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INTRODUCTION Obesity is a common health problem and is defined as a body mass index (BMI) of 30 kg/m2 or greater; morbid obesity is defined as a BMI ≥40 kg/m2(1). In the United States of America, the incidence of obesity among adults has been reported to increase two-fold during the past decade(2). In European and Mediterranean regions, the incidence of overweight (i.e., BMI between 25 and 30 kg/m2) and obesity have increased during recent decades, regardless of the level of development(3,4,5). Obesity is associated with an increased risk of diabetes mellitus, polycystic ovary syndrome, hypertension, dyslipidaemia and coronary heart diseases(6). Obese patients have a significantly higher risk of postoperative myocardial infarction, surgical site infections, nerve injury, and urinary infection. Obesity is an independent risk factor for perioperative morbidity, and morbid obesity is a risk factor for perioperative mortality(7,8).

and coronary heart diseases(6). Obese patients have a significantly higher risk of postoperative myocardial infarction, surgical site infections, nerve injury, and urinary infection. Obesity is an independent risk factor for perioperative morbidity, and morbid obesity is a risk factor for perioperative mortality(7,8). Laparotomy is frequently used in surgical procedures for gynecologic disorders, such as myomas, adnexal masses, and tubo-ovarian abscess(9). Due to the increasing weight of the population, we encounter more obese patients in our gynecologic practice, even if we try to keep them away from surgical interventions. Physicians should avoid surgery (especially open abdominal surgery) in obese and morbid obese patients as well as they can. In laparotomies for gynecologic diseases, we generally use two types of skin incision. Pfannenstiel incisions are preferred because this type of incision provides adequate vision in the pelvic area and has good cosmetic results. However, a vertical skin incision is sometimes preferred for a giant myoma or a giant adnexal mass(10). There are insufficient data in the literature regarding complication rates arising from morbid obesity and the chosen type of skin incision in benign gynecologic hysterectomies. Thus, we aimed to evaluate the effect of morbid obesity and the type of incision on complication rates among patients who underwent surgery in our clinic.

sufficient data in the literature regarding complication rates arising from morbid obesity and the chosen type of skin incision in benign gynecologic hysterectomies. Thus, we aimed to evaluate the effect of morbid obesity and the type of incision on complication rates among patients who underwent surgery in our clinic. MATERIALS AND METHODS This retrospective study was performed between June 2006 and February 2007 at Etlik Zübeyde Hanım Women’s Health Training and Research Hospital, which is a tertiary referral center in Ankara. Ethical approval for our study was obtained from the Local Ethics Committee. The research was completed in accordance with the Helsinki Declaration(11). It included adult women who attended to our hospital for a benign gynecologic pathology and underwent total abdominal hysterectomy. Patients were excluded if they had any malignant disease, skin disease (such as psoriasis), autoimmune disease or were immunosuppressed. All patients were Caucasian Turkish women with no history of alcohol or drug use before and after surgery. We collected data from hospital records and patient files, and the same author called all patients to inquire about the presence of any complications within 30 days of surgery or more lately after discharge from the hospital. The subject characteristics and demographics were analyzed. Demographic preexisting variables included age, BMI, obstetric history, tobacco use, history of any previous abdominal surgery, and presence of any systemic comorbidity. BMI (kilograms per square meter) was calculated using the patient’s height and weight. The subjects were divided into two BMI categories according to the World Health Organization classification system(12). The morbid obesity group included consecutive subjects who had a BMI ≥40 kg/m2, and the non-morbid obesity group included consecutive subjects who had a BMI lower than 40 kg/m2.

t’s height and weight. The subjects were divided into two BMI categories according to the World Health Organization classification system(12). The morbid obesity group included consecutive subjects who had a BMI ≥40 kg/m2, and the non-morbid obesity group included consecutive subjects who had a BMI lower than 40 kg/m2. Moreover, we classified the same samples into sub-groups in terms of skin incision types: vertical incision or pfannenstiel incision. All surgeries were performed by the same surgical team using a standardized technique. We performed surgery for benign gynecologic disorders such as myoma uteri, adnexal mass, persistent uterine hemorrhage, and tubo-ovarian abscess, and performed total abdominal hysterectomies with or without salpingo-oophorectomy for all subjects, based on the indication for surgery. Operative time (minutes), preoperative and postoperative haemoglobin (Hb) values

disorders such as myoma uteri, adnexal mass, persistent uterine hemorrhage, and tubo-ovarian abscess, and performed total abdominal hysterectomies with or without salpingo-oophorectomy for all subjects, based on the indication for surgery. Operative time (minutes), preoperative and postoperative haemoglobin (Hb) values (g/dL), estimated blood loss (EBL) (mL), requirement for blood product transfusion, length of hospital stay (days), and drain presence were recorded for each patient. A surgical drain was placed into the abdominal space based on the preference of the surgeon. When the thickness of the subcutaneous layer was greater than 2 centimetres, the subcutaneous space was closed with 2/0 poliglactic acid-poliglactin (vicryl). Subcutaneous drains were not used in any case. Cefazolin (1 gram) was used as the primary preoperative prophylaxis; clindamycin was used for patients with a history of penicillin allergy. Both drugs were administered intravenously, and additional doses were administered when the operation lasted longer than two hours. Prophylaxis for venous thromboembolic events was performed according to the chest guidelines released by the American College of Chest Physicians(13). Early postoperative complications were defined as complications that occurred during the operation or within 30 days of the surgery. Late postoperative complications were defined as complications that occurred more than 30 days after the surgery. The operative time was defined as the time from the first skin incision to the final closure of the skin incision. Wound complications were defined as a subcutaneous infection or hemorrhage requiring surgical debridement and repair. Superficial skin separation was not considered as a wound complication. Wound infection was defined as a wound with purulent or serous drainage in combination with tissue warmth, erythema, and increasing tenderness. The primary outcome measure was defined as the presence of any early and/or late complications in morbid obese patients. The presence of complications with any incision type was also recorded. Continuous variables were recorded as the mean ± standard deviation or the median and interquartile ranges, and categorical variables were reported as frequencies and column percentages. The normality of the variables was analyzed using the Kolmogorov-Smirnov test.

omplications with any incision type was also recorded. Continuous variables were recorded as the mean ± standard deviation or the median and interquartile ranges, and categorical variables were reported as frequencies and column percentages. The normality of the variables was analyzed using the Kolmogorov-Smirnov test. Student’s t-test was used to compare normally distributed continuous variables, and the Mann-Whitney U test was used to compare non-normally distributed continuous variables. The chi-square test or Fisher’s exact test (when chi-square test assumptions do not hold due to low expected cell counts), where appropriate, was used to compare categorical variables. Two-sided p-values were considered statistically significant at p<0.05. Statistical analyses were performed using the statistical package SPSS version 17.0 for Windows (SPSS Inc., Chicago, IL, USA). RESULTS Patient characteristics The demographic characteristics of a total of 132 patients are listed in Table 1. Patients in the study group with morbid obesity were significantly older and had a significantly higher prevalence of comorbidities than patients in the non-morbid obesity group. The two groups were similar with respect to tobacco use, previous abdominal surgery, and menopause status.

32 patients are listed in Table 1. Patients in the study group with morbid obesity were significantly older and had a significantly higher prevalence of comorbidities than patients in the non-morbid obesity group. The two groups were similar with respect to tobacco use, previous abdominal surgery, and menopause status. Perioperative outcomes The surgical data of the two groups are shown in Table 2. Skin incision types were comparable between the two groups. Vertical incisions were midline incisions below the umbilicus in all cases except one, in which the incision also extended above the umbilicus. The pre-operative Hb values were significantly lower, and the mean operative time (minutes) was significantly longer in the morbid obesity group than the non-morbid obesity group. EBL, the requirement for blood transfusion, post-operative Hb values, and the presence of an abdominal drain were similar between groups. The mean length of hospital stay was longer in the group with morbid obesity than the other group (Table 2). Complications In our study, no intraoperative complications were observed, but there were some post-operative complications. We assessed the effect of morbid obesity on post-operative complications (Table 3). Early and late complications were significantly more frequent in the morbid obesity group than the non-morbid obesity group. We observed no wound cellulitis or fascial dehiscence in any patients.

were some post-operative complications. We assessed the effect of morbid obesity on post-operative complications (Table 3). Early and late complications were significantly more frequent in the morbid obesity group than the non-morbid obesity group. We observed no wound cellulitis or fascial dehiscence in any patients. We also compared the complications between incision types (i.e., vertical and pfannenstiel). Patients with a vertical incision had significantly more early complications (n=9; 23.1%) than patients with a pfannenstiel incision (n=3; 3.2%) (p<0.05). Late complications occurred in 4 subjects (10.3%) in the vertical incision group and 3 subjects (3.2%) in the pfannenstiel incision group. No significant differences in late complications were observed between the two types of skin incision (Table 4).

1%) than patients with a pfannenstiel incision (n=3; 3.2%) (p<0.05). Late complications occurred in 4 subjects (10.3%) in the vertical incision group and 3 subjects (3.2%) in the pfannenstiel incision group. No significant differences in late complications were observed between the two types of skin incision (Table 4). DISCUSSION We assessed the consequences of morbid obesity in our gynecologic surgery practice. Morbidly obese patients had more comorbidities, longer operation times, longer hospital stays, more early and late complications than the other group of patients. History of previous abdominal surgery, tobacco use, menopause status, and skin incision types were comparable between the two groups, so these variables are not likely to affect differential complication rates. Hysterectomy is the most common major gynecologic surgery(14). To our knowledge, no recent study in the literature has evaluated complications related to obesity and chosen skin incision types in benign gynecologic practice. Some studies investigated obesity and gynecologic cancer surgery(15,16). However, benign gynecologic operations are performed more frequently than gynecologic cancer operations. The pelvic area where we performed surgery was deeper in morbidly obese patients, and the surgeons had difficulty obtaining an adequate field of vision; thus, a longer operative time was needed in morbidly obese patients. A study by Kodama et al.(16) demonstrated that a longer operative time was an independent predictor of the incidence of early postoperative complications. The results of our study confirmed this finding.

fficulty obtaining an adequate field of vision; thus, a longer operative time was needed in morbidly obese patients. A study by Kodama et al.(16) demonstrated that a longer operative time was an independent predictor of the incidence of early postoperative complications. The results of our study confirmed this finding. A previous study stated that obese women had greater blood loss, longer operative times and hospital stays, and an increased rate of wound infection in comparison to non-obese patients(17). However, we obtained different results concerning blood loss, because we observed no differences in EBL, postoperative Hb or the need for blood transfusion between the two groups. In our daily practice, we attempt to mobilize morbidly obese patients as early as possible, direct them to use antiembolic stockings to prevent thromboembolic events, and encourage them to return to their daily lives. The utmost importance of thromboembolic prophylaxis in morbid obese patients was denoted well in a systematic review by Hodges et al.(18). Increased venous stasis, which has already been provoked by morbid obesity and major surgery, has been cited as responsible for venous thromboembolism(13). In our study, no intraoperative complications were detected. We can attribute it to our experienced surgical team. A recent study performed by the Gynecologic Oncology Group LAP2 reported no differences in intra-operative complications between obese and non-obese patients(19). Another study found that obese patients did not experience an increased risk of serious morbidity after vaginal and abdominal hysterectomy compared with normal weight women(20). These studies compared obese and non-obese patients; however, we studied surgical complications in morbidly obese and non-morbidly obese patients. When we evaluated the groups with respect to postoperative complications, significantly higher rates of early and late complications were observed in the morbidly obese group. This finding was not surprising. In most studies, morbidly obese patients have been found to have a greater risk of postoperative complications than non-obese patients(21). A study about vaginal procedures in overweight patients found no difference in postoperative complications between the study and the control groups(22). However, the sample specifications and surgical procedures in that study were different from ours.

ter risk of postoperative complications than non-obese patients(21). A study about vaginal procedures in overweight patients found no difference in postoperative complications between the study and the control groups(22). However, the sample specifications and surgical procedures in that study were different from ours. In a study by Geppert et al.(23) robotic-assisted laparoscopy and open surgery for benign hysterectomy indications in obese and morbidly obese patients were compared in terms of surgical outcomes. As a result, the complication rate in the robotic surgery group was found lower than the open surgery group. However, no control groups to date have comprised normal BMI or overweight (25 kg/m2< BMI <30 kg/m2) patients. Therefore, that study could not have indicated the disadvantages of obesity on surgical outcomes(23). Clinical surveys of other surgical fields, such as orthopedics and gastroenterologic surgery concluded that surgery was safe for obese patients, except in emergency operations(24,25). Our study demonstrated that one-third of 38 patients with morbid obesity (13 patients) had one early or late complication. Most of the early complications were wound infections. In a recent study, increasing BMI was found associated with increased operative time and surgical site infections in patients undergoing abdominal hysterectomy. The results of that study are consistent with ours, but our study has different characteristics of indications for hysterectomy and salpingo-oophorectomy status(26). We wondered whether fewer wound infections would occur if we used a subcutaneous drain. A previous study reported that subcutaneous drains and prophylactic antibiotics were recommended to minimise wound disruption(27). However, when we reviewed the literature, we found that for patients with more than 3 cm of subcutaneous fat, the use of a subcutaneous drain was not effective for the prevention of superficial wound disruption(9). We do not believe that surgical drains would lead to fewer wound infections because the development of a surgical site infection after a surgical procedure depends on the interaction between the host, the microorganism, and the surgical environment. In our study, no significant differences were observed between the non-morbidly obese and morbidly obese groups in terms of skin incision type. We investigated the complication rates according to the type of skin incision.

ure depends on the interaction between the host, the microorganism, and the surgical environment. In our study, no significant differences were observed between the non-morbidly obese and morbidly obese groups in terms of skin incision type. We investigated the complication rates according to the type of skin incision. The frequency of late complications was comparable between the two types of skin incision, but the early complication rate was significantly higher in the vertical incision group. A previous study of cesarean section revealed a higher incidence of wound complications in morbidly obese patients, and indicated that a vertical skin incision was associated with a higher rate of wound complications than a transverse incision(28). Likewise, two other studies showed that in comparison to low transverse incisions, vertical skin incisions were associated with increases in postoperative pain, postoperative atelectasis, superficial wounds, and fascial dehiscence(10,29).

ociated with a higher rate of wound complications than a transverse incision(28). Likewise, two other studies showed that in comparison to low transverse incisions, vertical skin incisions were associated with increases in postoperative pain, postoperative atelectasis, superficial wounds, and fascial dehiscence(10,29). No patients in our study had major complications such as massive bleeding or bowel injuries; this finding may be have been caused by the limited number of patients in the study. Further studies with a larger sample sizes may generate different findings. In our study, gynecologic operations were performed using an abdominal incision only; we did not include any vaginal or laparoscopic gynecologic surgeries. There are some limitations to our study. Absence of sample size analysis is one of them. Owing to the cross-sectional study design, all of the consecutive patients who attended our hospital and fulfilled the inclusion criteria between the mentioned dates were recruited for the study. The strengths of our study include the investigation of the effects of morbid obesity and skin incision types on surgical outcomes in major gynecologic surgery.

esign, all of the consecutive patients who attended our hospital and fulfilled the inclusion criteria between the mentioned dates were recruited for the study. The strengths of our study include the investigation of the effects of morbid obesity and skin incision types on surgical outcomes in major gynecologic surgery. CONCLUSION Hysterectomy with or without salpingo-oophorectomy is significantly associated with early and late postoperative complications in morbidly obese patients. Early complications in patients undergoing abdominal hysterectomy with a vertical incision were encountered more frequently than in patients undergoing hysterectomy with a transverse incision. Wound infection was seen as an early complication in predominantly morbidly obese patients. Further studies that compare larger samples with more clinical risks and complications may generate different results. Obesity remains an important factor in everyday gynecologic practice. We thank Assistant Professor Dr. Mehmet Ersoy (Department of Computer Education and Instructional Technology, Osmangazi University, Eskişehir, Turkey) for his help in statistical analyses. Ethics: Ethics Committee Approval: The study was approved by the Etlik Zubeyde Hanim Women’s Health Training and Research Hospital local ethics committee, Informed Consent: Consent form was filled out by all participants. Peer-review: Externally and Internally peer-reviewed.

We thank Assistant Professor Dr. Mehmet Ersoy (Department of Computer Education and Instructional Technology, Osmangazi University, Eskişehir, Turkey) for his help in statistical analyses. Ethics: Ethics Committee Approval: The study was approved by the Etlik Zubeyde Hanim Women’s Health Training and Research Hospital local ethics committee, Informed Consent: Consent form was filled out by all participants. Peer-review: Externally and Internally peer-reviewed. Authorship Contributions: Surgical and Medical Practices: Özlem Evliyaoğlu, Okyar Erol, Mehmet Akif Akgül, Concept: Ebru Ersoy, Özlem Evliyaoğlu, Ali Haberal, Design: Ebru Ersoy, Okyar Erol, Ali Haberal, Mehmet Akif Akgül, Data Collection or Processing: Okyar Erol, Mehmet Akif Akgül, Analysis or Interpretation: Özlem Evliyaoğlu, Ali Özgür Ersoy, Literature Search: Ebru Ersoy, Ali Özgur Ersoy, Writing: Ebru Ersoy, Özlem Evliyaoğlu. Conflict of Interest: No conflict of interest was declared by the authors. Financial Disclosure: The authors declared that this study received no financial support. Table 1 Individual characteristics of the patients in the two groups Table 2 Perioperative characteristics of the two groups Table 3 Comparison of post-operative complications between groups Table 4 Comparison of early and late complications according to incision type

INTRODUCTION Preeclampsia is defined as the clinical condition associated with hypertension (systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg) and proteinuria or end-organ dysfunction in a woman who was normotensive before 20 weeks gestation(1,2). Hypertensive diseases in pregnancy account for 16% of maternal deaths in developed countries(1). According to data in the United States in 2010, 12% of pregnancy-associated maternal deaths are due to preeclampsia and eclampsia(1). The main characteristics of hypertensive disorders and fetal growth restriction in pregnancy are gestation-specific restructuring of spiral arteries and defects in trophoblastic invasion(3,4,5). In normal implantation, highly invasive trophoblast cells migrate to the decidua and myometrium and invade the endothelium of spiral arteries along with the muscularis tunica media. Smooth muscle structures at the distal part of uterine spiral arteries disappear. Terminal branches of the uterine artery transform into vessels that bear high capacity and low resistance, and provide the blood flow needed for development of the placenta(6,7). Although gestation-specific restructuring of the spiral arteries begins at the end of the first trimester and is completed by the 18-20th weeks, it is not known when trophoblastic invasion is terminated. Although they infiltrate the decidual spiral arteries, cytotrophoblasts cannot penetrate into the myometrium and pseudovasculogenesis does not occur(8,9). This in turn leads to undesirable conditions such as placental hypoperfusion, placental infarction and atherosclerosis, fetal demise during the second trimester, placental abruption, preeclampsia, intrauterine growth restriction (IUGR), preterm labor, and premature rupture of membranes(1,10,11). Invasion of spiral arteries by trophoblasts, release of special matrix metalloproteinases, and embodiment of the extracellular matrix (ECM) structure are necessary(12). ECM has an active role in regulating cellular activity and behaviors such as shaping the cell, differentiation, division and programmed cell death.

1). Invasion of spiral arteries by trophoblasts, release of special matrix metalloproteinases, and embodiment of the extracellular matrix (ECM) structure are necessary(12). ECM has an active role in regulating cellular activity and behaviors such as shaping the cell, differentiation, division and programmed cell death. Matrix metalloproteinases are a member of the ADAM and ADAMTS zinc-dependent proteinases family. ADAMTS degrade molecules that act on regulation of the tissue microenvironment. Some of these molecules belong to the ECM (collagen, proteoglycan, and many other glycoproteins), and others do not (receptors, growth factors, and cytokines). It was shown that spiral artery invasion was limited in preeclampsia (Figure 1). Changes in the ECM in the placentas and umbilical cords of the pregnant women with preeclampsia are different than those in normal pregnancies; however, the etiology is not yet clear(13,14,15). The roles of cellular adhesion molecules, angiogenic proteins, and the inflammation system on microvascular dysfunction are undeniable in patients with preeclampsia(16). Impairment of trophoblastic cell differentiation accounts for the inability of spiral arteries to invade into trophoblasts. Cytokines, adhesion molecules, ECM metalloproteinases, and class 1b major histocompatibility complex molecules released during trophoblastic invasion of endothelial cells and changes in HLA-G expression act on trophoblast differentiation(17,18).

accounts for the inability of spiral arteries to invade into trophoblasts. Cytokines, adhesion molecules, ECM metalloproteinases, and class 1b major histocompatibility complex molecules released during trophoblastic invasion of endothelial cells and changes in HLA-G expression act on trophoblast differentiation(17,18). Preeclampsia can result in maternal complications such as eclampsia, edema, hypertensive encephalopathy, stroke, kidney and liver failure, liver rupture, retinal detachment, blindness, disseminated intravascular coagulation, and death(19); and fetal outcomes such as IUGR, oligohydramnios, asphyxia, prematurity, preterm labor, and perinatal death. Studies on biological markers are needed in order to understand the etiology of this disease and predict preeclampsia. ADAMTS genes were discovered in 1997 and were first defined by Kuno et al.(20) as associated with colon cancer and inflammation. ADAMTS proteinases currently involve many physiologic and pathologic processes such as the those of the female reproductive system (Figure 2)(21,22).

Preeclampsia can result in maternal complications such as eclampsia, edema, hypertensive encephalopathy, stroke, kidney and liver failure, liver rupture, retinal detachment, blindness, disseminated intravascular coagulation, and death(19); and fetal outcomes such as IUGR, oligohydramnios, asphyxia, prematurity, preterm labor, and perinatal death. Studies on biological markers are needed in order to understand the etiology of this disease and predict preeclampsia. ADAMTS genes were discovered in 1997 and were first defined by Kuno et al.(20) as associated with colon cancer and inflammation. ADAMTS proteinases currently involve many physiologic and pathologic processes such as the those of the female reproductive system (Figure 2)(21,22). ADAMTS play a role in events such as restructuring of tissue, coagulation, angiogenesis, degradation of the ECM and basal membrane, and tumoral cell invasion and metastasis(23,24). ADAMTS should be expressed, and the ECM must be degraded and formed so that trophoblasts can invade maternal tissues and spiral arteries. Invasion of the ECM is provided by the release of complicated proteases. ADAMTS-1, -2, -4, -6, -7, -9, and -12 subtypes are expressed during the first trimester in human placenta(25). In addition, ADAMTS-1, -4, -5, -6, -7, -9, and -10 mRNA expressions were detected in term placenta(26,27,28,29,30). Therefore, it is important to interpret the molecular organization and function of ADAMTS.

s. ADAMTS-1, -2, -4, -6, -7, -9, and -12 subtypes are expressed during the first trimester in human placenta(25). In addition, ADAMTS-1, -4, -5, -6, -7, -9, and -10 mRNA expressions were detected in term placenta(26,27,28,29,30). Therefore, it is important to interpret the molecular organization and function of ADAMTS. ADAM-12 is among factors that predict preeclampsia(1). One of two types of ADAM-12 is secreted (ADAM-12s), which interferes with the function of insulin-like growth factor- binding protein 3 (IGFBP-3) and IGFBP-5, which in turn leads to the development of preeclampsia(31). The difference between ADAMTS and ADAM is the thrombospondin (TSP) portion, which resides at the molecular level. TSP is the ECM adhesion glycoprotein secreted from thrombocytes and is an angiogenesis inhibitor(32). ADAMTS-12 is expressed in precedence by extravillous trophoblasts as compared with other ADAMTS(33). Independent from the proteolytic activity of the enzyme, loss or decrease of ADAMTS-12 function diminishes the trophoblastic invasion. ADAMTS-12 regulates the cell invasion by regulating the avβ3 integrin heterodimer function and expression, and controls the trophoblast invasion by affecting the in vitro level of ADAMTS-12-transforming growth factor-β1 and interleukin-1β(33). As a result, compared with other ADAMTS, ADAMTS-12 is secreted in precedence from the placental tissues and increases the invasion of trophoblasts. Deficiency of ADAMTS enzymes leads to several pregnancy complications, mainly preeclampsia. Eda Gokdemir et al.(34) provided evidence that ADAMTS-12 levels were significantly decreased in the serum of patients with preeclampsia. Deficiency of ADAMTS-12 may cause defective trophoblast differentiation, abnormal remodeling of spiral arteries, and abnormal development of the placenta, which induces preeclampsia. Thus, ADAMTS proteinases play crucial roles in a variety of normal and pathophysiologic processes of placentation (Figure 3).

eeclampsia. Deficiency of ADAMTS-12 may cause defective trophoblast differentiation, abnormal remodeling of spiral arteries, and abnormal development of the placenta, which induces preeclampsia. Thus, ADAMTS proteinases play crucial roles in a variety of normal and pathophysiologic processes of placentation (Figure 3). Daglar et al.(35) studied placental levels of ADAMTS-12 to determine whether levels of enzymes differed among early-onset and late-onset severe preeclampsia. Early-onset preeclampsia was more likely associated with placental factors in impaired implantation and invasion than maternal factors. However, there were no significant differences in ADAMTS-12 levels between the groups. Also, ADAMTS genes are associated with other diseases such as ovarian cancer, polycystic ovarian syndrome, and premature ovarian failure(36,37). These genes play multiple roles in male and female fertility(38). RESULT Preeclampsia is one of the important complications of pregnancy. Early prediction of the disease is crucial in order to prevent maternal and fetal morbidity and mortality. A simple, cost-effective test performed in pregnant women with high-risk of developing preeclampsia would have significant effects on maternal and fetal morbidity and mortality of this disease. In ADAMTS function deficiency, impairments in differentiation of trophoblasts, invasion of spiral arteries, angiogenesis, and ECM restructuring ensue. Implantation failure can lead to abortion, preterm labor, early membrane rupture, pregnancy-associated hypertensive diseases, and preeclampsia.

ortality of this disease. In ADAMTS function deficiency, impairments in differentiation of trophoblasts, invasion of spiral arteries, angiogenesis, and ECM restructuring ensue. Implantation failure can lead to abortion, preterm labor, early membrane rupture, pregnancy-associated hypertensive diseases, and preeclampsia. CONCLUSION ADAMTS genes are potential candidates in the pathophysiology of preeclampsia. Further studies are needed to determine whether these molecules can predict preeclampsia. Ethics: Peer-review: Externally peer-reviewed. Authorship Contributions: Surgical and Medical Practices: İrem Eda Gökdemir, Concept: İrem Eda Gökdemir, Buğra Çoşkun, Design: Buğra Çoşkun, Data Collection or Processing: Özlem Evliyaoğlu, Analysis or Interpretation: İrem Eda Gökdemir, Özlem Evliyaoğlu, Literature Search: İrem Eda Gökdemir, Özlem Evliyaoğlu, Writing: İrem Eda Gökdemir, Buğra Çoşkun. Conflict of Interest: No conflict of interest was declared by the authors. Financial Disclosure: The authors declared that this study received no financial support. Figure 1 Normal placentation-pseudovasculogenesis (upper panel) and abnormal placentation in preeclampsia (lower panel)(11) Figure 2 The role of the ADAMTS: A new biological marker candidates in physiological and pathological processes in female reproductive system(22) Figure 3 Deficiency of ADAMTS-12 may cause defective trophoblast differentiation and matrix reshaping, abnormal remodeling of spiral arteries and finally abnormal development of the placenta that induce preeclampsia(34)

INTRODUCTION Breast cancer usually spreads to the lungs, bone, liver, brain, gastrointestinal (GI) tract, peritoneum or retroperitoneum. Extramammarial metastasis of breast cancer such as in the uterus is rarely seen(1,2,3,4). Invasive lobular carcinoma (ILC) differs from infiltrating ductal carcinoma (IDC) with respect to sites of metas-tasis. IDC metastases are frequently seen in the lung, bones, and liver. However, ILC’s metastatic sites are GI peritoneum and the retroperitoneum(3,4). ILC of the breast spreads to gynecologic organs more frequently than invasive ductal carcinoma(2,3). Recurrence of breast cancer usually occurs during the first two years. The incidence of recurrence decreases over time; however, it never disappears completely(5). In this report, we present a patient with recurrent metastatic invasive ductal breast carcinoma in the uterus 12 years after the initial diagnosis, with 3 years survival following successful treatment.

ring the first two years. The incidence of recurrence decreases over time; however, it never disappears completely(5). In this report, we present a patient with recurrent metastatic invasive ductal breast carcinoma in the uterus 12 years after the initial diagnosis, with 3 years survival following successful treatment. CASE REPORT A woman aged 34 years with a history of ductal carcinoma of the breast was referred to the gynecology outpatient clinic for routine follow-up. She had a history of left-sided total mastectomy and axillary lymph node dissection due to a malignant mass in her left breast 12 years ago. The histopathologic result was reported as invasive ductal carcinoma and the patient underwent 6 courses of taxotere, adriamycin, cyclophosphamide chemotherapy and 25 days of radiotherapy (a total dose of 5000 cGy) following the operation. Hormonotherapy with tamoxifen was given for five years owing to the positive (90%) estrogen and progesterone hormone receptors. The current diagnostic tests and gynecologic examination revealed a 4.8x3.2 cm lesion that caused diffuse thickening of the uterine wall (Figure 1). She was referred to the gynecologic oncology department for further evaluation. An endometrial biopsy was performed to eliminate any endometrial pathology caused by tamoxifen treatment, which was found negative.

ogic examination revealed a 4.8x3.2 cm lesion that caused diffuse thickening of the uterine wall (Figure 1). She was referred to the gynecologic oncology department for further evaluation. An endometrial biopsy was performed to eliminate any endometrial pathology caused by tamoxifen treatment, which was found negative. The mass on the uterine wall was removed under laparotomy. The pathologic investigation revealed metastasis of invasive ductal carcinoma of the breast. Breast carcinoma metastases in the myometrium were confirmed histopathologically and immunohistochemically (Figure 2). The results of the pathologic investigation were consulted with the medical oncology department and additional chemotherapy with gemcitabine and capecitabine (1-8/28 days) was given to the patient. The chemotherapy was completed and the patient has been under follow-up for 3 years with normal imaging on computerized tomographic (CT) examination and positron-emission tomography-CT (PET/CT).

cal oncology department and additional chemotherapy with gemcitabine and capecitabine (1-8/28 days) was given to the patient. The chemotherapy was completed and the patient has been under follow-up for 3 years with normal imaging on computerized tomographic (CT) examination and positron-emission tomography-CT (PET/CT). DISCUSSION Metastases to the female genital tract from extragenital cancers are rare. Breasts and the GI tract are the most common sites of the primary tumor. Ovaries are most frequently affected by metastases, which account for 75.8%, followed by the vagina (13.4%), uterine corpus (4.7%), cervix (3,4%), vulva (2%), and salpinx (0.7%)(6). Uterine metastases usually occur secondary to local lymphatic spread due to ovarian involvement and thus isolated uterine metastases from the extragenital tumors are rare and probably hematogenous. The initial symptoms of uterine metastasis depend on the anatomic involvement site. If the infiltration affects only the myometrium, patients may often be asymptomatic, as seen in our case(7). To detect metastatic disease early, routine gynecologic follow-up examinations should always be performed, even in asymptomatic patients with breast cancer under tamoxifen therapy. Additionally, it is important to distinguish whether the uterine lesions are primary or metastatic because of the different treatment options. The uterus is an uncommon site for breast cancer metastasis. Nevertheless, most uterine metastases are found at autopsy(2).

patients with breast cancer under tamoxifen therapy. Additionally, it is important to distinguish whether the uterine lesions are primary or metastatic because of the different treatment options. The uterus is an uncommon site for breast cancer metastasis. Nevertheless, most uterine metastases are found at autopsy(2). Tamoxifen has played an essential role in the treatment of hormone receptor-positive breast cancers. Five years of treatment with tamoxifen can reduce the risk of both recurrence and mortality due to breast cancer by approximately 30%(7). However, tamoxifen exerts a partial agonistic effect on the endometrium. Therefore, treatment with tamoxifen increases the incidence of endometrial hyperplasia, polyps, and endometrial neoplasms(8,9). Precise diagnosis affects critical decision-making with regard to the treatment of the uterine cancer. A primary uterine tumor should be resected, whereas a metastatic uterine tumor should be treated with systemic therapy as the first choice(10,11). In the present case, tamoxifen was used as an adjuvant hormone therapy with no additional surgical intervention.

n-making with regard to the treatment of the uterine cancer. A primary uterine tumor should be resected, whereas a metastatic uterine tumor should be treated with systemic therapy as the first choice(10,11). In the present case, tamoxifen was used as an adjuvant hormone therapy with no additional surgical intervention. Although there are few reports on the prognosis of patients with metastatic uterine tumors from breast cancer, most patients have been reported to have poor prognosis. However, given the limited number of reported cases, further studies are needed, along with a larger number of case reports to further our understanding of the prognosis of these cancers, and to determine the best course of treatment(12). There has been no recurrence in our patient for the last 3 years and this is the longest disease-free survival report in such cases. Any patient with abnormal imaging should be evaluated for vaginal, cervical, and uterine pathology. As this case aptly demonstrates, negative endometrial biopsy should not reduce the concern for pathology or alter the examination of a patient with abnormal imaging.

Although there are few reports on the prognosis of patients with metastatic uterine tumors from breast cancer, most patients have been reported to have poor prognosis. However, given the limited number of reported cases, further studies are needed, along with a larger number of case reports to further our understanding of the prognosis of these cancers, and to determine the best course of treatment(12). There has been no recurrence in our patient for the last 3 years and this is the longest disease-free survival report in such cases. Any patient with abnormal imaging should be evaluated for vaginal, cervical, and uterine pathology. As this case aptly demonstrates, negative endometrial biopsy should not reduce the concern for pathology or alter the examination of a patient with abnormal imaging. This case demonstrates the importance of maintaining a broad differential diagnosis in patients with abnormal imaging in the setting of a history of breast cancer and tamoxifen use. While performing ultrasound examination, like with this patient, focusing on endometrial thickness, endometrial polyps or suspicion of endometrial neoplasm may cause suspicious findings to be missed, except endometrium. In addition, endometrial biopsy alone is not sufficient for a diagnosis, and may be misleading. Evaluation of symptoms with imaging remains essential in identifying the underlying pathology. In conclusion, it should be kept in mind that patients with breast cancer who have received tamoxifen may develop primary endometrial cancers, and may also demonstrate uterine metastases.

This case demonstrates the importance of maintaining a broad differential diagnosis in patients with abnormal imaging in the setting of a history of breast cancer and tamoxifen use. While performing ultrasound examination, like with this patient, focusing on endometrial thickness, endometrial polyps or suspicion of endometrial neoplasm may cause suspicious findings to be missed, except endometrium. In addition, endometrial biopsy alone is not sufficient for a diagnosis, and may be misleading. Evaluation of symptoms with imaging remains essential in identifying the underlying pathology. In conclusion, it should be kept in mind that patients with breast cancer who have received tamoxifen may develop primary endometrial cancers, and may also demonstrate uterine metastases. I thank Levent Şentürk, MD, for checking and editing the manuscript. Ethics: Informed Consent: Consent form was filled out by all participants. Peer-review: External and Internal peer-reviewed. Authorship Contributions: Surgical and Medical Practices: Tayfur Çift, Şennur İlvan, Concept: Berna Aslan, Design: Tayfur Çift, Berk Bulut, Data Collection or Processing: Berna Aslan, Analysis or Interpretation: Tayfur Çift, Berk Bulut, Literature Search: Berna Aslan, Tayfur Çift, Writing: Berna Aslan, Berk Bulut. Conflict of Interest: No conflict of interest was declared by the authors. Financial Disclosure: The authors declared that this study has received no financial support. Figure 1 Ultrasound image of the uterine mass Figure 2 Pathologic examination of the excised material

Authorship Contributions: Surgical and Medical Practices: Tayfur Çift, Şennur İlvan, Concept: Berna Aslan, Design: Tayfur Çift, Berk Bulut, Data Collection or Processing: Berna Aslan, Analysis or Interpretation: Tayfur Çift, Berk Bulut, Literature Search: Berna Aslan, Tayfur Çift, Writing: Berna Aslan, Berk Bulut. Conflict of Interest: No conflict of interest was declared by the authors. Financial Disclosure: The authors declared that this study has received no financial support. Figure 1 Ultrasound image of the uterine mass Figure 2 Pathologic examination of the excised material Pathologic examination. Pathologic microscopic examination demonstrating malignant epithelial tumor cells; (Hematoxylin-Eosin, x100)

INTRODUCTION Gestational diabetes mellitus (GDM) is a relatively common disorder of pregnancy. The prevalence of GDM ranges from 1 to 6% depending on the studied population(1,2). Large population-based studies are lacking in Turkey but some available data from cohort studies suggest that the prevalence of GDM ranges between 4-10% in Turkey(3,4,5). Prediction and diagnosis of GDM is important for ongoing pregnancy and has important implications for subsequent health of the mother. GDM is considered a significant risk factor for subsequent development of type II diabetes and is associated with a poorer cardiovascular risk profile compared with women without GDM(6,7). The method of screening (one-step versus two-step), application of screening (broad versus risk-dependent), and diagnostic criteria of GDM have been the subject to debate. Risk- dependent screening is being abandoned world-wide after the recommendation of the American Diabetes Association for screening all women without prior known diabetes between 24 and 28th gestational week(8). The recommendation was based upon the inefficiency of the current history-based risk assessment method. However, the benefits of broad screening have not yet been established. A recent study by Koivunen et al.(9) reported no benefit of broad screening on cesarean section rates and birthweight despite increased rates of GDM diagnosis, glucose-challenge test applications, and labor induction. Until the benefits of broad screening are established there is a need of a better risk assessment method.

ecent study by Koivunen et al.(9) reported no benefit of broad screening on cesarean section rates and birthweight despite increased rates of GDM diagnosis, glucose-challenge test applications, and labor induction. Until the benefits of broad screening are established there is a need of a better risk assessment method. Uric acid has been investigated as a possible risk factor for the development of GDM. Several researchers reported an association of uric acid levels with development of GDM(10,11,12). The aim of the current study was to investigate the association of first trimester serum uric acid levels with development of GDM in a population of low-risk pregnant women.

ossible risk factor for the development of GDM. Several researchers reported an association of uric acid levels with development of GDM(10,11,12). The aim of the current study was to investigate the association of first trimester serum uric acid levels with development of GDM in a population of low-risk pregnant women. MATERIALS AND METHODS This was a retrospective case-control study including pregnant women who were followed-up entirely at Ankara University Hospital between January 2012 and December 2014. Our antenatal follow-up program includes routine blood tests during the first trimester with biochemical panel and a two-step approach for screening of GDM, in accordance with the American Diabetes Association recommendations(13). The two-step approach consists of a 50-g oral glucose challenge test (GCT) performed between the 24th and 28th weeks of gestation, followed by a 100-g oral GCT if the initial 50-g oral GCT serial glucose result is over 140 mg/dL. The results of the 100-g oral GCT were interpreted in accordance with the Carpenter and Coustan(14) criteria for diagnosis of GDM. Uric acid levels were analyzed from serum samples obtained in the first trimester. Gestational ages were calculated from crown-rump length measurements in the first trimester(15).

40 mg/dL. The results of the 100-g oral GCT were interpreted in accordance with the Carpenter and Coustan(14) criteria for diagnosis of GDM. Uric acid levels were analyzed from serum samples obtained in the first trimester. Gestational ages were calculated from crown-rump length measurements in the first trimester(15). Pregnant women who had completed both first trimester biochemical panel and GDM screening were included for analysis. Women with prior diabetes, hypertension, chronic kidney disease, multiple pregnancy, chronic liver disease, gout arthritis or history of alcohol use were excluded from the analysis. The primary outcome of the study was the association of uric acid levels with occurrence of GDM. For the statistical analysis, the pregnant women were divided into three groups according to their respective GDM screening results. Women who took the 100-g oral GCT were divided into two groups, those whose results indicated GDM (GDM group) and those whose results had at least one abnormal or no abnormal results and did not meet the criteria for diagnosis of GDM (impaired glucose tolerance group). A maternal age-, gestational age-, and body mass index (BMI) matched control group was used to compare uric acid levels between groups.

ndicated GDM (GDM group) and those whose results had at least one abnormal or no abnormal results and did not meet the criteria for diagnosis of GDM (impaired glucose tolerance group). A maternal age-, gestational age-, and body mass index (BMI) matched control group was used to compare uric acid levels between groups. To determine the size of the case and control groups, first trimester serum uric acid levels of a small group of healthy pregnant women without GDM were used. The mean uric acid level of this group was 3.72 mg/dL ±1.14. To detect a 0.5 mg/dL mean between-group difference in uric acid levels, 41 samples in each group was required for the study to have 80% or more power with a two-sided type I error rate of 0.05.

f a small group of healthy pregnant women without GDM were used. The mean uric acid level of this group was 3.72 mg/dL ±1.14. To detect a 0.5 mg/dL mean between-group difference in uric acid levels, 41 samples in each group was required for the study to have 80% or more power with a two-sided type I error rate of 0.05. All statistical analyses were performed using SPSS version 21.0 (IBM Corporation, Armonk NYC, USA). Parameters with normal distribution are described in means with standard deviation. Parameters with non-normal distribution are described in median with minimum maximum values. Student’s t-test was used to compare continuous variables between independent groups. For each group, one-way ANOVA was used to test maternal age, pre-gestational BMI, and the gestational week serum samples as covariates to see if adjustment in a multivariable logistic regression model was necessary. Receiver-operating characteristics (ROC) curves were used to test the utility of first trimester serum uric acid levels for diagnosis of GDM. P values below 0.05 were considered statistically significant. This study was considered exempt from ethical approval by the Local Ethics Committee of Ankara University.

cessary. Receiver-operating characteristics (ROC) curves were used to test the utility of first trimester serum uric acid levels for diagnosis of GDM. P values below 0.05 were considered statistically significant. This study was considered exempt from ethical approval by the Local Ethics Committee of Ankara University. RESULTS A total of 4.812 pregnant women completed their antenatal follow-up in Ankara University Department of Obstetrics and Gynecology outpatient clinic between 2012 and 2014. Five hundred ten pregnant women were scheduled for a 100-g oral GCT because of a positive result of 50-g oral GCT. The results of the 100-g oral GCT revealed that 86 women had GDM and the remaining 410 women were diagnosed as having IGT. The prevalence of GDM was 1.7% in our study group. Twenty-six women in the GDM group and 66 women in the IGT group were excluded from the final analysis because they had co-morbidities (gestational hypertension, chronic liver or kidney diseaes), multiple gestations or missing first trimester serum uric acid levels. Two hundred two healthy age- and BMI-matched pregnant women were included as a control group. Baseline characteristics of the study groups can be found in Table 1. In each separate group, one-way ANOVA was used to test for an association of BMI, maternal age, and gestational age serum samples measured for serum uric acid levels, which revealed no association of tested covariates with serum uric acid levels (p>0.05).

RESULTS A total of 4.812 pregnant women completed their antenatal follow-up in Ankara University Department of Obstetrics and Gynecology outpatient clinic between 2012 and 2014. Five hundred ten pregnant women were scheduled for a 100-g oral GCT because of a positive result of 50-g oral GCT. The results of the 100-g oral GCT revealed that 86 women had GDM and the remaining 410 women were diagnosed as having IGT. The prevalence of GDM was 1.7% in our study group. Twenty-six women in the GDM group and 66 women in the IGT group were excluded from the final analysis because they had co-morbidities (gestational hypertension, chronic liver or kidney diseaes), multiple gestations or missing first trimester serum uric acid levels. Two hundred two healthy age- and BMI-matched pregnant women were included as a control group. Baseline characteristics of the study groups can be found in Table 1. In each separate group, one-way ANOVA was used to test for an association of BMI, maternal age, and gestational age serum samples measured for serum uric acid levels, which revealed no association of tested covariates with serum uric acid levels (p>0.05). Student’s t test revealed serum uric acid levels were significantly different between the groups with 5.94±0.97 mg/dL in the GDM group, 4.76±1.51 mg/dL in IGT group, and 3.76±1.07 mg/dL in the control group (p<0.001). ROC curve was obtained for the first trimester serum uric acid levels to detect GDM (Figure 1). The area under the curve was 0.92 [95% CI: (0.88-0.95)] with a diagnostic threshold of 3.95 mg/dL; first trimester serum uric acid levels had a sensitivity of 100% and specificity of 60% for the prediction of GDM.

(p<0.001). ROC curve was obtained for the first trimester serum uric acid levels to detect GDM (Figure 1). The area under the curve was 0.92 [95% CI: (0.88-0.95)] with a diagnostic threshold of 3.95 mg/dL; first trimester serum uric acid levels had a sensitivity of 100% and specificity of 60% for the prediction of GDM. DISCUSSION Uric acid is the final product of the oxidation step of purine catabolism and is an important marker for insulin resistance and the future development of metabolic syndrome. The prevalence of GDM is rising across the globe and the benefits of broad screening for GDM has not yet been proven(9,16). Considering that the prevalence of GDM varies greatly between populations, a better risk assessment model could prevent unnecessary oral GCTs for screening of GDM, especially in populations such as ours where the prevalence of GDM is exceedingly low. In our study, we saw that first trimester uric acid levels had a linear association with the development of GDM and IGT. First trimester serum uric acid levels along with other parameters such as sex-hormone binding globulin, high-sensitive C-reactive protein, and adiponectin could be incorporated into a risk model to assess the need for oral GCT later in pregnancy(17,18).

els had a linear association with the development of GDM and IGT. First trimester serum uric acid levels along with other parameters such as sex-hormone binding globulin, high-sensitive C-reactive protein, and adiponectin could be incorporated into a risk model to assess the need for oral GCT later in pregnancy(17,18). The strong points of our research are that our test sample was sufficiently powered and also demonstrated the diagnostic power of serum uric acid levels in a population of pregnant women with very low prevalence of GDM. Our study was retrospective in nature and had certain limitations that might have confounded our results, such as missing data in the study group and limited control over the study groups. Our study adds to the body of literature about the association of serum uric acid levels with the development of GDM(10,11,12,20). There is a conflicting study by Maged et al.(21) which suggested no association, but their study was insufficiently powered to demonstrate a lack of difference between groups. Our study is different from the previous study with a GDM prevalence of 1.7%, which is much lower than other studies, and it is the first to report the association and predictive value of the test in a low-prevalence population. Further studies in this field should investigate the predictive value of uric acid levels combined with other biochemical tests in an effort to create a screening model.

which is much lower than other studies, and it is the first to report the association and predictive value of the test in a low-prevalence population. Further studies in this field should investigate the predictive value of uric acid levels combined with other biochemical tests in an effort to create a screening model. CONCLUSION In summary, first trimester serum uric acid levels are associated with subsequent development of IGT and GDM. The test has good predictive value for the diagnosis of GDM and it can be used in a risk assessment model. Ethics: Ethics Committee Approval: The study were approved by the Ankara University of Local Ethics Committee, Informed Consent: Consent form was filled out by all participants. Peer-review: External and Internal peer-reviewed. Authorship Contributions: Surgical and Medical Practices: Seda Şahin Aker, Concept: Seda Şahin Aker, Tuncay Yüce, Design: Erkan Kalafat, Data Collection or Processing: Seda Şahin Aker, Analysis or Interpretation: Tuncay Yüce, Feride Söylemez, Literature Search: Seda Şahin Aker, Murat Seval, Writing: Seda Şahin Aker, Erkan Kalafat. Conflict of Interest: No conflict of interest was declared by the authors. Financial Disclosure: The authors declared that this study received no financial support. Table 1 Maternal demographic characteristics Figure 1 Receiver-operating characteristics curve for prediction of gestational diabetes mellitus with first trimester serum uric acid levels

PRECIS: No significant difference was found between patients who were sampled for culture and those who were not sampled in terms of pregnancy rates in intracytoplasmic sperm injection cycles. INTRODUCTION Significant increase in the number of couples seeking treatment for infertility. Their increased use has been associated with significant economic costs because they are expensive procedures. As stated in a study in the Netherlands, costs per cycle started at €2381 and €2578 for in vitro fertilization (IVF) and Intracytoplasmic sperm injection (ICSI), respectively(1). The pregnancy rate in IVF programmes remains about 20-50% inspite of the high rate of successful fertilization. This has led to the proposition that additional factors critical for the implantation process must be limiting(2). There is growing evidence that cervical-vaginal flora may strongly influence pregnancy rates. A few studies showed that the presence of microbial flora of the cervix on embryo transfer (ET) catheter was associated with poor IVF-ET outcomes(3,4,5). Chlamydia trachomatis (C. trachomatis) and Neisseria gonorrhoeae (N. gonorrheae) are the most prevalent sexually-transmitted bacterial infections worldwide. Although most genitourinary tract infections of C. trachomatis in women are asymptomatic, it is a major public health problem because of the recent rises in the reported number of cases and the severe reproductive morbidity that results from untreated infections and associated costs to the health services(6). However, bacterial vaginosis (BV) is being increasingly implicated in upper genital tract infections in women(7). Trichomonas vaginalis is a far more prevalent sexually-transmitted infection than either Chlamydia trachomatis or Neisseria gonorrhoeae, yet in stark contrast, little attention is paid to trichomoniasis. It is suggested that it can reduce the chances of conception from both female and male factors and should be considered in the diagnostic tests of infertile couples(8).

ly-transmitted infection than either Chlamydia trachomatis or Neisseria gonorrhoeae, yet in stark contrast, little attention is paid to trichomoniasis. It is suggested that it can reduce the chances of conception from both female and male factors and should be considered in the diagnostic tests of infertile couples(8). The primary objective of our study was to investigate the effect of screening for vaginal infections on pregnancy success in patients undergoing ICSI in our clinics. MATERIALS AND METHODS Women undergoing IVF at the Assisted Conception Unit of Etlik Zubeyde Hanim Women’s Health Education and Research Hospital between April 2009 and June 2009 were recruited for this case-control study. Ethical approval for the study was obtained from the local ethics committee (approval date/number: 13.03.2009/7) and all participants gave their written consent to participate. The research was completed in accordance with the Declaration of Helsinki(9).

il 2009 and June 2009 were recruited for this case-control study. Ethical approval for the study was obtained from the local ethics committee (approval date/number: 13.03.2009/7) and all participants gave their written consent to participate. The research was completed in accordance with the Declaration of Helsinki(9). Women who had basal serum levels of follicle-stimulating hormone <10 mIU/L, prolactin, free triiodothyronine (fT3), free thyroxine (fT4), and thyroid-stimulating hormone levels within the normal range, aged <38 years, and asymptomatic for leukorrhea underwent a long luteal GnRH-analog protocol. Patients who had received antibiotic treatment during the previous three months were excluded from the study. All the enrolled women were informed that they had been investigated for sexually-transmitted microorganisms and had been thoroughly tested in accordance with our clinic protocol, which included a baseline early follicular phase endocrine profile, and baseline transvaginal ultrasonography including antral follicle count. Age, cause, and duration of infertility was recorded. On completion of the investigations, 60 patients were randomly assigned to the study group (group 1) and 60 patients to the control group (group 2). Randomization was based on computer-generated codes. In group 1, patients were screened for vaginal infections and no screening was performed in group 2. The women entered the study on the day of gonadotropin initiation. The women were treated with a conventional superovulation regimen of pituitary down-regulation followed by stimulation with gonadotropins.

erated codes. In group 1, patients were screened for vaginal infections and no screening was performed in group 2. The women entered the study on the day of gonadotropin initiation. The women were treated with a conventional superovulation regimen of pituitary down-regulation followed by stimulation with gonadotropins. Specimens were collected immediately after menses. Cultures for N. gonorrhea and C. trachomatisvaginosis and Trichomonas were collected separately from the endocervix and vaginal cultures were taken to investigate the presence of bacterial vaginosis and Trichomonas vaginalis. A non-lubricated bivalve speculum was inserted and the vaginal walls and posterior fornix were sampled using two sterile cotton swabs. One swab was rolled on a glass slide for Gram staining, and the flora were investigated for BV using Nugent’s criteria. One swab was placed in aerobic transport media. A second droplet of discharge was mixed with saline on another slide for the wet mount. The wet mount was immediately examined to detect motile Trichomonas trophozoites. C. trachomatis was investigated via QuickVue test using as enzyme immunoassay (EIA). QuickVue is a rapid chlamydial antigen capture assay based on genus-specific murine monoclonal antibody. Specimens for N. gonorrhoeae were collected from the endocervix as described above. The specimens were immediately plated directly onto modified Thayer-Martin medium.

QuickVue test using as enzyme immunoassay (EIA). QuickVue is a rapid chlamydial antigen capture assay based on genus-specific murine monoclonal antibody. Specimens for N. gonorrhoeae were collected from the endocervix as described above. The specimens were immediately plated directly onto modified Thayer-Martin medium. The time between obtaining the culture result and the day for oocyte pick up in each patient was at least 5 days because the cultures and gram stain were collected at the beginning of the IVF cycle after menses. Patients were treated with proper antimicrobials according to the recommendations of the Center for Disease Control and Prevention (CDC) when organisms are detected. For bacterial vaginosis, 500 mg oral metronidazole (Flagyl) taken twice daily for 7 days and metronidazole intravaginal 0.75% gel were used. The recommended treatment for tichomoniasis was 2 g oral metronidazole (Flagyl) in a single dose. Oral azithromycin 1 g was scheduled for patients with C. trachomatis and a single oral 400-mg dose of cefixime was scheduled for patients with N. gonorrhoeae. The treatments were completed before oocyte pick-up.

were used. The recommended treatment for tichomoniasis was 2 g oral metronidazole (Flagyl) in a single dose. Oral azithromycin 1 g was scheduled for patients with C. trachomatis and a single oral 400-mg dose of cefixime was scheduled for patients with N. gonorrhoeae. The treatments were completed before oocyte pick-up. When at least two leading follicles reached ≥18 mm in diameter, recombinant (rec) human Chorionic Gonadotropin (hCG Ovitrelle, Serono) was administered. Transvaginal ultrasound-guided oocyte retrieval was performed 34-36 hours after 0.25 mg rec hCG administration. Maximum 3 embryos were transferred on day 3 or 5 after oocyte retrieval. In both groups, good quality or blastocyst stage embryos were transferred. The luteal phase was supported with vaginal progesterone gel (Crinone 8%) administered daily starting on the day of oocyte pick-up. Conception was defined as a positive hCG titer on day 12. We considered concentrations greater than 10 U/L as a positive result. Follow up ultrasound at 6 and 8 weeks of gestation confirmed clinical pregnancy. We followed all the women through to completion of the pregnancy. The sample size of the study were calculated using G*Power (G*Power Ver. 3.00.10, Franz Faul, Üniversität Kiel, Germany) statistical package. The required sample size for 90% power, 5% Type I error, 10% Type II error and 20% effect size were calculated as 96 to better elucidate the impact of vaginal infection on pregnancy rates in intracytoplasmic sperm injection cycles. To protect the study from potential lost to follow-ups, we planned to enroll 120 patients.

e required sample size for 90% power, 5% Type I error, 10% Type II error and 20% effect size were calculated as 96 to better elucidate the impact of vaginal infection on pregnancy rates in intracytoplasmic sperm injection cycles. To protect the study from potential lost to follow-ups, we planned to enroll 120 patients. The statistical analyses were performed using the Statistical Package for Social Sciences (version 11.5; SPSS Inc., Chicago). Descriptive data are expressed as mean ± standard deviation. Student’s t-test or Mann-Whitney U test were used for the comparison between groups. Pearson’s Chi-square and Fisher’s exact tests were used to analyze categorical data. The level of significance was set at p<0.05. RESULTS One hundred twenty patients who met the inclusion criteria were enrolled into the study. Eighty-five patients (70.8%) who underwent IVF reached the embryo transfer stage. The mean age of the patients was 31±6.1 years. Clinical indications included male factor infertility in 56 (46.7%) cycles, ovulatory dysfunction in 24 (20.9%), unexplained infertility in 15 (12.5%), and tubal factor infertility in 6 (5%) cycles.

five patients (70.8%) who underwent IVF reached the embryo transfer stage. The mean age of the patients was 31±6.1 years. Clinical indications included male factor infertility in 56 (46.7%) cycles, ovulatory dysfunction in 24 (20.9%), unexplained infertility in 15 (12.5%), and tubal factor infertility in 6 (5%) cycles. There was no significant difference between the ages of patients who conceived and those who did not conceive. Likewise, the two groups of patients were similar regarding the duration of infertility. Six of 25 women (24%) with unexplained infertility, 18 of 37 women (48.6%) with male factor infertility, and 6 of 23 (26.1%) women with other causes of infertility conceived successfully, but there was no difference among causes of infertility regarding the rates of pregnancy (p=0.077) (Table 1). In group 1 (n=60), 45 patients underwent ET procedure. The rate of conception was 23.5% (n=4) in those with positive culture (n=17), and 42.9% (n=12) when no microorganism was detected (n=28). In group 2 (n=60), 40 patients reached ET. Of these 40 patients, conception was achieved in 35.0% (n=14). There was no significant difference between groups 1 and 2 in conception rates (p=0.96), and there was no difference among the groups of screen-positive, screen-negative, and not screened with culture, in terms of pregnancy success (p=0.42) (Table 2). None of the patients had N. gonorrhoeae or Trichomonas vaginalis. Bacterial vaginosis was detected in 13 patients, and in 4 patients both bacterial vaginosis and C. trachomatis were recovered (Table 3).

In group 1 (n=60), 45 patients underwent ET procedure. The rate of conception was 23.5% (n=4) in those with positive culture (n=17), and 42.9% (n=12) when no microorganism was detected (n=28). In group 2 (n=60), 40 patients reached ET. Of these 40 patients, conception was achieved in 35.0% (n=14). There was no significant difference between groups 1 and 2 in conception rates (p=0.96), and there was no difference among the groups of screen-positive, screen-negative, and not screened with culture, in terms of pregnancy success (p=0.42) (Table 2). None of the patients had N. gonorrhoeae or Trichomonas vaginalis. Bacterial vaginosis was detected in 13 patients, and in 4 patients both bacterial vaginosis and C. trachomatis were recovered (Table 3). Three of four patients who were screen-positive conceived and continued their pregnancy until a successful and healthy term delivery, but one spontaneously lost her pregnancy at six weeks of gestation. Eight of 12 patients who were screen-negative conceived and continued their pregnancy until a successful and healthy term delivery. DISCUSSION We have shown that there was no difference betwen the groups of screen-positive, screen-negative and not screened in culture in terms of pregnancy success in our study population.

Three of four patients who were screen-positive conceived and continued their pregnancy until a successful and healthy term delivery, but one spontaneously lost her pregnancy at six weeks of gestation. Eight of 12 patients who were screen-negative conceived and continued their pregnancy until a successful and healthy term delivery. DISCUSSION We have shown that there was no difference betwen the groups of screen-positive, screen-negative and not screened in culture in terms of pregnancy success in our study population. In previous studies, Chlamydial antibodies were found significantly higher in patients who attended clinics for tubal factor infertility and were candidates for IVF than patients who attended for other causes of female infertility(10,11,12). Gaudoin et al.(10) concluded that bacterial vaginosis and prior chlamydial infections had a significant association with tubal factor infertility, but were no associated with IVF outcomes in their study in 1999. However, in our study, these infections could not be accused for tubal factor infertility because the patients who were treated with IVF accounted for a small number. Chlamydial infections detected by favor of chlamydial antibodies were found not to effect IVF outcomes and embryonic implantation in a study by Osser et al.(11) that included 121 women with tubal infertility. Also, in our study, chlamydial infections detected using EIA were found not to effect IVF outcomes.

all number. Chlamydial infections detected by favor of chlamydial antibodies were found not to effect IVF outcomes and embryonic implantation in a study by Osser et al.(11) that included 121 women with tubal infertility. Also, in our study, chlamydial infections detected using EIA were found not to effect IVF outcomes. Apart from this, several different studies investigated the effects of lower genital tract infections on female infertility. Spandorfer et al.(13) studied the prevalence of bacterial vaginosis and abnormal bacterial vaginal microenvironment in infertile women, and cervical inflammatory cytokines caused by abnormal vaginal flora were found to be high in patients who presented Wilson with unexplained infertility; however, no effect was found on IVF outcomes(14). In another study by Wilson et al.(14) bacterial vaginosis was shown to be more frequent in patients undergoing IVF because of tubal infertility than in patients with other causes of infertility; these findings support the association among bacterial vaginosis, pelvic inflammatory disease, and tubal damage. Furthermore, in that study, bacterial vaginosis was detected more frequently in women undergoing IVF owing to anovulation, and hormones were shown to have effects on vaginal flora(14)">. Our study failed to show these effects because of the low number of patients. Ralph et al.(15) found that bacterial vaginosis had no effect on pregnancy rates, but had abortifacient effects in the first trimester of pregnancy in their large study that included 867 infertile women who presented for IVF. Additionally, bacterial vaginosis was found to be associated with endometritis and preterm labor in a study by Korn et al.(16).

rial vaginosis had no effect on pregnancy rates, but had abortifacient effects in the first trimester of pregnancy in their large study that included 867 infertile women who presented for IVF. Additionally, bacterial vaginosis was found to be associated with endometritis and preterm labor in a study by Korn et al.(16). The transmissive effects of bacterial vaginosis for sexually-transmitted diseases were studied by Yoshimura et al.(17) with a sample of 406 patients. C. trachomatis was more frequently detected in patients with bacterial vaginosis than in those without. In the same study, young women were shown to be more inclined to bacterial vaginosis and sexually-transmitted diseases, especially Chlamydial cervicitis. In our study, there was no difference between the ages of women who were culture-positive and culture-negative. However, in our study, all patients who had Chlamydial infection also had bacterial vaginosis, and our results were similar with that study.

nd sexually-transmitted diseases, especially Chlamydial cervicitis. In our study, there was no difference between the ages of women who were culture-positive and culture-negative. However, in our study, all patients who had Chlamydial infection also had bacterial vaginosis, and our results were similar with that study. Wittemer et al.(18) tried to determine the effects of treatment of vaginal and endocervical infections on IVF outcomes. The authors concluded that suspending the actual IVF cycle seemed more reasonable because of the possible deleterious effects of infection on embryonic implantation process, even if the patient was treated with a proper antimicrobial agent. Selim et al.(19) stressed that women with bacterial vaginosis and with a decreased vaginal concentration of hydrogen peroxide-producing lactobacilli may have decreased conception rates and increased rates of failed pregnancy. Liversedge et al.(20) stated that giving treatment for bacterial vaginosis before IVF could only be useful to lower the late pregnancy complications because there has been no confirmed effects of bacterial vaginosis on the rates of fertilization and implantation. However, in our study, there was no difference between the pregnancy rates of patients screened and not screened with culture, although lower pregnancy rates were detected in patients who were culture-positive.

se there has been no confirmed effects of bacterial vaginosis on the rates of fertilization and implantation. However, in our study, there was no difference between the pregnancy rates of patients screened and not screened with culture, although lower pregnancy rates were detected in patients who were culture-positive. The small number in our study group, and the subsequent scarcity of the patients who attended for IVF, and additionally, the unavailability of embryo transfer for every patient prevents us from being able to express the association between the types of infectious microorganisms and the etiology of infertility. A confirmatory culture was not taken after treatment. These represent the limitations of our study. In conclusion, this study was performed to investigate whether endocervical and vaginal infections had any effects on pregnancy rates in IVF cycles. The patients who underwent endocervical and vaginal culture were compared with patients who had no culture. No significant difference was found between the patients who were sampled for culture and patients who were not sampled in terms of pregnancy rates. Also, no difference was found between patients who were culture-negative and those who were treated with antimicrobials after a culture-positive result. Ethics: Ethics Committee Approval: Ethical approval for the study was obtained from the local ethics committee (approval date/number: 13.03.2009/7) and all participants gave their written consent to participate. The research was completed in accordance with the Declaration of Helsinki.

In conclusion, this study was performed to investigate whether endocervical and vaginal infections had any effects on pregnancy rates in IVF cycles. The patients who underwent endocervical and vaginal culture were compared with patients who had no culture. No significant difference was found between the patients who were sampled for culture and patients who were not sampled in terms of pregnancy rates. Also, no difference was found between patients who were culture-negative and those who were treated with antimicrobials after a culture-positive result. Ethics: Ethics Committee Approval: Ethical approval for the study was obtained from the local ethics committee (approval date/number: 13.03.2009/7) and all participants gave their written consent to participate. The research was completed in accordance with the Declaration of Helsinki. Peer-review: External and Internal peer-reviewed. Authorship Contributions: Surgical and Medical Practices: Gönül Aksu, Serdar Dilbaz, Concept: Özlem Eldivan, Özlem Evliyaoğlu, Design: Özlem Eldivan, Ebru Ersoy, Data Collection or Processing: Özlem Eldivan, Analysis or Interpretation: Özlem Evliyaoğlu, Ümit Göktolga, Literature Search: Özlem Evliyaoğlu, Ebru Ersoy, Writing: Özlem Eldivan, Özlem Evliyaoğlu, Ebru Ersoy. Conflict of Interest: No conflict of interest was declared by the authors. Financial Disclosure: The authors declared that this study received no financial support.

Authorship Contributions: Surgical and Medical Practices: Gönül Aksu, Serdar Dilbaz, Concept: Özlem Eldivan, Özlem Evliyaoğlu, Design: Özlem Eldivan, Ebru Ersoy, Data Collection or Processing: Özlem Eldivan, Analysis or Interpretation: Özlem Evliyaoğlu, Ümit Göktolga, Literature Search: Özlem Evliyaoğlu, Ebru Ersoy, Writing: Özlem Eldivan, Özlem Evliyaoğlu, Ebru Ersoy. Conflict of Interest: No conflict of interest was declared by the authors. Financial Disclosure: The authors declared that this study received no financial support. Table 1 Distributions and comparisons of age, duration of infertility, and cause of infertility in patients who did and did not conceive Table 2 Screening with culture and its association with pregnancy rates Table 3 Conception rates according to the cultured microorganism

PRECIS: We investigated the prevalence of the endometrial polyps in patients with uterine fibroids and associated factors with the coexistence of these two pathologies. INTRODUCTION Endometrial polyps and uterine fibroids are common causes of abnormal uterine bleeding and may coexist. Overgrowth of endometrial glands and stroma leads to endometrial polyps. The prevalence of endometrial polyps is 10-40% in women with abnormal uterine bleeding, and increases with age(1,2).Transvaginal sonography, saline infusion sonohysterography, and hysteroscopy are the diagnostic tools for endometrial polyps(3,4). Malignant tissue changes occur in 3.1% of endometrial polyps(1). Therefore, histopathologic examination of polyps is necessary to exclude malignancy(5,6). Uterine fibroids are the most common benign tumors in women. Abnormal uterine bleeding occurs in 30% of women with fibroids(7). Uterine fibroids are the leading causes of hysterectomy, and hysterectomy is the most effective treatment method for symptomatic fibroids in perimenopausal women(8,9). However, alternative treatments such as progestogens, levonorgestrel-releasing intrauterine system, tranexamic acid, nonsteroidal anti-inflammatory drugs, gonadotropin-releasing hormone analogs, myomectomy, and uterine artery embolization are also available in the management of uterine fibroids(9).

nopausal women(8,9). However, alternative treatments such as progestogens, levonorgestrel-releasing intrauterine system, tranexamic acid, nonsteroidal anti-inflammatory drugs, gonadotropin-releasing hormone analogs, myomectomy, and uterine artery embolization are also available in the management of uterine fibroids(9). As far as we know, no studies have investigated the coexistence of endometrial polyps and uterine fibroids in the literature. The aim of the retrospective study was to identify the prevalence of the endometrial polyps coexisting with uterine fibroids and associated factors of the coexistence of the two pathologies. Knowledge of the coexistence of these pathologies may help to choose the appropriate therapeutic management. Medical management, myomectomy, or uterine artery embolization are not appropriate treatment options in the presence of malignant endometrial polyps, and hysteroscopic resection alone of endometrial polyps may not be sufficient to relieve abnormal uterine bleeding symptoms in patients with multiple and large uterine fibroids.

management, myomectomy, or uterine artery embolization are not appropriate treatment options in the presence of malignant endometrial polyps, and hysteroscopic resection alone of endometrial polyps may not be sufficient to relieve abnormal uterine bleeding symptoms in patients with multiple and large uterine fibroids. MATERIALS AND METHODS Women who underwent hysterectomy due to uterine fibroid at a training and research hospital in Turkey, between January 2009 and December 2013, were included the retrospective study. Data were collected from medical records. The study was approved by the institutional review board and written informed consent was obtained from all participants. Exclusion criteria were hysterectomy because of gynecologic malignancy, benign ovarian neoplasm, and uterine prolapse. Patients who underwent myomectomy were also excluded.

ted from medical records. The study was approved by the institutional review board and written informed consent was obtained from all participants. Exclusion criteria were hysterectomy because of gynecologic malignancy, benign ovarian neoplasm, and uterine prolapse. Patients who underwent myomectomy were also excluded. Uterine fibroids were diagnosed using preoperative transvaginal ultrasonography, and confirmed through histopathologic examination of hysterectomy specimens, and endometrial polyps were diagnosed through histopathologic examination of the preoperative endometrial biopsy or hysterectomy specimens. Premenopausal patients with a history of abnormal uterine bleeding, and postmenopausal patients with bleeding symptoms and/or endometrial thickness ≥5 mm in ultrasonographic examination underwent preoperative endometrial biopsy. The women were divided into two groups: the study group consisted of women with endometrial polyps and uterine fibroids; and the control group comprised women with uterine fibroids alone. Women’s age, body mass index, gravidity, parity, menopausal status, contraception methods, preoperative hemoglobin levels, history of cesarean section, smoking, hypertension, diabetes mellitus, and abnormal uterine bleeding were compared between the two groups.

control group comprised women with uterine fibroids alone. Women’s age, body mass index, gravidity, parity, menopausal status, contraception methods, preoperative hemoglobin levels, history of cesarean section, smoking, hypertension, diabetes mellitus, and abnormal uterine bleeding were compared between the two groups. Heavy menstrual bleeding, intermenstrual bleeding, and postmenopausal bleeding were defined as abnormal uterine bleeding. Regular or irregular bleeding >7 days and/or >80 mL were considered heavy menstrual bleeding. Spotting or more bleeding among regular menses was considered intermenstrual bleeding. The number of uterine fibroids, size and location of the largest fibroid, and other accompanying gynecologic proliferative pathologies (adenomyosis, endometrial hyperplasia, cervical polyps, and endometriosis) were recorded from the womens’ histopathology reports.

regular menses was considered intermenstrual bleeding. The number of uterine fibroids, size and location of the largest fibroid, and other accompanying gynecologic proliferative pathologies (adenomyosis, endometrial hyperplasia, cervical polyps, and endometriosis) were recorded from the womens’ histopathology reports. Statistical analysis was performed usig Statistical Package for Social Science version 15.0 (SPSS Inc., Chicago, IL, USA) software. The normality for continuous variables was checked by using Kolmogorov-Smirnov test. Descriptive statistics are presented as mean ± standard deviation or median (minimum-maximum). Case numbers and percentages are given for categorical variables. Student’s t-test or Mann-Whitney U test were used for the comparison of continuous data. Pearson’s Chi-square test was used to examine the differences between groups for categorical variables. The odds ratio (OR) of endometrial polyps coexisting with uterine fibroids and 95% confidence interval (CI) were calculated using logistic regression analysis. Statistical significance was accepted as p<0.05.

s data. Pearson’s Chi-square test was used to examine the differences between groups for categorical variables. The odds ratio (OR) of endometrial polyps coexisting with uterine fibroids and 95% confidence interval (CI) were calculated using logistic regression analysis. Statistical significance was accepted as p<0.05. RESULTS A total of 772 women were analyzed: 155 women with endometrial polyps and uterine fibroids, and 617 women with uterine fibroids alone. The prevalence of endometrial polyps in women with uterine fibroid was 20.1%. The demographic and clinical characteristics of women and contraception methods used are shown in Table 1. Increased age was found as a risk factor for endometrial polyps coexisting with uterine fibroids. The endometrial polyp rate was significantly higher in women aged ≥45 years (OR 1.61; 95% CI: [1.06-2.44]). Hypertension was more common (23.9% vs. 17.5%; p=0.047) in women with endometrial polyps and uterine fibroids. When contraceptive methods were investigated, a protective effect of condom use was found. Condom use was more common in women without endometrial polyps (8.1% vs. 3.9%; p=0.044).

R 1.61; 95% CI: [1.06-2.44]). Hypertension was more common (23.9% vs. 17.5%; p=0.047) in women with endometrial polyps and uterine fibroids. When contraceptive methods were investigated, a protective effect of condom use was found. Condom use was more common in women without endometrial polyps (8.1% vs. 3.9%; p=0.044). The median uterine sizes of both groups were equivalent to 12 weeks pregnancy in the genital examination, ranging from 6-22 weeks in patients with endometrial polyps, and 6-24 weeks in patients without endometrial polyps; p=0.368). As shown in Table 2, no statistical differences were found between the symptoms of women with and without endometrial polyps. Abnormal uterine bleeding rates (56.1% vs. 57.1%; p=0.453), and the mean preoperative hemoglobin levels (11.2±2.4 g/dL vs. 11.4±4.5 g/dL; p=0.874) were similar in both groups.

polyps; p=0.368). As shown in Table 2, no statistical differences were found between the symptoms of women with and without endometrial polyps. Abnormal uterine bleeding rates (56.1% vs. 57.1%; p=0.453), and the mean preoperative hemoglobin levels (11.2±2.4 g/dL vs. 11.4±4.5 g/dL; p=0.874) were similar in both groups. Table 3 shows the association between the histopathologic findings and the coexistence of endometrial polyps and uterine fibroids. The endometrial polyp rate was higher in women with ≥2 fibroids (OR 1.51; 95% CI: [1.02-2.24]) and with a largest fibroid <8 cm (OR 1.67; 95% CI: [1.10-2.50]). Presence of endometrial hyperplasia (OR 4.00; 95% CI: [1.92-8.33]) and cervical polyps (OR 3.13; 95% CI: [1.69-5.88]) were found significantly associated with the coexistence of endometrial polyps and uterine fibroids. Women with endometrial polyps had higher endometrial hyperplasia rates (9.7% vs. 2.6%; p<0.001) and cervical polyp rates (12.3% vs. 4.2%; p<0.001) than women with uterine fibroids alone. There was no relationship between adenomyosis, endometriosis, and endometrial polyps coexisting with uterine fibroids (p>0.05).

oids. Women with endometrial polyps had higher endometrial hyperplasia rates (9.7% vs. 2.6%; p<0.001) and cervical polyp rates (12.3% vs. 4.2%; p<0.001) than women with uterine fibroids alone. There was no relationship between adenomyosis, endometriosis, and endometrial polyps coexisting with uterine fibroids (p>0.05). DISCUSSION Endometrial polyps are one of the common causes of abnormal uterine bleeding in premenopausal and postmenopausal women, and its incidence increases with age(10). The pathogenesis of this pathology is not known exactly. Presence of estrogen and progesterone receptors in polyp specimens suggests that the increased endogenous and exogenous estrogen level plays a role in the endometrial polyp growth(11). In the literature, association between endometrial polyps and tamoxifen use in breast cancer, postmenopausal hormone therapy, and obesity has been shown(12,13,14). Unopposed, high estrogen levels increase the insulin-like growth factor (IGF)-1 level, and the number of IGF-1 receptors within the endometrial tissue and causes endometrial polyp growth(15). Studies reported that hypertension and hyperglycemia also induce endometrial polyp growth by locally modifying the expression of IGF(2,16). We investigated the risk factors for the coexistence of endometrial polyps and uterine fibroids and found that the mean age and hypertension rates were significantly higher in women with endometrial polyps coexisting with uterine fibroids. However, there was no relationship between diabetes mellitus, obesity, and coexistence of these two pathologies.

for the coexistence of endometrial polyps and uterine fibroids and found that the mean age and hypertension rates were significantly higher in women with endometrial polyps coexisting with uterine fibroids. However, there was no relationship between diabetes mellitus, obesity, and coexistence of these two pathologies. The present study showed the protective effect of condom use against endometrial polyp growth. The rate of condom use was lower in women with endometrial polyps. Cicinelli et al.(17) reported that the presence of endometrial micropolyps was significantly associated with chronic endometritis. Expression of cyclooxygenase-2 and matrix metalloproteinase-2 in immunohistochemical analyses of endometrial polyps has also been shown in some studies(18,19). These findings suggest that the endometrial polyps may have an inflammatory etiopathogenesis. An inflammatory response to sexually transmitted microorganisms or seminal antigens may play a role in the etiology of endometrial polyps. Korucuoglu et al.(20) reported that human papillomavirus (HPV) infection might cause endometrial polyp growth. Condom use inhibits endometrial polyp growth by preventing the inflammatory response to these antigens.

lly transmitted microorganisms or seminal antigens may play a role in the etiology of endometrial polyps. Korucuoglu et al.(20) reported that human papillomavirus (HPV) infection might cause endometrial polyp growth. Condom use inhibits endometrial polyp growth by preventing the inflammatory response to these antigens. In the present study, endometrial polyps were more common in women with ≥2 fibroids and largest fibroid size <8 cm. The endometrial cavity should be examined using transvaginal ultrasonography, endometrial biopsy, and saline infusion sonohysterography and/or hysteroscopy in the presence of suspected premalignant and malignant endometrial polyp, before choosing the treatment method. Savelli et al.(21) reported that hyperplastic changes were more common in endometrial polyps. In another study, 248 women with abnormal uterine bleeding were investigated, and hyperplasia was found more common in women with endometrial polyps(22). Similarly, we found an association between endometrial hyperplasia,cervical polyps, and the coexistence of endometrial polyps and uterine fibroids(21,22,23).

polyps. In another study, 248 women with abnormal uterine bleeding were investigated, and hyperplasia was found more common in women with endometrial polyps(22). Similarly, we found an association between endometrial hyperplasia,cervical polyps, and the coexistence of endometrial polyps and uterine fibroids(21,22,23). Indraccolo and Barbieri reported that adenomyosis was associated with endometrial polyps(24). Their study had limitations due to the method used to obtain specimens. Adenomyosis was diagnosed in histopathologic examinations of specimens obtained in deep biopsies of the endometrium, reaching the deeper myometrial layer during hysteroscopic resection of endometrial polyps. However, in our study, specimens obtained with hysterectomy were examined and we found no association between endometrial polyps and adenomyosis. Shen et al.(25) noted that the endometrial polyp rate was higher in infertile patients with endometriosis. The authors suggested that patients with endometriosis should be evaluated using hysteroscopy. Our study population included fertile and infertile women, and no association was found between endometriosis and endometrial polyps. Even though approximately 95% of endometrial polyps are benign,resection of endometrial polyps is recommended to rule out malignancy(1,5). The risk of malignancy and the presence of abnormal uterine bleeding increases in the postmenopausal period(1,26,27,28). Histopathologic examinations of endometrial polyps provide the selection of optimal treatment methods in patients with both endometrial polyps and uterine fibroids. Medical management, myomectomy or uterine artery embolization are not appropriate treatment methods in the presence of malignant endometrial polyps.

7,28). Histopathologic examinations of endometrial polyps provide the selection of optimal treatment methods in patients with both endometrial polyps and uterine fibroids. Medical management, myomectomy or uterine artery embolization are not appropriate treatment methods in the presence of malignant endometrial polyps. Uterine fibroids and endometrial polyps are common causes of abnormal uterine bleeding in the reproductive period(29). Hysterectomy is the definitive therapy for uterine fibroids, whereas hysteroscopic resection is the optimal treatment method for endometrial polyps to reduce the cost and morbidity associated with surgery(1,9). In the study population, abnormal uterine bleeding rates were similar in women with endometrial polyps and uterine fibroids, and with uterine fibroids alone, and the median uterine size was the equivalent of 12 weeks pregnancy in both groups. Therefore, it was considered that just hysteroscopic polypectomy may not be enough to relieve the abnormal uterine bleeding symptoms and treatment of uterine fibroids in women with both endometrial polyps and fibroids with uteri greater than 12 weeks-pregnancy in size. Nevertheless, further randomized controlled trials are needed to confirm this hypothesis. The present study was not designed to investigate the impact of fibroid size, number, and location in the success of treatment in patients with endometrial polyps and uterine fibroids.

teri greater than 12 weeks-pregnancy in size. Nevertheless, further randomized controlled trials are needed to confirm this hypothesis. The present study was not designed to investigate the impact of fibroid size, number, and location in the success of treatment in patients with endometrial polyps and uterine fibroids. As far as we know, ours is the first study to investigate the coexistence of endometrial polyps and uterine fibroids, and is one of the largest studies on uterine fibroids. However, the major limitation is the retrospective design of the study. Data were obtained retrospectively and control and study groups were nonhomogeneous. Therefore, it is not known whether the defined risk factors were independent risk factors for the coexistence of endometrial polyps and uterine fibroids. CONCLUSION The present study showed that age, number of fibroids, size of the largest fibroid, presence of hypertension, endometrial hyperplasia, and cervical polyps were associated factors with the coexistence of endometrial polyps and uterine fibroids. Condom use has a protective effect against endometrial polyp growth in these patients. Ethics: Ethics Committee Approval: The study was approved by the Etlik Zübeyde Hanım Women’s Health Training and Research Hospital Local Ethics Committee, Informed Consent: Consent form was filled out by all participants. Peer-review: External and Internal peer-reviwed.

CONCLUSION The present study showed that age, number of fibroids, size of the largest fibroid, presence of hypertension, endometrial hyperplasia, and cervical polyps were associated factors with the coexistence of endometrial polyps and uterine fibroids. Condom use has a protective effect against endometrial polyp growth in these patients. Ethics: Ethics Committee Approval: The study was approved by the Etlik Zübeyde Hanım Women’s Health Training and Research Hospital Local Ethics Committee, Informed Consent: Consent form was filled out by all participants. Peer-review: External and Internal peer-reviwed. Authorship Contributions: Concept: Tuğba Kınay, Fulya Kayıkçıoğlu, Sevgi Koç, Design: Tuğba Kınay, Fulya Kayıkçıoğlu, Sevgi Koç, Data Collection or Processing: Zehra Öztürk Başarır, Serap Fırtına Tuncer, Funda Akpınar, Analysis or Interpretation: Tuğba Kınay, Literature Search: Tuğba Kınay, Zehra Öztürk Başarır, Writing: Tuğba Kınay, Zehra Öztürk Başarır. Conflict of Interest: No conflict of interest was declared by the authors. Financial Disclosure: The authors declared that this study received no financial support. Table 1 Demographic, clinical characteristics, and contraception methods of women with endometrial polyps and uterine fibroids, and with uterine fibroids alone Table 2 Symptoms of women with endometrial polyp and uterine fibroid and with uterine fibroid alone Table 3 Histopathologic findings of women with endometrial polyp and uterine fibroid and with uterine fibroid alone

INTRODUCTION Pyometra is purulent fluid accumulation inside the uterine cavity as a consequence of impaired drainage(1). Although pyometra is a rare disease seen in 0.1-0.2% of all gynecologic cases, it is more common in the elderly (13.6%)(2). Spontaneous uterine rupture and generalized peritonitis caused by pyometra occurs rarely, approximately 50 cases have been reported in the literature to date. We present a patient aged 82 years old, who underwent surgery for spontaneous uterine rupture and generalized peritonitis as a result of pyometra. The patient developed multiorgan failure and died on the second post operative day.

INTRODUCTION Pyometra is purulent fluid accumulation inside the uterine cavity as a consequence of impaired drainage(1). Although pyometra is a rare disease seen in 0.1-0.2% of all gynecologic cases, it is more common in the elderly (13.6%)(2). Spontaneous uterine rupture and generalized peritonitis caused by pyometra occurs rarely, approximately 50 cases have been reported in the literature to date. We present a patient aged 82 years old, who underwent surgery for spontaneous uterine rupture and generalized peritonitis as a result of pyometra. The patient developed multiorgan failure and died on the second post operative day. CASE REPORT A patient aged 82 years, parity 6, who was postmenopausal for 35 years was admitted to our hospital because of abdominal pain and deterioration of general condition, which had lasted for three days. She had a history of hypertension and was a smoker of 1 pack/day. Her gynecologic history was unremarkable with no postmenopausal bleeding or discharge and she had not had an endometrial biopsy or dilatation curettage operation before. On physical examination her general condition was poor, blood pressure was 80/50 mmHg, body temperature 37.8 °C, and pulse rate was 120 beats/min. On admittance, the laboratory investigations revealed white blood cell count: 31.400/µL, hemoglobin: 10.4 g/dL, urea: 71 mgr/dL, creatinine 2.1 mgr/dL, and CRP: 195 mgr/L. The patient was in a septic condition and the abdominal computerized tomography showed generalized fluid and free air; abdominal purulent fluid was obtained via paracentesis by the surgery department. An emergency laparotomy was performed with the diagnosis of gastrointestinal perforation. There was approximately 1000 cc purulent fluid in the abdominal cavity, further exploration revealed a 2.5-cm-long perforation at the anterior of the uterus (Figure 1) from which purulent drainage continued. Other abdominal organs were normal and emergency gynecology consultation was acquired. The uterus was necrotic and showed no signs of malignancy. Total abdominal hysterectomy with bilateral salpingo-oopherectomy was performed and histopathologic examination revealed ischemic necrosis and chronic cervicitis.

continued. Other abdominal organs were normal and emergency gynecology consultation was acquired. The uterus was necrotic and showed no signs of malignancy. Total abdominal hysterectomy with bilateral salpingo-oopherectomy was performed and histopathologic examination revealed ischemic necrosis and chronic cervicitis. The patient was treated in the intensive care unit, ceftriaxone 0.5 g bid and metranidazole 0.5 g tid was administered. On the first postoperative day, liver function tests showed an abrupt increase (alanine transaminase: 392 U/L, aspartate transaminase: 1517 U/L), like kidney functions (urea: 72 mgr/dL creatinine: 2.4 mgr/dL). The patient’s general condition continued to deteriorate and she died on the second post operative day of multiple organ dysfunction syndrome. DISCUSSION Pyometra, although rare in the general population, is found more frequently in postmenopausal women as result of conditions like occlusion of the cervical channel by malignant or benign tumors, surgery, radiotherapy, and senile cervicitis(3). The classical triad of symptoms includes postmenopausal vaginal bleeding, purulent vaginal discharge, and suprapubic pain(4). However, more than 50% of all cases are asymptomatic(5). Our patient had abdominal pain for three days but had no postmenopausal bleeding or discharge.

y, radiotherapy, and senile cervicitis(3). The classical triad of symptoms includes postmenopausal vaginal bleeding, purulent vaginal discharge, and suprapubic pain(4). However, more than 50% of all cases are asymptomatic(5). Our patient had abdominal pain for three days but had no postmenopausal bleeding or discharge. Spontaneous uterine rupture occurs rarely and shows two incidental peaks. It occurs due to pregnancy or intra uterine devices in the reproductive period and as a result of pyometra postmenopause(6). The frequent symptoms of uterine perforation due to pyometra include abdominal pain (97.6%), fever (54.8%), and vomiting (31%)(7). Although atrophic endometrium is a common cause, perforation is usually seen in the presence of serious causes such as cervical or endometrial carcinoma or a forgotten intrauterine device. Malignant disease is present in 35% of cases(1). Our patient had no evidence of malignancy during surgery and at pathology, she had no intrauterine device, and had not undergone endometrial biopsy or dilatation curettage operations before. Therefor, the most probable cause of pyometra was postmenopausal changes and stenosis of the cervix. Uterine perforation is usually seen at the fundus (77%), but may occur anteriorly (4%)(7).

t pathology, she had no intrauterine device, and had not undergone endometrial biopsy or dilatation curettage operations before. Therefor, the most probable cause of pyometra was postmenopausal changes and stenosis of the cervix. Uterine perforation is usually seen at the fundus (77%), but may occur anteriorly (4%)(7). Preoperative diagnosis of uterine perforation due to pyometra is difficult. Imaging modalities show pneumoperitoneum and intrabdominal fluid, which frequently leads to the misdiagnosis of gastrointestinal perforation(5). Sagittal and coronal reformats in multi-detector computerized tomography are very helpful in depicting the site and size of uterine breach by demonstrating the resultant intra-abdominal collections thus playing an important role in the diagnosis of ruptured pyometra. Sonography has limited use in the diagnosis of ruptured pyometra because of its inability to demonstrate the uterine breach and the limited sonographic window available due to perforation(8). However, correct preoperative diagnosis is made in 30% of patients(7). In our patient, abdominal computerized tomography showed generalized fluid and free air; abdominal purulent fluid was obtained via paracentesis by the surgery department. An emergency laparotomy was performed with a diagnosis of gastrointestinal perforation owing to the patient’s age and no gynecologic symptoms.

ts(7). In our patient, abdominal computerized tomography showed generalized fluid and free air; abdominal purulent fluid was obtained via paracentesis by the surgery department. An emergency laparotomy was performed with a diagnosis of gastrointestinal perforation owing to the patient’s age and no gynecologic symptoms. The mortality rate of uterine perforation caused by pyometra is 15%. In the majority of patients the cause of death is multiple organ dysfunction syndrome due to sepsis(7). Despite the interventions, our patient died on the second postoperative day of multiple organ failure syndrome and sepsis. The patient sought medical advice on the third day of her complaints and was already in septic shock and was a smoker, both of which probably contributed to her poor prognosis. Uterine rupture caused by pyometra is serious and occurs rarely with high morbidity and mortality. The patients present with diffuse abdominal peritonitis and gynecologic symptoms are less frequent, which makes preoperative diagnosis difficult. Uterine rupture should be borne in mind in postmenopausal patients who present with acute abdomen and pneumoperitoneum. Peer-review: Externally and Internal peer-reviewed. Concept: Ayşe Filiz Avşar, Design: Ayşe Filiz Avşar, Data Collection or Processing: Elçin İşlek Seçen, Hilal Ağış Tan, Canan Altunkaya, Analysis or Interpretation: Hilal Ağış Tan, Literature Search: Elçin İşlek Seçen, Writing: Elçin İşlek Seçen. Conflict of Interest: No conflict of interest was declared by the authors.

Peer-review: Externally and Internal peer-reviewed. Concept: Ayşe Filiz Avşar, Design: Ayşe Filiz Avşar, Data Collection or Processing: Elçin İşlek Seçen, Hilal Ağış Tan, Canan Altunkaya, Analysis or Interpretation: Hilal Ağış Tan, Literature Search: Elçin İşlek Seçen, Writing: Elçin İşlek Seçen. Conflict of Interest: No conflict of interest was declared by the authors. Financial Disclosure: The authors declared that this study has received no financial support. Figure 1 Photograph showing the perforated area and hysterectomy material

INTRODUCTION Isolated tubal torsion is a very rare entity, reported as 1 in 1.5 million women(1). It is a challenging preoperative differential diagnosis because of its non-specific clinical findings such as lower abdominal pain, nausea, vomiting and fever, and should be kept in mind while approaching patients with abdominal pain(2). This report presents five cases of isolated tubal torsion and their successful preoperative diagnosis using ultrasonography (USG) imaging and management with a laparoscopic approach at a tertiary health center within 2 years, and an evaluation of literature findings.

d while approaching patients with abdominal pain(2). This report presents five cases of isolated tubal torsion and their successful preoperative diagnosis using ultrasonography (USG) imaging and management with a laparoscopic approach at a tertiary health center within 2 years, and an evaluation of literature findings. CASE REPORT Patients diagnosed as having isolated tubal torsion between January 2014 and January 2017 were included in this presentation after acquiring informed consent from all patients. Five patients with lower abdominal pain at different intensities were diagnosed as having tubal torsion using USG imaging. All five patients had significant acute lower abdominal pain. The patients described a sudden onset of symptoms, and four patients had slightly increased white blood cell counts (WBC). Only case 5 had a normal WBC count. Three of five patients had nausea and vomiting as other symptoms. The decision was made for all patients to undergo surgery with a preoperative diagnosis of tubal torsion with or without coexisting adnexal masses. No other imagining modality beyond USG was used for the preoperative diagnosis. All diagnoses were confirmed under laparoscopy, but coexisting risk factors were misdiagnosed in case 1 and 2, as listed at Table 1. Four of the five patients were managed with salpingectomy, and detorsion was performed in only one patient who desired future fertility. None of the patients had postoperative complications and all were discharged within 48 hours. The important feature of these five patients was the correct preoperative diagnosis acquired using just USG, which was confirmed during the operation, and also through postoperative pathologic examination of specimens.

tility. None of the patients had postoperative complications and all were discharged within 48 hours. The important feature of these five patients was the correct preoperative diagnosis acquired using just USG, which was confirmed during the operation, and also through postoperative pathologic examination of specimens. DISCUSSION The potential risk factors for isolated tubal torsion are tubal pathologies such as hydrosalpinx, paratubal cysts or ovarian masses, and altered tubal function. However, normal tubal appearance was mostly found in cases of isolated tubal torsion(3). One of our five cases had normal tubal structure, two had paratubal cysts, and one had hydrosalpinx, consistent with the literature. The USG features of tubal torsion may vary widely. Preoperative suspicion may rise with an image of elongated, convoluted cystic mass, tapering as it nears the uterine cornua(4). An increased resistance index due to decreased blood flow determined using Doppler USG may also strengthen the suspicion of torsion(5). Nevertheless, abnormal Doppler findings are not a necessity for the diagnosis of torsion. Identifying a normal ipsilateral ovary may strongly suggest tubal torsion.

uterine cornua(4). An increased resistance index due to decreased blood flow determined using Doppler USG may also strengthen the suspicion of torsion(5). Nevertheless, abnormal Doppler findings are not a necessity for the diagnosis of torsion. Identifying a normal ipsilateral ovary may strongly suggest tubal torsion. As in other torsion cases, a systematic evaluation of the adnexal areas is needed in order to be able to identify isolated tubal torsion cases with USG. A systematic evaluation of symptomatic patients should always include evaluation of tubal segments. In the correct evaluation of the adnexal area, the starting point should be the interstitial tubal segment, which is the starting point of the adnexa, and from here onwards, the entire tuba continues to medial to the fimbrial tip. Neighboring structures should also be evaluated at the same sections. The interstitial and trunk part of the uterine tube, the proper ovary ligament (ligamentum ovarii proprium) and the round ligament are located in the cornual area near the uterus. Over-torsions in this region are mostly around the proprium ligament axis, and tubal torsion mostly occurs by rotating around its own axis.

The interstitial and trunk part of the uterine tube, the proper ovary ligament (ligamentum ovarii proprium) and the round ligament are located in the cornual area near the uterus. Over-torsions in this region are mostly around the proprium ligament axis, and tubal torsion mostly occurs by rotating around its own axis. In isolated tubal torsion cases, torsional twist is directly observed on USG imaging (Figure 1). This finding must be seen and seen absolutely for the exact diagnosis of any kind of torsion in all cases. This finding is enough for the diagnosis of torsion because it is the physical image of torsion. Due to circulation problems, the tuba seems edematous and swollen and it is easily distinguishable from the overdose around the hypoechoic irregular soft tissue mass formed by the adnexal inferior tubal edema. When the “whirlpool” finding is evaluated with power Doppler, the venous circulation may be observed in a circular pattern (Figure 2). However, with the deterioration of the arterial circulation by the progress of the tubal torsion, this Doppler “whirlpool” image may disappear, but the sonographic image sign of turning around the axis remains. As the event progresses, the walls of the tuba become thicker with the edema and findings of hydrosalpinx and hematosalpinx in the lumen of the tuba begin to show themselves. Tubal torsion of this size may ultimately be regarded as ovarian torsion because the hematosalpinx is very enlarged and it is difficult to monitor the ovary when it starts to form incomplete septations.

cker with the edema and findings of hydrosalpinx and hematosalpinx in the lumen of the tuba begin to show themselves. Tubal torsion of this size may ultimately be regarded as ovarian torsion because the hematosalpinx is very enlarged and it is difficult to monitor the ovary when it starts to form incomplete septations. The progression of torsion causes hematosalpinx, tubal rupture, and peritubal hematomas, which become more complicated and harder to diagnose. If the heterogeneous mass forming in the adnexal area is not carefully evaluated, it can easily be confused with a ruptured ectopic pregnancy. The primary approach to tubal and ovarian torsion should be laparoscopy and recommended as primary approach(2). Torsions are mostly treated with this approach owing to the advanced accessibility with laparoscopy. We prefer the laparoscopic approach for both ovarian and tubal torsions, as in these 4 cases, which were successfully managed using laparoscopy (Figure 3, 4). In conclusion, tubal torsion is an emergency condition and a correct preoperative diagnosis should be acquired immediately. Ultrasound criteria for tubal torsion diagnosis require careful evaluation, thus it should only be performed by an experienced practitioner, and laparoscopy should be the primary choice of treatment.

In conclusion, tubal torsion is an emergency condition and a correct preoperative diagnosis should be acquired immediately. Ultrasound criteria for tubal torsion diagnosis require careful evaluation, thus it should only be performed by an experienced practitioner, and laparoscopy should be the primary choice of treatment. LITERATURE REVIEW Isolated tubal torsion is a very rare clinical entity. Correct diagnosis requires great caution and experience because of it is rarity and non-specific symptoms. The most common symptoms were listed as abdominal pain, vomiting, and fever in pediatric case series(6). Also, bowel and bladder problems, lower abdominal mass diagnosed during examination, and elevated WBCs may be other symptoms(7). The etiology remains unclear, but anatomic changes, positional changes, trauma, previous surgeries or gravid uterus are listed as potential risk factors(8). There is also a higher probability for right tubal torsion then left due to the position of the sigmoid colon and slow venous drainage of the right tuba(9). Paratubal or adherent cysts may also play an important role in the etiology according to literature and our findings(10). This situation may be seen in pregnant patients; isolated tubal torsion should be considered as a diagnosis because of difficulties in imaging(11). Magnetic resonance imaging (MRI) may be used with clinical suspicion both in pregnant and non-pregnant patients for differential diagnosis(9,12). MRI may also show the “whirlpool” sign, which is the image of physical torsion of tubas(13).

rsion should be considered as a diagnosis because of difficulties in imaging(11). Magnetic resonance imaging (MRI) may be used with clinical suspicion both in pregnant and non-pregnant patients for differential diagnosis(9,12). MRI may also show the “whirlpool” sign, which is the image of physical torsion of tubas(13). Diagnosing torsion correctly using USG is also challenging, but very important because of its speed and easy accessibility. Ultrasonographic findings listed in the literature are mostly the same as the criteria used at our clinic. MRI or computed tomography scans may play role in diagnosis, but have disadvantages such as cost, radiation exposure, and potential hazards during pregnancy(14). Prompt diagnosis is also very important due to the possible results of delay such as necrosis(15). Management of tubal torsion mostly requires surgical intervention. Salpingectomy may be performed if there is no further desire for fertility, but the proper approach should be detorsion of tuba for preserving fertility(14). Urgent intervention should be performed in symptomatic patients and rare results of chronic tubal torsion such as tubal autoamputation should be known(16).

ntion. Salpingectomy may be performed if there is no further desire for fertility, but the proper approach should be detorsion of tuba for preserving fertility(14). Urgent intervention should be performed in symptomatic patients and rare results of chronic tubal torsion such as tubal autoamputation should be known(16). Isolated tubal torsion is a very rare entity and may be misdiagnosed due to its non-specific symptoms. All physicians must know the diagnostic criteria for prompt diagnosis and a proper evaluations should always include the adnexal area and tubas. A systematic approach to the adnexal area as mentioned may diagnose most tubal torsion cases. After proper preoperative diagnosis, tubal torsions may be managed via laparoscopy. In conclusion, the most important point in managing these patients is a correct and rapid diagnosis. Ethics Informed Consent: Consent form was filled out by all participants. Peer-review: External and internal peer-reviewed. Authorship Contributions Surgical and Medical Practices: R.D., M.K., Concept: E.D., Ç.Ö., Design: R.D., Ö.L.T., Data Collection or Processing: E.F., E.D., Analysis or Interpretation: E.D., Ç.Ö., Literature Search: E.F., Ş.F., Writing: E.F., Ş.F. Conflict of Interest: No conflict of interest was declared by the authors. Financial Disclosure: The authors declared that this study received no financial support.

Surgical and Medical Practices: R.D., M.K., Concept: E.D., Ç.Ö., Design: R.D., Ö.L.T., Data Collection or Processing: E.F., E.D., Analysis or Interpretation: E.D., Ç.Ö., Literature Search: E.F., Ş.F., Writing: E.F., Ş.F. Conflict of Interest: No conflict of interest was declared by the authors. Financial Disclosure: The authors declared that this study received no financial support. Table 1 Summary of five cases with preoperative diagnosis and postoperative pathologic results Figure 1 *“Whirlpool” sign, **hydrosalpinx at the distal side of tubal torsion, #ovarian tissue Figure 2 Ongoing circulation within the “whirlpool” sign showing circular pattern Figure 3 Isolated tubal torsion captured during laparoscopy without any other adnexal pathologies (case 3) Figure 4 Isolated tubal torsion with concurrent paratubal cyst (case 5)

PRECIS: To identify the possible risk factors for postpartum urinary retention. Introduction Female genital mutilation (FGM) includes procedures that intentionally alter or cause injury to the female genital organs for non-medical reasons. The practice, which is also known as female circumcision or female genital cutting, is typically performed by a traditional circumciser using a blade under unsafe conditions, mostly on young girls between infancy and age 15 years. The idea of performing the procedure by medical staff in order to make it safer is condemned because this procedure is internationally accepted as a violation of the human rights of girls and women(1,2). More than 3 million girls are estimated to be at risk each year, and 200 million women living today in 30 countries have undergone the procedures(1). The practice is most common in the western, eastern, and north-eastern regions of Africa, in some countries of the Middle East and Asia, as well as among migrants from these areas. There have been international efforts to persuade practitioners to abandon FGM, and it has been outlawed or restricted in most of the countries in which it occurs.

mon in the western, eastern, and north-eastern regions of Africa, in some countries of the Middle East and Asia, as well as among migrants from these areas. There have been international efforts to persuade practitioners to abandon FGM, and it has been outlawed or restricted in most of the countries in which it occurs. The procedures are mostly performed on young girls sometime between infancy and adolescence, and occasionally on adult women. The reasons why FGM is performed vary from one region to another. It is often considered as a necessary part of raising a girl, and a way to prepare her for adulthood and marriage. FGM is a social convention (social norm), there is social pressure to comply with the expectations of society, and the need to be accepted socially and the fear of being rejected by the community leads to FGM being performed in these countries. FGM is often motivated by beliefs about what is considered as acceptable sexual behavior(3). Globalization and immigration has led to the recognition of this problem in countries where FGM is not practiced(4). The European Institute of Gender Equality estimates that 180,000 women and girls are at risk for FGM each year in Europe. World Health Organization (WHO) classifies this procedure in four types(4). WHO classification of female genital mutilation Type I (clitoridectomy): this is the partial or total removal of the clitoris (a small, sensitive and erectile part of the female genitals), and in very rare cases, only the prepuce (the fold of skin surrounding the clitoris).

World Health Organization (WHO) classifies this procedure in four types(4). WHO classification of female genital mutilation Type I (clitoridectomy): this is the partial or total removal of the clitoris (a small, sensitive and erectile part of the female genitals), and in very rare cases, only the prepuce (the fold of skin surrounding the clitoris). Type II (excision): this is the partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora. Type III (infibulation): this is the narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the labia minora, or labia majora, sometimes through stitching, with or without removal of the clitoris (clitoridectomy). Type IV: this includes all other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping, and cauterizing the genital area. In some populations, infibulation, which involves cutting the labia and suturing the vulva leaving a small orifice for urination and menstruation, constitutes 15% of cases(5). FGM in the short term may lead to severe complications such as pain, excessive bleeding (hemorrhage), genital tissue swelling, fever, infection, urinary problems (painful urination, urinary tract infections), vaginal problems (discharge, infections), menstrual problems (dysmenorrhea, hematocolpos), sexual and psychological problems, and difficulty in pregnancy and childbirth may arise after the procedure.

(hemorrhage), genital tissue swelling, fever, infection, urinary problems (painful urination, urinary tract infections), vaginal problems (discharge, infections), menstrual problems (dysmenorrhea, hematocolpos), sexual and psychological problems, and difficulty in pregnancy and childbirth may arise after the procedure. Long-term consequences include: urinary problems (painful urination, urinary tract infections; vaginal problems (discharge, itching, bacterial vaginosis and other infections), menstrual problems (e.g. painful menstruations, difficulty in passing menstrual blood), keloid formation on the scar tissue, sexual problems (e.g. pain during intercourse, decreased satisfaction), increased risk of childbirth complications (e.g. perineal tear, difficult or prolonged labor, increased rate of cesarean section and postpartum hemorrhage, increased need for newborn resuscitation), and rarely newborn deaths. A need for later surgeries may arise due to FGM, especially with FGM procedures that seal or narrow the vaginal opening, which needs to be cut open later to allow for sexual intercourse and childbirth (de-infibulation). Sometimes genital tissue is stitched again several times (re-infibulation), especially after the delivery. Then the woman has to endure repeated opening and closing procedures and thus immediate and long-term risks, psychological problems (e.g. depression, anxiety, post-traumatic stress disorder, low self-esteem), and health complications of FGM are augmented(6).

veral times (re-infibulation), especially after the delivery. Then the woman has to endure repeated opening and closing procedures and thus immediate and long-term risks, psychological problems (e.g. depression, anxiety, post-traumatic stress disorder, low self-esteem), and health complications of FGM are augmented(6). A patient with type III FGM who presented to our clinic because of sexual dysfunction and underwent de-infibulation surgery is presented. Case Report Our patient was a 31-year-old, gravida 0 woman with regular menstrual cycles. She had been married for two weeks. She was admitted to our clinic because she was unable to have vaginal sexual intercourse. The patient had undergone genital mutilation at the age of 7 years in Somalia. A gynecologic examination revealed a totally excised labia majora and labia minora and clitoris, and a single orifice was observed in the perineum (Figure 1).

admitted to our clinic because she was unable to have vaginal sexual intercourse. The patient had undergone genital mutilation at the age of 7 years in Somalia. A gynecologic examination revealed a totally excised labia majora and labia minora and clitoris, and a single orifice was observed in the perineum (Figure 1). Detailed counselling was conducted by the gynecologist and a written signed consent was obtained that covered an explanation of the de-infibulation procedure, and the patient also gave consent for the publication of the case.  The de-infibulation procedure was performed under anesthesia. The patient was prepared in the lithotomy position under sterile conditions. A Kelly clamp was gently inserted through the orifice and moved caudally into the tunnel-shaped space formed under the fusion line of the scar tissue. The scar tissue was then excised medially under the guidance of the Kelly clamp. The urethral orifice was observed at the upper part of the vaginal introitus and the hymenal membrane was found to be intact (Figure 2). The separated ends of the remains of the labia were repaired by suturing. Subsequently, bladder catheterization was performed in order to control the patency of the urethra, which showed a normal urethra (Figure 3). At the end of the procedure, a dressing with estriol cream and nitrofurazone was applied on the incision site in order to enhance epithelization. The patient had daily cleaning and dressing applications and was discharged uneventfully at day 3 postoperatively. The couple upon discharge was referred to the sexual dysfunction clinic of the hospital. During the 2-month follow-up after the surgery, the patient had a full recovery and was able to perform vaginal intercourse uneventfully.

cleaning and dressing applications and was discharged uneventfully at day 3 postoperatively. The couple upon discharge was referred to the sexual dysfunction clinic of the hospital. During the 2-month follow-up after the surgery, the patient had a full recovery and was able to perform vaginal intercourse uneventfully. Discussion Girls ranging from newborn up to the adolescent period and rarely adult women are at risk for FGM in societies and communities where FGM is a tradition. Cultural and social reasons of FGM vary according to region. The reasons include: religion, fear of exclusion by society, protection of virginity before marriage, reduction of extramarital sexual unity, being seen as a part of the upbringing of girls or as a preparation for marriage and adulthood, perception of beauty and cleansing, and a necessity for being a woman.

to region. The reasons include: religion, fear of exclusion by society, protection of virginity before marriage, reduction of extramarital sexual unity, being seen as a part of the upbringing of girls or as a preparation for marriage and adulthood, perception of beauty and cleansing, and a necessity for being a woman. For many years, international efforts have been made to ensure that those who practice FGM abandon this procedure(1). As a result of these efforts, implementation is prohibited or restricted in most countries; however, these laws are not fully implemented. The short-term complications of FGM range from pain, infection, and bleeding to death due to these complications. HIV and tetanus infections are the most serious infections that might arise after FGM. These infections have a higher incidence in women with type II FGM(7). Reyners et al.,(8) reported an estimated mortality of 1 in 500 circumcisions. In countries where FGM is not a tradition or a norm, acute complications of FGM can be very rarely seen, but medical workers may still encounter women with FGM-related long-term health problems ranging from urogenital disorders to sexual and mental health problems because of immigration from the countries where FGM is a well-accepted practice among the community members. Difficulty during the first vaginal penetration is very common especially in women with infibulation because the first vaginal sexual act results in pain and sometimes requires a surgical intervention or results in perineal tearing(9). De-infibulation restores urinary and vaginal function, but these women need further counselling and support due to the psychological effects of this traumatizing experience(10,11).

tion because the first vaginal sexual act results in pain and sometimes requires a surgical intervention or results in perineal tearing(9). De-infibulation restores urinary and vaginal function, but these women need further counselling and support due to the psychological effects of this traumatizing experience(10,11). Ethics Informed Consent: written signed consent was obtained by patient. Peer-reviewed: External and internal peer-reviewed. Authorship Contributions Surgical and Medical practices: B.D., Concept: B.D., Design: B.D., Data Collection and Processing: N.İ., S.A.T., Analysis and Interpretation: B.D., Literature Search: N.İ., S.A.T., Writing: B.D. Conflict of Interest: No conflict of interest was declared by the authors. Financial Disclosure: The authors declared that this study received no financial support. Figure 1 Insertion of Kelly clamp through the orifice and moved caudally in the tunnel-shaped space formed under the fusion line of the scar tissue Figure 2 After the scar tissue was excised urethral orifice, vaginal introitus and an intact hymenal membrane were observed Figure 3 Restoration and visualization of the vaginal introitus and urethral orifice