes and
embryos are exposed to during each step of the entire procedure.
Exposure means the actual and effective temperature in the droplet
or in medium and not the temperature set point of the incubator,
heated stage, etc. A major source for temperature problems is the
initial process of follicular puncture and oocyte identification /
selection. Oocytes are most vulnerable to a temperature drop as
the tubulin polymers of the metaphase-II spindle may disintegrate
and below a certain threshold a spindle will not reform again to
its normal constitution. Fertilization and embryo development
may still occur but the resulting embryos are not developed from a
physiologically normal oocyte.
Equally important is proper maintenance of physiological
conditions for pH and osmolality. For osmolality, dish preparation
is of uttermost importance, as a wrong procedure can immediately
cause an evaporation of water from the medium during dish set up.
Most media are in the range of 270-290 mOsm. An evaporation
of only 5% of water from the medium can raise the osmolality to
above 300 mOsm, which is considered to be no longer a proper set
point. Practical experimentation has shown, that this can occur if
someone is not aware of the underlying effect.
Maintaining a proper pH at all times is important for optimal results,
be it handling of oocytes and embryos outside of the incubator or
be it the culture itself. Obtaining the correct pH requires a thorough
understanding of the buffer system used. In media for culture this
is based on the bicarbonate buffer system used and the pH is a
result of the interaction between CO2 and bicarbonate. Media from
different suppliers do have different concentrations of bicarbonate
and thus there is no universal CO2 set point that fits every medium.
, whereas in handling media it is a MOPS- or HEPES-base that
warrants the proper pH. Some media suppliers recommend a very
narrow pH-range for optimal performance of their products, while
others give a very broad range. It is the responsibility of the user,
namely the IVF laboratory, to know the proper settings, how to
measure these and how to make sure that the CO2 settings used
will give the correct pH. As for temperature, oocytes are more
sensitive if exposed to a wrong external pH setting, as they cannot
regulate the internal pH to the same extend as embryos.
All the above topics require a proper quality control system in order
to detect deviations from what is considered as being the standard
for a given laboratory. Standard settings for one laboratory do not
necessarily match to those of another laboratory, especially for
temperature. However, media are consistent within the batches
provided by the manufacturer and if used in different labs but
according to the intended usage, media should less influence
results then other factors.
Oocytes/embryos can tolerate a certain degree of stress, but as
soon as stress accumulates, the results will be affected. Therefore
it is an absolute requirement that the procedure chain is under full
control and that the weak points within this chain can be identified
by a proper quality management system.
Last but not least it is the handling performance that has a
direct influence on the outcome. This requires a proper ratio of
embryologists and technicians in relation to the workload, which
is determined by the number of fresh and frozen/thawed cycles,
as well as by special procedures that are offered along standard
IVF treatment. The equipment should be equally well adapted,
as minimalistic conditions will require compromises that finally
affect the embryos. In summary, there are many factors that must be
considered while running an IVF laboratory. A good performance
within the lab and a good interaction between the laboratory and
the clinical part of an IVF center is the base for the synergy that
makes a successful center.
Quantitative and qualitative grading of human blastocysts and its
association with neonatal outcome
Thomas Ebner, M.D.
Kepler University, Kinderwunsch Zentrum, Linz, Austria
Prolonged in vitro culture is thought to affect pre- and postnatal
development of the embryo. It is to determine whether quality/
size of ICM (from which the fetus ultimately develops) and
TE (from which the placenta ultimately develops) is reflected
neonatal outcome. In more than 200 patients qualitative scoring
of blastocysts was done according to the criteria expansion,
ICM and TE appearance. In parallel, all three parameters were
quantified semi-automatically. TE quality and cell number were
the only parameters that predicted treatment outcome. In detail,
pregnancies that continued on to a live-birth could differed from
those pregnancies that aborted on the basis of TE grade and cell
number. Male blastocysts had a 2.5 higher chance of showing TE
of quality A compared to female ones. There was no correlation
between the appearance of both cell lineages and birth or placental
weight, respectively. The correlation of TE with outcome indicates
that TE scoring could replace ICM scoring in terms of priority.

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