A New Classification For Female Infertility

See
discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/221769281
A new classification for female infertility

Article in Clinical and experimental obstetrics & gynecology January 2011
Source: PubMed
CITATIONS
READS
1,273
7 authors, including:
Behnam Baghianimoghadam
Payman Hemmati
Babol University of Medical Sciences
Ministry of Health and Medical Education
42 PUBLICATIONS 83 CITATIONS
SEE PROFILE
SEE PROFILE
Nasim Tabibnejad
Shahid Sadoughi University of Medical Scie
SEE PROFILE
All in-text references underlined in blue are linked to publications on ResearchGate,

letting you access and read them immediately.
Available from: Behnam Baghianimoghadam

Retrieved on: 21 September 2016
01 Frontespizio n. 4-2011:01 Frontespizio n. 3/2009 15/11/11 14:05 Pagina 309
Vol. XXXVIII, no. 4, 2011
ISSN: 0390-6663
CLINICAL AND EXPERIMENTAL

OBSTETRICS & GYNECOLOGY
an International Journal
Founding Editor
A. Onnis
Montral (CND)
Editors-in-Chief
M. Marchetti
J.H. Check
Montral (CND)
Camden, NJ (USA)
Assistant Editor
J. Wilson
San Diego - CA (USA)
Editorial Board
Audet-Lapointe P., Montral (Canada)
Axt-Fliedner R., Lbeck (Germany)
Basta A., Krakow (Poland)
Bender H.J., Dusseldorf (Germany)
Bhattacharya N., Calcutta (India)
Bonilla Musoles F., Valencia (Spain)
Charkviani T., Tbilisi (Georgia)
Dexeus S., Barcelona (Spain)
Di Paola G., Buenos Aires (Argentina)
Eskes T.K.A.B.,
Nijmegen (The Netherlands)
Farghaly S.A., New York (USA)

Friedrich M., Homburg (Germany)
Gomel V., Vancouver (Canada)
Gorins A., Paris (France)
Grella P.V., Padua (Italy)

Holub Z., Kladno (Czech Republic)
Jordan J.A., Birmingham, England (UK)
Kaplan B., Petach Tikva (Israel)
Kralj B., Ljubljana (Slovenia)
Markowska J., Poznan (Poland)
Marth C., Innsbruck (Austria)
Meden-Vrtovec H., Ljubljana (Slovenia)
Ohara N., Kobe (Japan)
Papadopoulos N., Alexandroupolis (Greece)
Rakar S., Ljubljana (Slovenia)
Sciarra J.J., Chicago, IL (USA)
Stelmachow J., Warsaw (Poland)
Varras M.N., Athens (Greece)
Winter R., Graz (Austria)
Publishing Organization (M. Morsani):

I.R.O.G. CANADA, Inc. - 4900 Cte St-Luc - Apt # 212 - Montral, Qu. H3W 2H3 (Canada)
Tel. +514-4893242 - Fax +514-4854513 - E-mail: canlux@mgroup-online.com - www.irog.net
Editorial Office (M. Critelli):
Galleria Storione, 2/A - 35123 Padua (Italy) - Tel. (39) 049 8756900 - Fax (39) 049 8752018
CLINICAL AND EXPERIMENTAL OBSTETRICS AND GYNECOLOGY (ISSN 0390-6663) publishes original work, preferably
brief reports, in the fields of Gynecology, Obstetrics, Fetal Medicine, Gynecological Endocrinology and related subjects. (Fertility
and Sterility, Menopause, Uro-gynecology, Ultrasound in Obstetrics and Gynecology, Sexually Transmitted Diseases, Reproductive
Biological Section). The Journal is covered by INDEX MEDICUS, MEDLINE, EMBASE/Excerpta Medica.
CLINICAL AND EXPERIMENTAL OBSTETRICS AND GYNECOLOGY is issued every three months in one
volume per year by IROG CANADA Inc. Montral. Printed in Italy by La Garangola, Tipografia Editrice - Via E. Dalla Costa, 6 35129 Padova (Italy).
02 Contents 4-2011:02 Contents 2/2009 15/11/11 14:07 Pagina 310
Contents
Clinical and Experimental Obstetrics & Gynecology - Vol. XXXVIII, no. 4, 2011
EDITORIAL ARTICLE
Choosing the right stimulation protocol for in vitro fertilization-embryo transfer in poor, normal,
and hyper-responders
J.H. Check, B. Slovis - Camden, NJ (USA)
313
Various factors need to be considered before choosing a mild vs normal ovarian hyperstimulation protocol for IVF-ET.
ORIGINAL ARTICLES
Reproductive Biology Section
Evaluation of the importance of late follicular phase endometrial echo patterns and pregnancy outcome
following embryo transfer by evaluating infertile donor/recipient pairs
J.H. Check, J.K. Choe, J. Amui, D. Brasile, T. Jamison - Camden, NJ (USA)
318
The triple-line pattern in late follicular phase may allow a better pregnancy rate for donors but not recipients.
Blastomere number and pregnancy rates in the succeeding in vitro fertilization cycle in women who
formed all embryos with 5 blastomeres
J.H. Check, J. Amui, J.K. Choe, D. Brasile, R. Cohen - Camden, NJ (USA)
320
Most women demonstrating all embryos with slow cleavage in one transfer will have embryos with better cleavage rates in the
next cycle but those who do not, will usually not conceive.
Effect of serum progesterone level on the day of human chorionic gonadotropin injection on outcome
following in vitro fertilization-embryo transfer in women using gonadotropin releasing hormone
antagonists
B. Katsoff, J.H. Check, C. Wilson, J.K. Choe - Camden, NJ (USA)
322
Serum progesterone level on the day of hCG injection does not influence pregnancy rates in IVF-ET cycles using GnRH antagonists.
Effect of multiple source vs single source of donor embryos on pregnancy and implantation rates per
transfer
C. Wilson, J.H. Check, J. Amui, J.K. Choe, D. Brasile - Camden, NJ (USA)
324
Choosing donated embryos from multiple sources is associated with similar pregnancy rates as from a single source even
though a higher percentage of the embryos are de-selected.
Evidence that the main adverse effect of ganirelix on pregnancy and implantation rates is on the embryo
rather than the endometrium
J.H. Check, R. Cohen, J. Amui, J.K. Choe, D. Brasile - Camden, NJ (USA)
For unknown reasons, the GnRH antagonist ganirelix seems to have a direct adverse effect on the ability of
an embryo to implant since both fresh and frozen embryos are affected.
Successful twin pregnancy in a donor oocyte recipient despite a maximum endometrial thickness in the
late proliferative phase of 4 mm
J. Amui, J.H. Check, R. Cohen - Camden, NJ (USA)
326
328
A case is presented of a successful pregnancy though complicated by HELLP syndrome in a 47-year-old donor oocyte recipient despite a maximum endometrial thickness of 4 mm.
Live fetus following embryo transfer in a woman with diminished egg reserve whose maximal
endometrial thickness was less than 4 mm
J.H. Check, R. Cohen - Camden, NJ (USA)
A live fetus resulted from IVF-ET despite poor endometrial thickness in a woman complicated by oocyte depletion.
330
Contents
Speculum retention during embryo transfer does not improve pregnancy rates following embryo
transfer - a randomized study
J. Amui, J.H. Check, D. Brasile - Camden, NJ (USA)
311
333
Theoretically retention of the speculum for seven minutes following embryo transfer will help prevent expulsion of embryos
but this randomized study failed to show a benefit.
Successful pregnancy following a single fresh embryo transfer in a 45-year-old woman whose early
follicular phase serum follicle stimulating hormone was 29 mIU/ml
J.H. Check, J.K. Choe, R. Cohen - Camden, NJ (USA)
335
The first case of a successful pregnancy following in vitro fertilization-embryo transfer in a 45-year-old woman with a day 3
FSH > 15 mIU/ml is reported.
General Section
Kiwisch von Rotterau - a pioneer of European obstetrics, gynecology and gynecopathology
H. Pickel, O. Reich, R.H. Young - Graz, AUSTRIA
338
Kiwisch was one of the first clinicians to introduce modern pathologic-anatomical concepts into clinical gynecology and
obstetrics.
Induction of plasminogen activators in pregnant women with Toxoplasma gondii infection

C.S. Chou, M.C. Chou, K.M. Chen, C.Y. Lu, S.C. Lai - Taiwan, ROC
341
Plasminogen activators involved in toxoplasmosis of pregnant women.
Effects of inherited trombophilia in women with recurrent pregnancy loss

Z. Habibovic, B. Zeybek, C. Sanhal, Z. Eroglu, E. Karaca, M. Ulukus - Izmir, TURKEY
347
The relationship between inherited thromobophilias and recurrent miscarriages was examined.
Infectious respiratory diseases in pregnancy - results of a 15-year study in Seoul

J.Y. Cheung, S.S. Shim, Y. Kim - Seoul, KOREA
351
The incidence of pneumonia in pregnant women is not higher than that in non pregnant women.
Serum osteoprotegerin correlates with age and bone mass in postmenopausal, but not in fertile age
women
G. Mainini, M. Incoronato, L. Urso, C. Scaffa - Naples, ITALY
355
The OPG/RANKL system is significantly associated with menopausal status and could play a role in postmenopausal osteoporosis.
Clinical effects of transvaginal vesicovaginal fistula repair surgery mediated by the Foley catheter (64
cases)
L. Bing-shu, H. Li, W. Qin, H. Min, C. Yan-xiang - Hubei, CHINA
360
Vescicovaginal fistula repair with a Foley catheter is superior with respect to surgical treatment as the operation is shortes, there
is less blood loss and higher success rate.
Evaluation of clinical and cytogenetic fndings on 1,068 second-trimester amniocenteses in Southeast

Turkey
M. Balkan, H. Akbas, S. Kalkanli, M. Erdemoglu, M. Fidanboy, M.N. Alp, T. Budak - Diyarbakir, TURKEY
364
A prenatal diagnosis by amniocentesis offers the possibility to evaluate prognosis for newborns and eventual risks for further
pregnancies.
Distribution of etiological factors of hypergonadotropic amenorrhea

H. Meden-Vrtovec, K. Gerak, D. Franic - Rogaska Slatina, SLOVENIA
369
Women with itiopathic hypergonadotropic amenorrhea and normal karyotype, prolactin levels and thyroid function might benefit
from estrogens and progestins in terms of pregnancy.
Validation of ultrasound scan in the diagnosis of female stress urinary incontinence

A. Lukanovic, T.S. Patrelli - Parma, ITALY
373
Perineal ultrasound in preoperatie diagnosis of female stress urinary incontinence is inexpensive, harmless and well tolerated by
patients: a new technique is presented.

A. Aflatoonian, B. Baghianimoghadam, P. Partovi, A. Abdoli, P. Hemmati, N. Tabibnejad, M. Dehghani Yazd, IRAN
A proposed new classification of female infertility is based on the inclusion of all relevant features implicated in the clinical presentation.
379
312
Contents
Correlation between fetal movement revealed in actography and fetal-neonatal well-being: observational
study on 3,805 pregnancies followed in a Northern Italy tertiary care hospital
T.S. Patrelli, F. DAddetta, S. Gizzo, L. Franchi, S. Di Gangi, N. Sianesi, F. Peri, G. Pedrazzi, R. Berretta,
G. Piantelli, A. Lukanovic, G.B. Nardelli, A. Bacchi Modena - Parma, ITALY
382
Is the actografic track usable to assess the fetal-neonatal wellbeing and to evaluate the clinical evolution of labor in medicolegal area?
Factors associated with the success of external cephalic version (ECV) of breech presentation at term
N. Obeidat, I. Lataifeh, M. Al-Khateeb, F. Zayed, W. Khriesat, Z. Amarin - Irbid, JORDAN
386
Success predictors of ECV for term breech were evaluated. Multiparity, flexed breech, posterior placenta, and anter or back are
favorable factors.
New results regarding trends in Iranian womens health and a comparison with WHO data
E. Barooti, N. Sadeghi, M. Karimi-Zarchi, H.R. Soltani - Yazd, IRAN
390
Womens health indicators in Iran were compared with data from the World Health Organization.
Frequency of ovarian endometriosis in epithelial ovarian cancer patients

O. Dzatic-Smiljkovic, M. Vasiljevic, M. Djukic, R. Vugdelic, J. Vugdelic - Belgrade, SERBIA
394
The frequency of ovarian endometriosis in epithelial ovarian cancer patients was analyzed.
Evaluation of adolescent pregnancies: 10-year experience of a hospital in rural Turkey

B. Demir, A.I. Guzel, Y. Celik, S. Demir, F. Demir - Diyarbakir, TURKEY
399
Maternal age is significantly correlated with gestational age at birth, fetal birth weight, and fetal birth length.
Morphologic and functional vascular alterations in patients with polycystic ovary syndrome
B. Demir, S. Pasa, S. Demir, R. Buyukkaya, A.E. Atay, Y. Atamer, T. Gul - Diyarbakir, TURKEY
401
Increased androgen level in patients with polycystic ovary syndrome causes modification of insulin resistence, lipid profile and
blood pressure thus influencing vascular function.
Ultrasonography-guided amniocentesis in singleton pregnancies: a review of the first 1,000 cases

G.O. Ajayi - Lagos, NIGERIA
405
Prenatal amniocentesis offers a good prognosis for the newborn and useful information for further pregnancies.
Rate of use of contraceptive methods and risk factors in Tehran, the capital of Iran, in 2010 compared
to other cities and regions
E. Barooti, N. Sadeghi, M. Karimi-Zarchi, H.R. Soltani - Yazd, IRAN
408
Comparison of the use of contraceptives with relative risk factors between women residing in Tehran and other cities.
CASE REPORTS
Sympathetic neural hyperalgesia edema syndrome, a frequent cause of pelvic pain in women, mistaken
for Lyme disease with chronic fatigue
J.H. Check, R. Cohen - Camden, NJ (USA)
412
Sympathomimetic amine therapy was effective for chronic fatigue syndrome which had been mistakenly diagnosed as Lyme
disease and would have subjected the patient to the risk of prolonged antibiotic therapy.
Swyer syndrome, 46,XY gonadal dysgenesis, a sex reversal disorder with dysgerminoma: a case report
and literature review
Jing Zhu, Xishi Liu, Hongyan Jin, Xin Lu - Shanghai, CHINA
414
A case of Swyer syndrome is reported together with a review of the literature.
Gynandroblastoma with the symptoms of infertility and secondary amenorrhea: a case report
S. Xiao, M. Xue, Y. Wan, Z. Su - Hunan Province, CHINA
419
A case of an infertile woman who became pregnant after diagnosis and treatment for an ovarian gynandroblastoma is presented.
Vasa previa and postpartum hysterectomy in maternal Rh alloimunization

I. Babovic, D. Plecas, S. Plesinac, O. Antonovic - Belgrade, SERBIA
Vasa previa may be an etiological factor for uterine atony, but repeated intravascular transfusions is not a risk factor for the
uterus.
421
03 1187-30 - Editorial :1648_29 Incidence of multiple 15/11/11 14:08 Pagina 313
[1187/30]
313
Editorial Articles
Choosing the right stimulation protocol for in vitro

fertilization-embryo transfer in poor, normal,
and hyper-responders
J.H. Check, B. Slovis
The University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School at Camden
Cooper Hospital/University Medical Center, Department of Obstetrics and Gynecology
Division of Reproductive Endocrinology & Infertility, Camden, NJ (USA)
Summary
Purpose: To describe the advantages of low-dose stimulation for poor responders, the pros and cons of low dose vs high dose stimulation for normal responders and multiple strategies for hyper-responders especially to reduce the risk of the ovarian hyperstimulation
protocol. Methods: Various strategies are described for these three types of responders. Results: Poor responders do best with mild stimulation protocols. Conventional stimulation protocols for normal responders have the advantage of providing embryos for future embryo
transfers assuming the IVF center has a good cryopreservation program. Mild stimulation protocols save money for normal responders.
There are many strategies for hyper-responders to prevent ovarian hyperstimulation syndrome including mild stimulation, high LH/FSH
ratio for stimulation combination, GnRH agonist instead of hCG and using clomiphene citrate or aromatase inhibitors. Conclusions: It
is important to choose the right protocol for a given patient. An infertile couple can often help in making the decision.
Key words: Mild ovarian hyperstimulation; Poor responders; Hyper-responders; In vitro fertilization; Cryopreservation.
Diminished oocyte reserve

There is an often quoted article suggesting that younger women with an elevated day 3 follicle stimulating hormone
(FSH) have a very high percentage of oocytes that have chromosome abnormalities similar to women of very advanced
reproductive age [1].
A study by one of the most renowned in vitro fertilization (IVF) centers in the world stated that when the serum FSH
on day 3 is > 15 mIU/ml the success rate of transferring normal appearing embryos in women of any age despite adequate response to stimulation will result in no live pregnancies [2]. Thus these two studies would agree with each other.
The 2005 Fertility and Sterility article recommended and has influenced the large majority of IVF centers to immediately recommend donor oocytes with day 3 serum FSH > 15 mIU/ml [2].
Evidence will be provided that the above conclusions are wrong. Evidence will be provided that the very poor pregnancy rates experienced by some IVF centers in women with diminished egg reserve is related to using the wrong controlled ovarian hyperstimulation (COH) regimen.
Table 1 shows the comparative pregnancy rates in younger women < age 35 according to four ranges of FSH
(mIU/ml) normal < 11, slightly high [12-14], moderately high with attainment of the critical level reported by Roberts
et al. of 15-17 and extremely high of 717 mIU/ml. Tables 2, 3, and 4 compare these same parameters according to different age groups of 36-39, 40-42 and 43-44. No differences were found in women up to age 42 according to the four
FSH ranges. It should be noted however that all the women with increased day 3 serum FSH were stimulated with mild
stimulation protocols [3].
Tables 5 and 6 clearly show that age rather than day 3 serum FSH more relates to the attainment of live deliveries.
These data clearly do not show any adverse effect of a high day 3 serum FSH in contrast to the conclusions reached
by many IVF centers including the aforementioned IVF center reporting in Fertility and Sterility, 2005 [2]. Thus we
attribute the difference in conclusions to the other centers purposely using very high dosages of FSH and our use of mild
ovarian stimulation in those with diminished oocyte reserve. Since frozen embryos from women hyperstimulated by
high-dosage FSH regimens in women with diminished oocyte reserve fail to produce pregnancies when thawed and
transferred (unpublished data), we conclude that the adverse effect of controlled ovarian hyperstimulation on pregnancy rates in women with diminished oocyte reserve seems to be on the embryo itself rather than the endometrium.
Table 7 shows the live delivered pregnancy rates according to age and serum FSH. One question that arises from looking at this table is why do the women with normal FSH not do better than the women with diminished oocyte reserve?
Though no significant differences were found there seemed to be a trend for lower pregnancy rates.
Revised manuscript accepted for publication December 15, 2010

Clin. Exp. Obst. & Gyn. - ISSN: 0390-6663
XXXVIII, n. 4, 2011
314
Table 1. Pregnancy rates according to day 3 serum FSH

following IVF-ET in women aged 35.
There are several possible explanations for the relatively

lower pregnancy rates in the group with normal reserve. For
Serum FSH (mIU/ml)
one, there is a greater likelihood of previous failed IVF
11
12-14
15-17
> 17
cycles in other IVF centers. Our IVF center has a reputation
for finding solutions when others have failed such as the
# transfers
2120 111 37 88
% clinical pregnancies per transfer 33.8 32.4 40.5 44.3
woman who had two successful deliveries at our infertility
% live delivered per transfer
30.8 29.7 40.5 38.6
center, once with IVF-ET and once naturally despite failing
% spontaneous abortion
six years of ovulation induction with intrauterine inseminaper clinical pregnancy
13.5 13.9 13.3 15.4
tion and ten IVF-ET cycles with the transfer of 92 fresh
embryos [4, 5]. These cases support larger studies suggestTable 2. Pregnancy rates according to day 3 serum FSH ing that one additional possible explanation for not finding
higher pregnancy rates in those with normal oocyte reserve
following IVF-ET in women aged 36-39.
is that high-dose gonadotropin stimulation may adversely
Serum FSH (mIU/ml)
11
12-14
15-17
> 17
effect embryo implantation in some cases even with normal
day 3 serum FSH [6, 7].
# transfers
1313 120 47 93
De-selection of embryos is another possible explanation
% clinical pregnancy per transfer
28.1 36.7 29.8 37.6
24.3 30.8 21.4 30.1
for lower pregnancy rates in the first fresh embryo transfer.
We have developed a simplified slow cool embryo freezing
per clinical pregnancy
21.1 20.5 21.4 22.9
technique that avoids the programmable freezer which we
believe is the weak part of the standard slow cool procedure
[8]. This modified technique allows good success rates in
Table 3. Pregnancy rates according to day 3 serum FSH
all stages of embryo development, e.g., 2 pronuclear, multifollowing IVF-ET in women aged 40-42.
cell and blastocyst but produces the highest survival rates
Serum FSH (mIU/ml)
and subsequent pregnancy rates when embryos are frozen
11
12-14
15-17
> 17
at the 2 pronuclear phase [8].
# transfers
737 103 30 05
We previously published an article bringing up the con% clinical pregnancy per transfer
23.4 30.1 36.7 35.4
cept
of pregnancy rate per oocyte harvest, i.e., the pregnan% live delivered per transfer
18.5 18.4 23.0 23.1
cy rate following a given oocyte retrieval before another
oocyte retrieval has to be performed [9]. Thus this allows
31.8 45.2 36.4 39.1
all the cryopreserved embryos to be used before doing
another expensive IVF-ET cycle and expensive controlled
Table 4. Pregnancy rates according to day 3 serum FSH ovarian hyperstimulation. Table 8 shows that the chance of
a live delivery before going to another IVF-ET cycle was
following IVF-ET in women aged 43-44.
65% for women < 35 and 45.6% for women 36-39 [9].
Serum FSH (mIU/ml)
11
12-14
15-17
> 17
We have published data using women with diminished
oocyte
reserve showing that the clinical pregnancy rate per
# transfers
121
30
18 25
transfer ranged from 38-42% with day 3 embryos having
% clinical pregnancy per transfer
26.4 26.7 16.7 32.0
six to eight cells but only 3.8 and 9.5%, respectively for
21.5 16.0 6.0 8.0
embryos with four or five blastomeres [10]. Because our
40.6 75.0 100 87.5
frozen protocol gives us a better pregnancy rate when
frozen at the 2 pronuclear stage we typically will allow only
twice as many embryos to develop to day 3 as the woman
Table 5. Pregnancy rates according to age following IVF- intends to transfer and freeze the rest at the 2 pronuclear
stage. If we allowed all the embryos to be developed on day
ET in women with normal FSH 11 mIU/ml.
3 we would have a better chance of transferring the best
Age
morphologic day 3 embryos during the fresh transfer but
Serum FSH 11
35 36-39 40-42 43-44
perhaps at the sacrifice of subsequent frozen embryo trans# transfers
2120
1313
737 121
fer success. Nevertheless this policy could somewhat
% clinical pregnancy rate
reduce our pregnancy rate per transfer in women with norper transfer
33.8
28.1
23.9 26.4
mal day 3 FSH level using the standard higher dose-con% delivered pregnancy rate
per transfer
30.8
24.3
18.5 21.5
trolled ovarian hyperstimulation protocols to possibly
13.5
21.1
31.8 40.6
explain why the pregnancy rates following fresh embryo
transfer in women with normal oocyte reserve was similar
to those with diminished oocyte reserve.
If other centers can show that the pregnancy rates following frozen or fresh embryo transfer are similar, it can not be
known whether our policy of limiting the number of embryos to cleave is the better way. However the pregnancy rates
shown in Table 8 do not include the remaining frozen embryos that can result in pregnancies at a later time.
Even if all the embryos are allowed to cleave to day 3 and a transfer of all day 3 embryos having eight blastomeres
with little fragmentation can be achieved, one cannot be sure that the best embryo has been selected. The FSH recep-
Choosing the right stimulation protocol for in vitro fertilization-embryo transfer in poor, normal, and hyper-responders
315
Table 6. Pregnancy rates according to age following IVFET in women with serum FSH > 11 mIU/ml.
tor is especially susceptible to down regulation [11]. The

concept is that the main purpose of the down-regulation
Age
process is to allow the one best oocyte in the cohort to
develop each menstrual cycle [3]. This supposedly will proSerum FSH 11
35 36-39 40-42 43-44
duce the best embryo. Thus one other explanation for sim# transfers
88
93
65
25
% clinical pregnancy rate
ilar results with women with normal vs diminished oocyte
per transfer
94.3
37.6
35.4 32.0
reserve when minimal stimulation protocols are used for
% delivered pregnancy rate
the latter and traditional high-dose regimen used for the
per transfer
38.6
30.1
23.1 8.0
majority of women with normal day 3 serum FSH levels is
15.4
22.9
39.1 87.5
that the minimal stimulation protocol better allows the natural selection of the best oocyte.
Table 7. Live delivered pregnancy rates according to age
One may question so why do some very good IVF cenand day 3 serum FSH levels.
ters claim such low pregnancy rates when doing IVF with
Day 3 FSH (mIU/ml)
higher dosage protocols in women with diminished oocyte
Age
11 12-14 15-17 > 17
reserve [2, 12-16]. Our theory to explain the poor results of
35
30.8
29.7
40.5 38.6
those IVF centers using traditional high-dose or superhigh
36-39
24.3
30.8
23.4 30.1
dose use of exogenous FSH relates to the marked sensitiv40-42
18.5
18.4
30.0 23.1
ity of the FSH receptor to suppression. It could be hypoth43-44
21.5
10.0
0.0
8.0
esized that there is an FSH dependent implantation factor
that is attached to the embryo that is not adequately proTable 8. Pregnancy rate per oocyte harvest according to duced because its receptor is down-regulated. Thus in conage in women with normal serum FSH.
trast to the minority of women with normal oocyte reserve
Age
where controlled ovarian hyperstimulation may create an
adverse endometrial environment possibly related to pre 35 36-39 40-42 43
# transfers
408
239
135
16
mature trophoblast invasion (where one strategy would be
% clinical pregnancy
to freeze all the embryos and defer transfer to a later time)
per transfer
73.8
59.8
34.1 37.5
with diminished oocyte reserve this strategy will not work
% viable per transfer
65.0
45.6
25.2 25.0
because it is the embryo itself that is affected [17-18]. Also
with diminished oocyte reserve the adverse effect of controlled ovarian hyperstimulation affects the majority of cases rather than a minority with normal oocyte reserve [19-22].
Diminished oocyte reserve groups are more likely to include the best oocyte, i.e., the one that was destined to be the
dominant follicle [22].
High versus low-dose gonadotropin stimulation protocols for normal responders
One of the advantages of the traditional high-dosage controlled ovarian hyperstimulation protocol for women with
normal oocyte reserve is that the pregnancy rate per oocyte harvest would be higher than mild stimulation because of
more embryos (however, this requires a good embryo cryopreservation program).
Another advantage of traditional high-dosage controlled ovarian hyperstimulation protocol for women with normal
oocyte is that it provides embryos for a future pregnancy with pregnancy rates consistent with the younger age when
frozen. For those with insurance that pays for a limited number of IVF-ET cycles stockpiling embryos for the future
will reduce costs since if third party payments have expired a frozen embryo transfer is generally a lot cheaper than controlled ovarian hyperstimulation followed by IVF-ET.
One advantage of the low-dosage controlled ovarian hyperstimulation protocol for women with normal oocyte reserve
is that the chance of pregnancy in the first IVF-ET cycle is probably higher using a low stimulation protocol than a highdose one since it eliminates the adverse effects of controlled ovarian hyperstimulation on the endometrium and allows
a greater chance for the embryo that would have resulted from the best oocyte that would have been selected in the
absence of controlled ovarian hyperstimulation.
Another advantage of the low-dose protocol is much less risk of ovarian hyperstimulation syndrome. Not only is mild
ovarian hyperstimulation less expensive because of lower cost of medication but also because of less work for the
embryologist (we cut the price in half).
Even for those with adequate financial means or insurance coverage the choice of the traditional controlled ovarian
hyperstimulation should only be made if one has a good cryopreservation program.
Some early studies suggested GnRH antagonists were more convenient but lowered pregnancy rates a bit [23]. Most
recent studies show no difference in outcome [23]. We found no difference in outcome in those who were taking it for
a longer vs shorter interval [23].
We typically use the GnRH antagonist in the late follicular phase. Some protocols use the GnRH antagonist earlier
than late follicular phase when the follicle attains an average diameter of 14 mm and still claim good pregnancy rates.
More oocytes are frequently found with GnRH antagonists vs GnRH agonists [23].
316
There are some disadvantages of GnRH agonists. Using GnRH agonists in the mid-luteal phase can interfere with a
possible pregnancy achieved that cycle without IVF-ET. They can sometimes cause a flare effect and advance a single follicle ahead of the rest of the cohort in the follicular phase. Furthermore the use of a GnRH agonist precludes the
use of a GnRH agonist to induce the LH surge and advance meiosis and avoid exposure to hCG injection in case of a
risk of ovarian hyperstimulation syndrome (OHSS). Finally it can sometimes blunt the response to exogenous FSH.
However there are several advantages of GnRH agonists. The main advantage of a GnRH agonist is that it is cheaper than a GnRH antagonist. We find it easier to use when coordinating donors and recipients. Finally it is less likely to
cancel an IVF-ET cycle because of premature luteinization when using a GnRH agonist vs GnRH antagonist.
Ways to reduce the risk of ovarian hyperstimulation syndrome in women with polycystic ovarian syndrome
There are several ways to reduce the risk of OHSS. One method is to use less FSH but sometimes even low dosage
leads to excessive numbers of follicles. One can use a higher LH:FSH ratio [24]. Another option is to use the GnRH
agonist (e.g., 1 mg leuprolide acetate x 2 doses 12 hours apart) instead of hCG [25-27]. Another method is to coast by
stopping the gonadotropin for one to two days (frequently lose follicle if go beyond 2 days) [28, 29]. Finally one can
use LH only when follicles ~12-14 mm (we have not found this very successful but others, e.g., Filicori et al. have had
success [30, 31].
There are other ways to reduce ovarian hyperstimulation syndrome in polycystic ovarian syndrome (POS). One can
use clomiphene citrate alone or follow it by low-dose hMG. Alternatively one can use an aromatase inhibitor alone, e.g.,
letrozol or followed by low-dose gonadotropins.
There are other options. One can perform in vitro maturation (only applies to a few experienced centers). Another
option is to freeze all the embryos and defer transfer to a later cycle (pregnancy worsens OHSS).
There are even more ways to reduce risk of ovarian hyperstimulation syndrome in POS. One can add bromocryptine
or cabergoline near the time of follicular maturation and continue it in the luteal phase in the hope of inhibiting vascular endothelial growth factor (VEGF) receptor [32]. Some have tried IV albumin but it is probably not effective despite
early positive reports. Another way to reduce the risk of ovarian hyperstimulation syndrome is to use sympathomimetic amines, e.g., dextroamphetamine sulfate (diminishes vascular permeability very effective but not well known) [33].
There are more ways to reduce the risk of ovarian hyperstimulation syndrome in POS hyper-responders. One can continue the GnRH agonist or GnRH antagonist into the luteal phase for at least a week after retrieval (especially in cycles
where all embryos are cryopreserved) or one can pretreat with two to three months of oral contraceptives to lower androgens or one can pretreat with metformin to restore down regulated insulin receptors and thus lower androgens.
Finally for the women with POS who are oligovulatory instead of anovulatory one can wait until a dominant follicle
emerges as established by careful monitoring without gonadotropin and then use mild ovarian stimulation.
Sometimes IVF-ET is used as a backup for women with increased androgens and polycystic ovaries who do not need
IVF-ET per se for tubal damage, male factor problems, luteinized unruptured follicle syndrome or unexplained infertility but merely because they fail to respond to conventional ovulation induction with either clomiphene citrate or conventional dosages of gonadotropins. Though drugs, e.g., metformin can restore down-regulated insulin receptors occasionally work after three months of treatment frequently they fail or the patient is unwilling to wait so long with no guarantee.
Another option for this group of patients to avoid higher dosage gonadotropin (using a high LH to FSH ratio but still
risking severe ovarian hyperstimulation syndrome) and thus avoiding IVF-ET.together is to try to reduce the adverse
effects of the androgens. Increased androgens are responsible for the increase in preantral follicles developing into the
antral stage where they can be stimulated to form mature follicles containing metaphase II oocytes but is also responsible for follicular atresia in the presence of a normal amount of FSH stimulation. In 1977 we showed that using a lowdose of glucocorticoids before bedtime which will not only reduce the inhibitors of adrenal androgens but also ovarian
androgens and can allow ovulation to clomiphene citrate in lower dosage even in women who failed to ovulate with
higher dosages [34].
Not only is free testosterone elevated in POS but so is dihydrotestosterone (DHT) [35]. The conversion to DHT could
be blocked by adding a 5 alpha reductase inhibitor, e.g., finasteride prior to ovulation but this would only be effective
if DHT plays a role in inhibiting folliculogenesis. Indeed a recent a study has found that the use of finasteride 5 mg
from day 1 of the cycle until the injection of human chorionic gonadotropin can help some women who have previously failed to ovulate with conventional lower dosage gonadotropin to now respond [35].
Of course the use of these anti-androgens could also be used in women who hyper-respond and who need IVF-ET to
respond to a mild ovarian stimulation protocol. It would be interesting to see if anti-androgens could also help to reduce
the hyper-response that some women with POS have even when given low-dose stimulation.
References
[1] Nasseri A., Mukherjee T., Grifo J.A., Noyes N., Krey L., Copperman A.B.: Elevated day 3 serum follicle stimulating hormone and/or estradiol may predict fetal aneuploidy. Fertil. Steril., 1999, 71, 715.
Choosing the right stimulation protocol for in vitro fertilization-embryo transfer in poor, normal, and hyper-responders
317
[2] Roberts J.E., Spandorfer S., Fasoulitotis S.J., Kashyap S., Rosenwaks Z.: Taking a basal follicle-stimulating hormone history is essential before
initiating in vitro fertilization. Fertil. Steril., 2005, 83, 37.
[3] Check J.H.: Mild ovarian stimulation. J. Assist. Reprod. Genet., 2007, 24, 621.
[4] Check J.H., Choe J.K., Nazari A., Summers-Chase D.: Ovarian hyperstimulation can reduce uterine receptivity. A case report. Clin. Exp.
Obstet. Gynecol., 2000, 27, 89.
[5] Check J.H., Check M.L.: A case report demonstrating that follicle maturing drugs may create an adverse uterine environment even when not
used for controlled ovarian hyperstimulation. Clin. Exp. Obstet. Gynecol., 2001, 28, 217.
[6] Check J.H., Choe J.K., Katsoff D., Summers-Chase D., Wilson C.: Controlled ovarian hyperstimulation adversely affects implantation following in vitro fertilization-embryo transfer. J. Assist. Reprod. Genet., 1999, 16, 416.
[7] Check J.H., Choe J.K., Nazari A., Fox F., Swenson K.: Fresh embryo transfer is more effective than frozen ET for donor oocyte recipients but
not for donors. Hum. Reprod., 2001, 16, 1403.
[8] Baker A.F., Check J.H., Hourani C.L.: Survival and pregnancy rates of pronuclear stage human embryos cryopreserved and thawed using a single step addition and removal of cryoprotectants. Hum. Reprod. Update, 1996, 2, 271.
[9] Katsoff B., Check J.H., Choe J.K., Wilson C.: A novel method to evaluate pregnancy rates following in vitro fertilization to enable a better
understanding of the true efficacy of the procedure. Clin. Exp. Obstet. Gynecol., 2005, 32, 213.
[10] Check J.H., Summers-Chase D., Yuan W., Horwath D., Wilson C.: Effect of embryo quality on pregnancy outcome following single embryo
transfer in women with a diminished egg reserve. Fertil. Steril., 2007, 87, 749.
[11] Katt J.A., Duncan J.A., Herbon L., Barkan A., Marshall J.C.: The frequency of gonadotropin-releasing hormone stimulation determines the
number of pituitary gonadotropin-releasing hormone receptors. Endocrinology, 1985, 116, 2113.
[12] Muasher S.J., Oehninger S., Simonetti S., Matta J., Ellis L.M., Liu H.C. et al.: The value of basal and/or stimulated serum gonadotropin levels in prediction of stimulation response and in vitro fertilization outcome. Fertil. Steril., 1988, 50, 298.
[13] Fenichel P., Grimaldi M., Olivero J.-F., Donzeau M., Gillet J.Y., Harter M.: Predictive value of hormonal profiles before stimulation for in vitro
fertilization. Fertil. Steril., 1989, 51, 845.
[14] Scott R.T., Toner J.P., Muasher S.J., Oehninger S., Robinson S., Rosenwaks Z.: Follicle-stimulating hormone levels on cycle day 3 are predictive of in vitro fertilization outcome. Fertil. Steril., 1989, 51, 651.
[15] Tanbo T., Dale P.O., Abyholm T., Stokke K.T.: Follicle-stimulating hormone as a prognostic indicator in clomiphene citrate/human menopausal
gonadotropin-stimulated cycles for in vitro fertilization. Hum. Reprod., 1989, 4, 647.
[16] Kolibianakis E., Zikopoulos K., Camus M., Tounaye H., Van Steirteghem A., Devroey P.: Modified natural cycle for IVF does not offer a realistic chance of parenthood in poor responders with high day 3 FSH levels as a last resort prior to oocyte donation. Hum. Reprod., 2004, 19,
2545.
[17] Check J.H., Check M.L.: Evidence that failure to conceive despite apparent correction of ovulatory defects by follicle-maturing drugs may be
related to premature trophoblast invasion. Med. Hypoth., 2002, 59, 385.
[18] Check J.H., Cohen R.: Evidence that oocyte quality in younger women with diminished oocyte reserve is superior to those of women of
advanced reproductive age. Med. Hypotheses., 2010, 74, 264.
[19] Check J.H.: Does it all come down to postnatal aging of the primary oocyte?. Fertil. Steril., 2003, 79, 1470.
[20] Check M.L., Check J.H., Kaplan H.: Pregnancy despite imminent ovarian failure and extremely high endogenous gonadotropins and therapeutic strategies: Case report and review. Clin. Exp. Obstet. Gynecol., 2004, 31, 299.
[21] Check J.H.: Pharmacological options in resistant ovary syndrome and premature ovarian failure. Clin. Exp. Obstet. Gynecol., 2006, 33, 71.
[22] Check J.H.: The concept and treatment methodology for inducing ovulation in women in apparent premature menopause. Clin. Exp. Obstet.
Gynecol., 2009, 36, 70.
[23] Check M.L., Check J.H., Choe J.K., Davies E., Kiefer D.: Effect of antagonists vs agonists on in vitro fertilization outcome. Clin. Exp. Obstet.
Gynecol., 2004, 31, 257.
[24] Check J.H., Wu C.H., Gocial B., Adelson H.G.: Severe ovarian hyperstimulation syndrome from treatment with urinary follicle stimulating hormone: Two cases. Fertil. Steril., 1985, 43, 317.
[25] Check J.H., Nazari A., Barnea E.R., Weiss W., Vetter B.H.: The efficacy of short-term gonadotrophin-releasing hormone agonists versus human
chorionic gonadotrophin to enable oocyte release in gonadotrophin stimulated cycles. Hum. Reprod., 1993, 8, 568.
[26] Check J.H., Vetter B.H., Weiss W.: Comparison of hCG versus GnRH analog for releasing oocytes following ultra-low-dose gonadotropin stimulation. Gynecol. Endocrinol., 1993, 7, 115.
[27] Check J.H., Vetter B.H., Weiss W.: Comparison of hCG versus GnRH analog in releasing oocytes following ultra low-dose gonadotropin stimulation. Reprinted from Frontiers in Gynecological Endocrinology Series, Chapter 41, 359. The Proceedings of the Second International Capri
Conference, Capri, Italy, 22, 1992.
[28] Rabinovici J., Kushnir O., Shalev J., Goldenberg M., Blankstein J.: Rescue of menotropin cycles prove to develop ovarian hyperstimulation.
Br. J. Obstet. Gynecol., 1987, 94, 1098.
[29] Urman B., Pride S.M., Ho Yuen B.: Management of overstimulated gonadotrophin cycles with a controlled drift period. Hum. Reprod., 1992,
7, 213.
[30] Filicori M., Cognigni C.E., Samara A., Melappioni S., Perri T., Cantelli B. et al.: The use of LH activity to drive folliculogenesis exploring
uncharterd territories in ovulation induction. Hum. Reprod. Update, 2002, 8, 543.
[31] Filicori M., Cognigni G.E., Taborelli C., Pocognoli P., Taraborrelli S., Spettoli D., Ciampaglia W.: Stimulation and growth of antral follicles
by selective LH activity administration in women. J. Clin. Endoc. Metab., 2002, 87, 1156.
[32] Russo C.E.: Symposium: Update on prediction and management of OHSS. Prevention of OHSS - dopamine agonists. Reprod. Biomed. Online,
2009, 19, 43.
[33] Check J.H., Katsoff D., Kaplan H., Liss J., Boimel P.: A disorder of sympathomimetic amines leading to increased vascular permeability may
be the etiologic factor in various treatment refractory health problems in women. Med. Hypotheses, 2008, 70, 671.
[34] Check J.H., Rakoff A.E., Roy B.K.: Induction of ovulation with combined glucocorticoid and clomiphene citrate therapy in a minimally hirsute woman. J. Reprod. Med., 1977, 19, 159.
[35] Tartagni M., Cicinelli E., DePerigola G., Lavopa S., DiNaro E., De Salvia M.A., Loverro G.: Effect of finasteride on ovulation induction in
nonresponder (hyperandrogenic) polycystic ovary (PCOS) women. Fertil. Steril., 2010, 94, 247.
Address reprint requests to:

J.H. CHECK, M.D., Ph.D.
7447 Old York Road
Melrose Park, PA 19027 (USA)
e-mail: laurie@ccivf.com
04 1118-30 - Original articles:1648_29 Incidence of multiple 15/11/11 14:10 Pagina 318
[789/27]
[1118/30]
318
Original Articles
Evaluation of the importance of late follicular phase

endometrial echo patterns and pregnancy outcome following
embryo transfer by evaluating infertile donor/recipient pairs
J.H. Check, J.K. Choe, J. Amui, D. Brasile, T. Jamison
Summary
Purpose: To investigate if the late follicular phase echo pattern is associated with pregnancy outcome in donors vs recipients.
Methods: Infertile donors sharing eggs with recipients were retrospectively evaluated. The endometrial echo pattern was evaluated on
the day of human chorionic gonadotropin injection in donors and on the day before progesterone was given to recipients. Results:
Almost twice as many donors conceived when the triple-line pattern was found compared to isoechogenic (IE) (51.5% or 52/101 vs
27.3% or 6/22) but there were inadequate numbers in the IE group to show a significant difference. There was not even a trend for a
difference in recipients (55.2%, 37/67 vs 53.8%, 14/26). Conclusions: The trend in this study for higher pregnancy rates in COH cycles
with triple-line isoechogenic pattern in the late follicular phase will prompt a study of a larger group of patients undergoing IVF-ET in
the modern era. If confirmed one treatment option would be to freeze and defer transfer to an estrogen/progesterone cycle.
Key words: Frozen embryo transfer; Proliferative phase; Endometrial echo pattern.
Introduction
Oocyte donation has allowed older women as well as
younger patients with premature ovarian failure to have
successful pregnancies. The shared donor oocyte program
allows infertile couples to get in vitro fertilization (IVF) at
no charge in exchange for half of the oocytes retrieved
which are given to recipients [1]. In this type of donor
program, the same pool of oocytes is equally divided
between two different women, which allows for a unique
way to evaluate the effect of certain fertility parameters on
pregnancy outcome [2, 3]. The study presented herein was
designed to evaluate factors which may affect outcome in
a shared donor oocyte program.
Materials and Methods
All shared donor oocyte IVF cycles were evaluated over a
six-year time period where both donor and recipients had transfers of fresh embryos. Only cycles where all blood tests and
ultrasounds were performed in our IVF facility were included.
Recipients received a graduated estrogen followed by progesterone regimen which suppressed their own ovulation. Donors
used either leuprolide acetate from the mid-luteal phase or the
gonadotropin releasing hormone (GnRH) antagonists cetrorelix
or ganirelix plus gonadotropin injections.
Donor-recipient pairs were divided into four groups: group 1
both donor and recipient achieved a clinical pregnancy, group
2 neither donor nor recipient achieved a pregnancy, group 3
only the recipient achieved a pregnancy, group 4 only the
donor achieved a pregnancy. Once pairs were selected, only one
of two had late proliferative echo patterns performed (i.e., some
Revised manuscript accepted for publication June 8, 2010
XXXVIII, n. 4, 2011
may have just measured thickness) the one having the ultrasound was still included in the data.
The parameters evaluated in each group included: age of the
donor, day 3 FSH (mIU/ml) of donor, endometrial thickness
(mm) of donor on day of hCG, endometrial thickness (mm) of
recipient on the day of donors hCG, donor serum E2 (ng/ml)
on day of hCG, donor serum P4 (pg/ml) on day of hCG, donor
serum E2 (ng/ml) on the day after hCG, number of eggs donor
received, number of eggs received by recipient and endometrial
echo patterns, triple-line (TL) or isoechogenic (IE) in donors
and recipients on day of hCG injection. The determination of
when to give hCG injection was based on follicular size and
serum estradiol levels and endometrial thickness in donors.
Results
There were 118 donor-recipient pairs included in the
analyses; group 1 = 39, group 2 =30, group 3 = 29 and
group 4 = 20. The pregnancy rate was 50% (59/118) in
donors and 57.6% (68/118) in recipients (p = NS, chisquare analysis).
No differences were seen in the mean number of eggs,
sera levels of FSH, E2 or progesterone (P) or the endometrial thickness among the four groups (Table 1) (ANOVA).
The mean age of the donor (Table 1) in Group 3
showed a trend to be slightly higher but the difference
was not quite significant (p = .059). Distribution of TL
endometrial echo patterns on the day of hCG was significantly lower in donors in group 3, p = .026 (Table 2)
(ANOVA). There was no difference in the distribution of
echo patterns in the recipient groups (Table 3) (ANOVA).
Pregnancy rates by echo pattern were 51.5% (52/101) in
donors who had a TL echo pattern and 27.3% (3/11) in
04 1118-30 - Original articles:1648_29 Incidence of multiple 15/11/11 14:10 Pagina 319
Evaluation of the importance of late follicular phase endometrial echo patterns and pregnancy outcome following embryo transfer etc. 319
Table 1. Potential confounding factors by pregnancy group*.

Age of donor
Number of eggs to donor
Donor day 3 FSH (mIU/ml)
Donor endometrial thickness (mm) day of hCG
Donor E2 (ng/ml) day of hCG
Donor P4 (pg/ml) day of hCG
Donor E2 (ng/ml) day after hCG
Number of eggs to recipient
Recipient endometrial thickness (mm)
on day of donors hCG
* p = NS.
Group 1
Group 2
Group 3
Group 4
30.9 2.7
9.7 4.2
5.3 2.2
11.3 2.3
2699.1 1082.7
1.4 .7
3219.6 1076.6
10.3 4.3
31.1 2.9
9.3 2.5
5.3 1.5
12.4 2.3
2498.6 1014.2
1.6 .7
3392.1 1387.4
9.8 2.5
32.7 3.1
8.5 3.3
6.2 4.5
11.0 2.6
2551.2 905.8
1.6 .7
3272.2 1380.6
9 3.2
30.9 3.6
7.9 3.4
5.7 1.9
11.5 2.5
2570.9 966.0
1.3 .6
3308.9 1029.3
9.2 2.9
9.4 2.2
9.0 2.2
9.4 2.3
9.3 1.9
Table 2. Distribution of late follicular phase echo patterns

in donors.
TL
IE
Group 1
Group 2
Group 3*
100%
(37/37)
0
93.1%
(27/29)
6.9%
(2/27)
78.6%
(22/28)
21.4%
(6/28)
Group 4
All groups
83.3%
90.2%
(15/18) (101/112)
16.7%
9.8%
(3/18) (11/112)
TL: triple-line; IE: isoechogenic; *p = .026.
Table 3. Distribution of late follicular phase echo patterns

in recipients.
TL
IE
Group 1
Group 2
Group 3*
Group 4
All groups
72.4%
(21/29)
27.6%
(8/21)
69.6%
(16/23)
30.4%
(7/23)
72.7%
(16/22)
27.3%
(6/22)
73.7%
(14/19)
26.3%
(5/19)
72%
(67/93)
28%
(26/93)
TL: triple-line; IE: isoechogenic.
Table 4. Pregnancy rates by echo pattern in donors vs

recipients.
TL
IE
overall
Donors
Recipients
Overall
51.5% (52/101)
27.3% (3/11)
49.1% (55/112)
55.2% (37/67)
53.8% (14/26)
54.8% (51/93)
53% (89/168)
45.9% (17/37)
51.7% (106/205)
TL: triple-line; IE: isoechogenic.
donors who had an IE echo pattern; however, statistically

no difference was observed using chi-square analysis,
which was most likely due to the small number of IE
echo patterns (Table 4). The pregnancy rate did not differ
by echo pattern in the recipients; 55.2% TL vs 53.8% IE
(Table 4).
Discussion and conclusions
Only TL and IE echo patterns were seen in this study
because, based on previous data, all embryos are frozen
and embryo transfer is deferred if the woman undergoing
controlled ovarian hyperstimulation (COH) has a homogeneous hyperechogenic (HH) pattern on the day of hCG [4].
Although not statistically significant, these data show
that nine more recipients than donors conceived, which is
consistent with previous data suggesting negative effects
of controlled ovarian hyperstimulation (COH) [5].
There was no difference or even a trend for lower pregnancy rates in recipients whether the echo pattern the day
before P supplementation was TL or IE. In contrast the
new data from the present study suggest that for a woman
undergoing COH and oocyte retrieval, having an isoechogenic endometrium on day of hCG may somewhat
decrease the chance of pregnancy; however, to determine
if clinical importance is such that embryo transfer should
be deferred and all embryos frozen, as is the policy for
the HH pattern, a large prospective study would be
required. It may be that the adverse effect of COH in
some women may be reflected by the failure to attain a
TL pattern on the day of hCG injection.
Evaluation of data, as in the present study, may also
help to determine cause for negative outcome in donorrecipient pairs; endometrial echo patterns were good in
the group in which neither donor or recipient conceived
suggesting the possible need to investigate egg quality
whereas the lowest proportion of TL echo pattern in
donors was seen in the group where only the recipients
conceived suggesting poor endometrial receptivity in the
donors in this group.
References
[1] Check J.H., Fox F., Choe J.K., Krotec J.W., Nazari A.: Sharing of
oocytes from infertile versus paid donors results in similar pregnancy and implantation rates. Fertil. Steril., 2004, 81, 703.
[2] Check J.H.: The shared donor oocyte program: the advantages and
insights it provides in determining etiologic factors of infertility.
Clin. Exp. Obstet. Gynecol., 2002, 29, 229.
[3] Check J.H., Cochrane H., Yuan W., Wilson C.: Evidence using a
shared oocyte pool that the sperm rather than the oocyte in some
cases may be responsible for the production of embryos with a high
percentage of fragmented blastomeres - Case report. Clin. Exp.
[4] Check J.H., Lurie D., Dietterich C., Callan C., Baker A.: Adverse
effect of a homogeneous hyperechogenic endometrial sonographic
pattern, despite adequate endometrial thickness on pregnancy rates
following in-vitro fertilization. Hum. Reprod., 1993, 8, 1293.
[5] Check J.H., Choe J.K., Katsoff D., Summers-Chase D., Wilson C.:
Controlled ovarian hyperstimulation adversely affects implantation following in vitro fertilization-embryo transfer. J. Assist.
Reprod. Genet., 1999, 16, 416.

7447 Old York Road
05 1125-30 - blastomere number:1648_29 Incidence of multiple 15/11/11 14:12 Pagina 320
[789/27]
[1125/30]
320
Blastomere number and pregnancy rates in the succeeding

in vitro fertilization cycle in women who formed
all embryos with 5 blastomeres
J.H. Check, J. Amui, J.K. Choe, D. Brasile, R. Cohen
The University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School at Camden,
Cooper Hospital/University Medical Center, Department of Obstetrics and Gynecology,
Summary
Purpose: To determine the likelihood of pregnancy following the transfer of embryos all with slow cleavage to day 3. Furthermore
to determine the likelihood that if slow cleavage happens once, it is likely to repeat. Methods: A 10-year retrospective review of in vitro
fertilization-embryo transfer (IVF-ET) cycles was performed to identify day 3 embryo transfers where none of the embryos had > 5
blastomeres. The pregnancy rate was then determined. If pregnancy did not occur and another IVF-ET cycle was performed it was
determined what percentage of those cycles also showed 100% slow cleavage. Results: The ongoing delivered pregnancy rate was
22.3% and the implantation rate was 15.6%. Of the 90 women trying another cycle 82.2% had at least one embryo with six blastomeres.
The implantation rate for cycle number 2 for those with at least one 6-cell embryo was 18% (34/187) but was zero (0/17) for those not
having at least a 6-cell embryo in cycle number 7. Conclusions: These data can help a couple decide whether to pursue a second cycle
following an IVF-ET cycle with 100% slow cleavage embryos.
Key words: Blastomere number; Slow cleavage; Embryo transfer.
Introduction
A study of single-embryo transfer in women with
diminished egg reserve found the following pregnancy
rates according to the blastomere number of a day 3
embryo: 4 cell - 3.8%, 5 cell - 9.5%, 6 cell - 37.8%, 7 cell
- 40.0% and 8 cell - 42.4% [1]. The present study evaluated pregnancy rates in a larger series of women not necessarily with diminished egg reserve following transfer of
all embryos (not reduced to one) with < 6 blastomeres.
The study also aimed to determine what the chance was
of having at least one embryo with six blastomeres in the
next cycle if the preceding one did not have any. In addition if a 6 cell embryo was present vs none in the second
embryo transfer, would it have an effect on the pregnancy
rate.
A 10-year retrospective study of IVF-ET cycles was carried
out to identify first embryo transfers where the maximum
number of blastomeres in any embryo transferred was 5.
All types of controlled ovarian hyperstimulation regimens
were used including luteal phase leuprolide acetate with highdose gonadotropins, an antagonist protocol using cetrorelix or
ganirelix, or mild stimulation protocol [2].
All embryo transfer cycles were counted including those with
only one embryo transferred and including female partners to
age 39.9.
The viable pregnancy rate from 8-12 weeks and live delivered

XXXVIII, n. 4, 2011
pregnancy rates were determined in cycle 1 when no embryos

had six blastomeres. These same parameters were also determined in cycle 2 and comparisons were made between those
cycles where again there were no embryos with six blastomeres
vs those which did not have at least one embryo with six cells.
Results
The first cycle results of transferring day 3 embryos
with a maximum of five blastomeres were 24.8%
(60/242) for 8-week viable pregnancy rates and 22.3%
for 12-week viable pregnancy rates (Table 1). The
implantation rate was 15.6%.
The number of women not having a live delivered pregnancy in the first cycle where no embryos had six blastomeres trying a second cycle was 90/191 (47.1%).
The majority of women attempting a second IVF-ET
cycle did have an embryo with six or more blastomeres
transferred: 74 of 90 (82.2%). Sixty-seven of these 90
women had two or more embryos transferred and 60 of
these 67 women (89.6%) with two or more embryos
transferred had at least one day 3 embryo with six blastomeres. The seven women in cycle 2 with 5 blastomeres and 2 embryos transferred had 17 embryos
transferred and not one implanted (implantation rate 0%).
A total of 16 women (single embryo transfers included)
in cycle 2 had 16 embryo transfers of 26 embryos and
none implanted. The 60 women with at least one embryo
with six blastomeres had 187 embryos transferred and 34
implanted (implantation rate 18% per embryo) (Table 1).
The live delivered pregnancy rates in cycles 3 and 4 are
shown in Table 1 according to whether there were any
05 1125-30 - blastomere number:1648_29 Incidence of multiple 15/11/11 14:12 Pagina 321
Blastomere number and pregnancy rates in the succeeding in vitro fertilization cycle in women who formed all embryos with 5 etc. 321
Table 1. Pregnancy outcome according to blastomere size

(based on patient age 39 from 1/1/97 to 12/31/07).
Cycle 1
Blastomere size
5
# transfers
242
# pregnancies
(beta-hCG
> 200 mIU/ml)
74
% pregnant/transfer 30.6
# 8-week viable
60
% 8-week viable
pregnancy rate
24.8
# 12-week viable
54
% 12-week viable
pregnancy rate
22.3
# miscarriages
9
% miscarriages/
8-week viable
15.0
# deliveries
51
Delivered pregnancy
rate/transfer
21.1
# embryos transferred 486
Avg. # embryos
per transfer
2.0
# sacs implanted
76
Implantation rate (%) 15.6
Cycle 2
Cycle 3
6
29
Cycle 4
5
16
6 5
74
7
5 6
5 26
0
0.0
0
29
2
11
0 17
39.2 28.6 37.9 0.0 65.4
22
2
9
0 14
0.0
0
29.7 28.6 31.0 0.0 53.8

21
2
8
0 13
0.0
0
28.4 28.6 27.6 0.0 50.0

1
0
1
0 1
0.0
0
4.5
21
0.0
26
28.4 28.6 27.6 0.0 50.0

201 18 80
6 75
1.6
0
0.0
2.7 2.6 2.8 1.2 2.9

35
2
11
0 21
17.4 11.1 13.8 0.0 28.0
0.0 11.1 0.0 7.1

2
8
0 13
day 3 embryos with six blastomeres or more: the group

with six or more blastomeres: 42/129 = 32.4%, implantation rates: 18.8% (67/356), mean number embryos transferred: 2.8. In contrast the group with a maximum of five
blastomeres: 2/28 = 7.1%, implantation rate: 4% (2/50),
mean number of embryos transferred: 1.8, number of
patients (1st cycle) with only 4 cell embryos: 128, number
of patients (cycles 2-4) with only 4 cell embryos: 16 (p <
0.01, Fishers exact test).
what related to a better oocyte quality since in the aforementioned study all patients had diminished oocyte
reserve with a mean serum FSH of 20 mIU/ml whereas
in this study the IVF-ET cycle included but were not
limited to females with diminished egg reserve.
Since the live delivered pregnancy rate was 50% higher
for women with at least one 6 cell embryo in succeeding
cycles compared to the first cycle with a maximum of
five cells it seems that blastomere number is an important
criteria for prediction of pregnancy rates, especially with
5 cells as the cut-off.
The study suggests that possibly slight variation in subsequent controlled ovarian hyperstimulation cycles or just
fortuitously that most women who do not achieve a 6 cell
embryo on their first IVF-ET cycle do not necessarily
have a condition that would predispose them to always
forming embryos with fewer blastomeres. However,
those who have slow cleavage in two consecutive cycles
seem to have some type of genetic defect that leads to a
high likelihood of failure. This group should probably be
discouraged from trying a third cycle. They should possibly consider a change in gametes.
The average number of blastomeres in the first cycle
group not making a 6 cell embryo was 4.2 and there were
128 (52.9%) cycles where there were only 4 cell
embryos. In the persistent group of < 6 blastomeres the
average number of blastomeres was 4.2 and the number
with only 4 cell embryos was 16 (57.1%).
References
[1] Check J.H., Summers-Chase D., Yuan W., Horwath D., Wilson C.:
Effect of embryo quality on pregnancy outcome following single
embryo transfer in women with a diminished egg reserve. Fertil.
Steril., 2007, 87, 749.
[2] Check J.H.: Mild ovarian stimulation. J. Assist. Reprod. Genet.,
2007, 24, 621.
Discussion
Based on these data transferring more than one embryo
with only four or five blastomeres does seem to more
than double the chance of a successful live delivery when
compared to single embryo transfers of similar numbers
of blastomeres [1]. The difference could also be some-

7447 Old York Road
06 1129-30 - Effect of serum:1648_29 Incidence of multiple 15/11/11 14:13 Pagina 322
[789/27]
[1129/30]
322
Effect of serum progesterone level on the day of human

chorionic gonadotropin injection on outcome following in
vitro fertilization-embryo transfer in women using
gonadotropin releasing hormone antagonists
B. Katsoff, J.H. Check, C. Wilson, J.K. Choe
Summary
Purpose: To determine if there is any association of serum progesterone (P) level at the time of human chorionic gonadotropin (hCG)
injection and pregnancy outcome in in vitro fertilization (IVF) cycles using gonadotropin releasing hormone (GnRH) antagonists for
controlled ovarian hyperstimulation (COH). Methods: A retrospective analysis of IVF cycles over a six and a half-year period where
either cetrorelix or ganirelix was used with COH and at least two embryos were transferred. Female partners were 35. Four different serum progesterone (P) ranges were evaluated from .5 ng/ml to 1.9 ng/ml; P was measured by ELISA. Results: There was no
significant difference in pregnancy rates or even a trend in that direction with increasing serum P levels with either GnRH antagonist.
Conclusions: At least with COH cycles using GnRH antagonists and where serum P is measured by ELISA there does not seem to be
any disadvantage of higher serum P levels up to 2 ng/ml at the time of hCG in IVF-ET cycles.
Key words: Progesterone; Cetrorelix; Ganirelix; Pregnancy outcome.
Introduction
Results
There have been several previous studies attempting to

determine if a higher level of serum progesterone (P) on
the day of taking human chorionic gonadotropin (hCG)
in in vitro fertilization-embryo transfer (IVF-ET) is associated with a lower pregnancy rate per ET [1-4].
Various conclusions as to the negative influence of a
higher serum P were reached. Most of these studies
involved the use of luteal phase gonadotropin releasing
hormone (GnRH) agonists [1-3].
The purpose of this study was to determine the pregnancy outcome according to various serum P ranges
under 2 ng/ml on the day of hCG in women taking GnRH
antagonists in a controlled ovarian hyperstimulation
(COH) regimen.
The clinical (ultrasound evidence of pregnancy) and

ongoing/delivered pregnancy rates (PRs), and implantation rates are presented in Table 1. The data were evaluated according to ranges of P, and according to whether
the GnRH antagonist was cetrorelix or ganirelix.
Even though some of the groups were small, there was
no trend for lower PRs as the serum P increased at least
< 2 ng/ml for either GnRH antagonist.
Table 1. Pregnancy rates according to the serum

progesterone level on the day of hCG injection in women
undergoing in vitro fertilization using antagonist controlled
ovarian hyperstimulation protocols.
A retrospective review was performed for all couples undergoing IVF-ET over a six-year time period in which either
cetrorelix or ganirelix was used following COH where at least
two embryos were transferred. The maximum age for the
female partner was 35.
The serum P levels were measured on the day of hCG injection by ELISA assay. Embryos were not transferred but instead
cryopreserved if the serum p was 2 ng/ml. Pregnancy and
implantation rates were calculated according to the serum P.

XXXVIII, n. 4, 2011
Conclusions
There does not appear to be any association of lower
pregnancy rates following IVF-ET and higher levels of
serum P (up to 2 ng/ml) on the day of hCG in women
Ganirelix
Serum P day of hCG

(ng/ml)
.5
# transfers ET
18
% clinical pregnancies/
transfers
55.6
% ongoing/delivered/
transfers
44.4
% embryos implanted 25.0
Mean no. embryos
transferred
3.1
Cetrotide
.6-.9 1.0-1.3 1.4-1.9 .5 .6-.9 1.0-1.3 1.4-1.9

29
15
4
7
18
15
7
44.8
33.3
50.0
71.4 33.3
60.0
57.1
44.8
29.8
33.3
19.6
25.0
25.6
57.1 33.3
28.6 18.8
53.3
26.2
57.1
38.9
2.9
3.1
2.3
3.0
2.8
2.6
2.7
06 1129-30 - Effect of serum:1648_29 Incidence of multiple 15/11/11 14:13 Pagina 323
Effect of serum progesterone level on the day of human chorionic gonadotropin injection on outcome following in vitro etc.
using GnRH antagonists in their controlled ovarian

hyperstimulation regimen.
If one favors the previous data showing higher PRs
with lower serum P levels when using GnRH agonist protocols, then this study suggests that when using antagonist protocols the association is no longer found.
Of course, if one favors the previous studies showing
no association of serum P at the time of hCG and pregnancy outcome then these data corroborate these studies
only now using COH protocols with antagonists. The
lack of association of serum P and outcome was found
whether ganirelix or cetrorelix were used.
323
[2] Silverberg K.M., Burns W.N., Olive D.L., Richl R.M., Schenken
R.S.: Serum progesterone levels predict success of in vitro fertilization/embryo transfer in patients stimulated with leuprolide
acetate and human menopausal gonadotropins. J. Clin. Endocrinol.
Metab., 1991, 73, 797.
[3] Check J.H., Lurie D., Askari H.A., Hoover L., Lauer C.: The range
of subtle rise in serum progesterone levels following controlled
ovarian hyperstimulation associated with lower in vitro fertilization
pregnancy rates is determined by the source of manufacturer. Eur.
J. Obstet. Gynecol. Reprod. Biol., 1993, 52, 205,
[4] Check J.H., Hourani C., Choe J.K., Callan C., Adelson H.G.:
Pregnancy rates in donors versus recipients according to the serum
progesterone level at time of human chorionic gonadotropin in a
shared oocyte program. Fertil. Steril., 1994, 61, 262.
Acknowledgement
We would like to thank Ascend Specialty Rx for providing
partial grant support.
References
[1] Schoolcraft W., Sinton E., Schlenker T., Huynh D., Hamilton F.,
Meldrum D.R.: Lower pregnancy rates with premature luteinization during pituitary suppression with leuprolide acetate. Fertil.
Steril., 1991, 55, 563.

7447 Old York Road
07 1133-30 - Effect of multiple:1648_29 Incidence of multiple 15/11/11 14:14 Pagina 324
[789/27]
[1133/30]
324
Effect of multiple source vs single source of donor embryos

on pregnancy and implantation rates per transfer
C. Wilson, J.H. Check, J. Amui, J.K. Choe, D. Brasile
Summary
Purpose: To evaluate whether using donated embryos from more than one source has a negative impact on pregnancy rates compared to a single source. Methods: Retrospective review of all donor embryo transfers that occurred in our IVF center over a 10-year
period. Embryos were all from our own patient pool. Results: There were no differences in clinical or live delivered pregnancy rates.
Conclusions: The willingness to choose multiple sources allows a marked reduction in the waiting time for donated embryos which are
scarce. This also reduced the financial burden for couples who for religious or for ethical reasons cannot destroy the embryos and have
to pay continuous embryo storage charges.
Key words: Donated embryos; Multiple source; De-selection.
Introduction
Results
Donor embryo programs using embryos from other

patients who no longer want them for themselves but do
not want to destroy them have been very successful [1,
2]. However supplies are scarce especially with new FDA
restrictions.
Sometimes there is only one or two frozen embryos left
from a given patient and one cannot guarantee all surviving the thaw. Thus to improve the pregnancy rate per
transfer and make it more economically feasible we allow
women to transfer embryos from more than one source.
The objective of the present study was to determine if
transferring donated embryos from more than one source
negatively or positively affects pregnancy rates.
There were 315 donor embryo transfers evaluated. The

majority used embryos from a single source 240
(76.1%). The clinical pregnancy rates per transfer (live
fetus at 8 weeks) were as follows: single source 44.8%
(107/240), multiple source 49.3% (37/75) (p = 0.35,
chi-square analysis).
The live delivered pregnancy rate per transfer were as
follows: single source 36.7% (88/240), multiple source
44.0% (33/75) (p = 0.56, chi-square analysis).
The implantation rates per embryo transfer were as
follows: single source 21.9% (160/732), multiple
source 16.9% (48/284) (p = 0.09, chi-square analysis).
Average number of embryos transferred were as
follows: single source 3.0, multiple source 3.7.
Discussion
The outcome of all donor embryo cycles over a 10-year time

period were evaluated according to whether all the embryos
transferred come from one source or two or more. They all
came from our own patient population, i.e., embryos in storage
that couples agreed to donate gratis to an anonymous couple.
Frequently these were deselected embryos with fewer blastomeres and more fragmentation. They could have been day 3
embryos or 2 pronuclear embryos (there were no blastocysts
donated).
The majority of embryos were frozen at our own institution
using a simplified freezing protocol employing a single-step
addition and removal of cryoprotectants [3]. Assisted embryo
hatching was used prior to the transfer of day 3 embryos [4].
Revised manuscript accepted for publication July 29, 2010

XXXVIII, n. 4, 2011
Live delivered pregnancy rates using frozen thawed

donated de-selected embryos are quite adequate whether
the source is from a single or multiple source. Some
researchers suggest that the allogeneic stimulus of trophoblasts could induce an inflammatory reaction that
would limit the depth of trophoblast invasion but this is
modified to some extent by exposure to and development
of immune tolerance to paternal antigens by exposure to
paternal sperm [5-7]. Obviously in the case of donated
embryos exposure to paternal sperm is not possible but
there does not seem to be adverse consequences. An even
greater allogeneic stimulus by exposure to embryos from
different sources does not seem to cause any adverse consequence on the achievement of a live pregnancy as evidenced by these data.
The majority (about ) of couples choose embryos
from a single source. However a substantial minority will
choose embryos from a multiple source. Choosing
07 1133-30 - Effect of multiple:1648_29 Incidence of multiple 15/11/11 14:14 Pagina 325
Effect of multiple source vs single source of donor embryos on pregnancy and implantation rates per transfer
donated embryos from a multiple source not only allows

some women to have a baby when availability is low, but
allows satisfaction to couples who no longer want children but feel uncomfortable not allowing the created life
to have the opportunity for birth. Furthermore allowing
the choice of embryos from a multiple source will allow
some couples to finally eliminate the financial burden of
having to pay for storage of embryos they no longer want
yet for moral or ethical reasons cannot destroy them.
References
[1] Check J.H., Wilson C., Krotec J.W., Choe J.K., Nazari A.: The
feasibility of embryo donation. Fertil. Steril., 2004, 81, 452.
[2] Keenan J., Finger R., Check J.H., Daly D., Dodds W., Stoddart R.:
Favorable pregnancy, delivery, and implantation rates experienced
in embryo donation programs in the United States. Fertil. Steril.,
2008, 90, 1077.
[3] Baker A.F., Check J.H., Hourani C.L.: Survival and pregnancy
rates of pronuclear stage human embryos cryopreserved and
thawed using a single step addition and removal of cryoprotectants. Hum. Reprod. Update, 1997, 2 (CD-ROM).
325
[4] Check J.H., Hoover L., Nazari A., O'Shaughnessy A., Summers D.:
The effect of assisted hatching on pregnancy rates after frozen
embryo transfer. Fertil. Steril., 1996, 65, 254.
[5] Kyrou D., Kolibianakis E.M., Devroey P., Fatemi H.M.: Is the use
of donor sperm associated with a higher incidence of preeclampsia
in women who achieve pregnancy after intrauterine insemination?.
Fertil. Steril., 2010, 93, 1124.
[6] Salha O., Sharma V., Dada T., Nugent D., Rutherford A.J., Tomlinson A.J. et al.: The influence of donated gametes on the incidence
of hypertensive disorders of pregnancy. Hum. Reprod., 1999, 14,
2268.
[7] Smith G.N., Walker M., Tessier J.L., Millar K.G.: Increased incidence of preeclampsia in women conceiving by intrauterine insemination with donor versus partner sperm for treatment of primary
infertility. Am. J. Obstet. Gynecol., 1997, 177, 455.

7447 Old York Road
08 1134-30 - Evidence that the:1648_29 Incidence of multiple 15/11/11 14:16 Pagina 326
[789/27]
[1134/30]
326
Evidence that the main adverse effect of ganirelix on

pregnancy and implantation rates is on the embryo rather
than the endometrium
J.H. Check, R. Cohen, J. Amui, J.K. Choe, D. Brasile
Summary
Purpose: To compare pregnancy rates following the transfer of thawed frozen embryos according to the type of GnRH antagonist or
agonist used during controlled ovarian hyperstimulation (COH). Methods: Retrospective review of frozen embryo transfers according
to whether a GnRH agonist or antagonist was used. Furthermore to determine if a specific antagonist/agonist resulted in higher pregnancy rates than the other. Results: The pregnancy rates in two different age categories were similar whether the COH regimen used
the GnRH agonist leuprolide acetate or the GnRH antagonist cetrorelix. However, lower pregnancy rates were found with the GnRH
antagonist ganirelix. Conclusions: These data reached similar conclusions as was found comparing these three agents in fresh embryo
transfer.
Key words: GnRH agonist; GnRH antagonist; Frozen embryo transfer.
Introduction
Some studies have suggested that the use of
gonadotropin releasing hormone (GnRH) antagonists,
e.g., ganirelix or cetrorelix, are associated with lower
pregnancy rates when used for controlled ovarian hyperstimulation (COH) compared to COH protocols using
leuprolide acetate [1, 2].
At the 2008 Pacific Coast Reproductive Society we
compared clinical and live delivered pregnancy rates
according to whether ganirelix or cetrorelix was used as
the GnRH antagonist for IVF-ET and found a significantly lower clinical and live delivered pregnancy rate
with ganirelix [3]. If this is an adverse effect of ganirelix
inhibiting embryo implantation theoretically it could
either be involving the endometrium or the embryo
directly.
The present study compared clinical and live delivered
pregnancy rates and implantation rates following frozen
embryo transfer. The hypothesis was that if the pregnancy
and implantation rates were also lower with ganirelix
compared to the other agents the evidence would favor
the adverse effect of ganirelix to be on the embryo rather
than the endometrium.
All frozen embryo transfer cycles over a 5-year period where
at least two embryos were transferred were retrospectively compared. Clinical (viable pregnancy at 8 weeks), viable (viable
pregnancy at 12 weeks) and live delivered pregnancy rates and
implantation rates were determined according to whether the

XXXVIII, n. 4, 2011
COH regimen used the GnRH agonist leuprolide acetate or the

GnRH antagonist ganirelix or the GnRH antagonist cetrorelix
prior to oocyte retrieval.
The average number of blastomeres per embryo transfer
according to these three groups was also determined. The data
was also stratified according to two age groups: 35 and age
36-39 counting the age of when the female partners had the
oocyte retrieval.
Embryos were frozen using a simplified protocol using a onestep removal of the cryoprotecant 1,2 propanediol [4]. Assisted
embryo hatching was performed prior to the transfer of these
day 3 embryos [5]. No cycles were included if leuprolide was
used to prepare for the graduated estradiol/progesterone protocol used to develop the endometrium for the frozen ET.
Results
A summary of the outcome following frozen embryo
transfer according to whether a GnRH agonist or GnRH
antagonist was used and according to which GnRH
antagonist was used during the oocyte retrieval cycle
divided into two age groups is seen in Table 1. In both
age groups the women who had taken cetrorelix or
leuprolide acetate for their COH protocol had similar
pregnancy and implantation rates but the pregnancy and
implantation rates were lower in those whose COH protocol used ganirelix (Table 1).
Comparing women aged 39, the clinical pregnancy
rate per frozen ET was 30.0% (52/173) for those whose
COH protocol used ganirelix vs 42.5% (289/680) for
those taking either cetrorelix or leuprolide acetate (p =
0.0038, chi-square). The live delivered pregnancy rates
were also lower with ganirelix 24.8% (43/173) vs
34.5% (235/680) (p = 0.019). The implantation rates
were also significantly lower with ganirelix: 13.1%
(69/525) vs 20.9% (506/1937) (p < 0.001).
08 1134-30 - Evidence that the:1648_29 Incidence of multiple 15/11/11 14:16 Pagina 327
Evidence that the main adverse effect of ganirelix on pregnancy and implantation rates is on the embryo rather than the endometrium 327
Table 1. Frozen embryo transfer pregnancy rates according to use of ganirelix, cetrorelix or leuprolide acetate during the
oocyte retrieval cycle.
Ganirelix
Age at retrievals
# Transfers
Avg. # blastomeres
# pregnancies
(beta-hCG >200 mIU/ml)
% pregnant/transfers
# clinical pregnancies
% clinical/transfers
# viable
% viable/transfers
# miscarriages
% miscarriage/preg.
# deliveries/ongoing
% delivered/ongoing
# total embryos transferred
Avg. # embryos transferred
# sacs implanted
Implantation rate (%)
Cetrorelix
Leuprolide acetate
Totals
173
6.5
35
116
6.6
36-39
57
6.5
Totals
244
6.3
35
179
6.5
36-39
65
6.2
Totals
436
6.4
35
369
6.4
36-39
67
6.3
62
35.8
52
30.1
45
26.0
9
17.3
43
24.9
525
3.0
69
13.1
40
34.5
33
28.4
28
24.1
6
18.2
27
23.3
329
2.8
44
13.4
22
38.6
19
33.3
17
29.8
3
15.8
16
28.1
196
3.4
25
12.8
116
47.5
103
42.2
87
35.7
24
23.3
79
32.4
677
2.8
136
20.1
86
48.0
76
42.5
62
34.6
21
27.6
55
30.7
474
2.6
102
21.5
30
46.2
27
41.5
25
38.5
3
11.1
24
36.9
203
3.1
34
16.7
220
50.5
186
42.7
163
37.4
30
16.1
156
35.8
1254
2.9
270
21.5
191
51.8
161
43.6
140
37.9
25
15.5
136
36.9
1038
2.8
232
22.4
29
43.3
25
37.3
23
34.3
5
20.0
20
29.9
216
3.2
38
17.6
The difference in pregnancy rates could not be

accounted for by embryos having fewer blastomeres.
Fragmentation indices were not evaluated but recent data
suggest that the number of blastomeres of day 3 embryos
is a better indicator of pregnancy outcome [6].
Discussion
Not all IVF centers share our observation that the use
of ganirelix leads to lower pregnancy rates following
fresh embryo transfer compared not only to the use of a
GnRH agonist but also the other GnRH antagonist
cetrorelix.
Whatever the reasons as to why our methodology leads
to lower pregnancy rates with ganirelix, the present study
aimed to determine if that adverse effect was on the
endometrium or the embryo.
The demonstration that lower pregnancy and implantation rates result from frozen ET when no antagonists or
agonists are used in the COH protocol strongly suggests
that for those centers whose methodology leads to similar
findings as to our IVF center (i.e., that ganirelix lowers
pregnancy rates) the adverse mechanism seems to have
some direct effect on the embryo rather than the
endometrium.
This study by showing lower pregnancy rates even with
frozen ET where embryos were developed using ganirelix corroborated our previous conclusions that for some
reason, in some IVF centers, ganirelix leads to lower
pregnancy rates compared to the other GnRH antagonist
cetrorelix.
References
[1] Ganirelix Dose-Finding Study Group: A double blind, randomized, dose finding study to assess the efficacy of the GnRH antagonist Ganirelix (Org 37462) to prevent premature luteinizing
hormone surges in women undergoing ovarian stimulation with
recombinant follicle stimulating hormone (Puregon). Hum.
Reprod., 1998, 13, 3023.
[2] Albano C., Felberbaum R.E., Smitz J., Riethmuller-Winzen H.,
Engel J., Diedrich K., Devroey P. on behalf of the European
Cetrorelix Study Group: Ovarian stimulation with HMG: results
of a prospective randomized phase III European study comparing
the luteinizing hormone-releasing hormone (LHRH)-antagonist
cetrorelix and the LHRH-agonist buserelin. Hum. Reprod., 2000,
15, 526.
[3] Maletteri N., Dietterich C., Check J.H., Dix E., Brasile D.: The
adverse effect of ganirelix versus cetrorelix on pregnancy rates
(PRs) and implantation rates is not associated with midluteal phase
echo patterns. 56th Annual Meeting of the Pacific Coast Reproductive Society, Rancho Mirage, California, April 9-13, 2008. Fertil.
Steril., 2008, 89, (suppl. 2), S24.
thawed using a single step addition and removal of cryoprotectants. Hum. Reprod. Update 2, (CD-ROM), 1997.
[5] Check J.H., Hoover L., Nazari A., OShaughnessy A., Summers D.:
The effect of assisted hatching on pregnancy rates after frozen
Steril., 2007, 87, 749.

7447 Old York Road
09 1135-30 - Successful twin:1648_29 Incidence of multiple 15/11/11 14:17 Pagina 328
[789/27]
[1135/30]
328
Successful twin pregnancy in a donor oocyte recipient

despite a maximum endometrial thickness in the late
proliferative phase of 4 mm
J. Amui, J.H. Check, R. Cohen
Summary
Purpose: To show that even a twin pregnancy is possible following embryo transfer despite a very thin endometrium. Methods: Two
embryos derived from donor oocytes were transferred into a 47-year-old woman despite a peak endometrial thickness of 4 mm. Results:
She delivered viable dichorionic twins at 30 weeks in a pregnancy complicated by HELLP syndrome. Conclusions: Anecdotal case
reports are important to establish precedents to allow patients to make decisions when presented with treatment options. A third precedent of a successful pregnancy with endometrial thickness of only 4 mm is presented. Without precedent she would have chosen embryo
freezing and subsequent transfer into a very expensive gestational carrier if thin endometrium persisted.
Key words: Thin endometrium; Twin gestation; Donor oocyte recipients.
Introduction
In the early era of in vitro fertilization-embryo transfer
(IVF-ET) lower pregnancy rates were found with thinner
endometrium on the day of the injection of human chorionic gonadotropin (hCG) [1-3]. With improved embryo
technology the embryos are heartier and pregnancies may
occur despite thin endometrium. However, in the literature there is only one case report of a successful pregnancy following IVF-ET with a 4 mm endometrium on
the day of hCG injection [4].
Sometimes if during a controlled ovarian hyperstimulation IVF-ET cycle the endometrial thickness is too thin,
one has the option of freezing the embryos hoping that
the endometrial thickness will increase with an artificial
graduated estrogen protocol. However, if a woman is
already in an estrogen replacement cycle, and the dosage
has already been increased and vaginal estrogen has been
added with the follicular phase extended for transfer of
embryos derived from donor eggs, one cannot assure the
woman that other therapeutic interventions can be made
in a succeeding cycle to improve the endometrial thickness. For example though there have been claims that the
addition of sildenafil can significantly improve endometrial thickness, this has not been our experience [5-7].
Similarly our data does not support the conclusion that
low-dose aspirin can improve endometrial thickness [8,
9]. In fact our studies suggest that low-dose aspirin given
during a similar graduated estrogen protocol for transfer
of frozen-thawed embryos is associated with a significant
decrease in subsequent pregnancy rates [9].

XXXVIII, n. 4, 2011
There are IVF centers who do well when they transfer

fresh embryos but have a relatively poor cryopreservation
program. At the Cooper Institute for Reproductive Hormonal Disorders we developed a protocol that generally
provides a pregnancy rate following frozen-thawed
transfer that approximates the pregnancy rate following
fresh embryo transfer in IVF-ET cycles using controlled
ovarian hyperstimulation [10-12]. However, even in our
IVF center we have data showing that in the absence of
controlled ovarian hyperstimulation the fresh embryo
has a better chance to implant than frozen-thawed
embryos [13].
Case Report
A 47-year-old woman with a history of two previous spontaneous abortions and a therapeutic abortion in the past with no
live children presented with secondary infertility of eight years
duration. A previous hysteroscopy found a normal uterine
cavity.
The woman based on her age requested to be a donor oocyte
recipient. After matching with an oocyte donor she was synchronized for fresh embryo with oral contraceptives, then
leuprolide acetate followed by a graduated oral estradiol
regimen of 2 mg x 5 days, 4 mg x 4 days, then 6 mg x 5 days
along with 2 mg per day of estradiol placed vaginally.
Despite an endometrial thickness of only 4 mm (triple line
echo pattern) she elected to proceed with fresh embryo transfer
rather than to freeze the embryos and try in another cycle. She
transferred on day 3 two 7-cell embryos (with < 25% fragmentation in one and 26-50% fragmentation in the other) on her 4th
day of progesterone support (progesterone vaginal suppositories
200 mg twice daily and 100 mg progesterone in oil IM).
The woman achieved a dichorionic diamniotic intrauterine
pregnancy. In her third trimester she developed HELLP syndrome and the decision was made to deliver by cesarean section
at 30 weeks. A live baby girl was born with a weight of 3
09 1135-30 - Successful twin:1648_29 Incidence of multiple 15/11/11 14:17 Pagina 329
Successful twin pregnancy in a donor oocyte recipient despite a maximum endometrial thickness in the late proliferative phase of 4 mm 329
pounds and 4 ounces (1.47 kg) and a baby boy with a weight of
3 pounds 2 ounces (1.41 kg). Both babies were detained for a
short time in the neonatal intensive care unit and then were discharged.
Discussion
The couple was advised that although the pregnancy
rate with fresh embryos derived from donor oocytes is
higher with fresh vs frozen thawed embryo transfer, the
pregnancy rates are still very respectable with frozenthawed embryo transfer [13].
On the other hand they were advised that although
pregnancy rates are lower with thinner endometrium,
there was a previous successful pregnancy with embryo
transfer at 4 mm [4]. In fact, since controlled ovarian
hyperstimulation may create a hostile uterine environment, theoretically the absence of controlled ovarian
hyperstimulation and the good quality oocytes from a
younger donor could make it more likely for these
embryos derived from donor oocytes on an estrogenprogesterone replacement cycle to implant [14].
Furthermore, the patient was advised that we were not
aware of any interventions that would necessarily
improve her endometrial thickness. Thus if she deferred
fresh transfer she could be faced with a similar endometrial thickness in the next cycle only then with possibly
less hearty frozen thawed embryos. Also she was advised
of another case where a successful conception occurred
with just natural intercourse and luteal phase progesterone support occurred with only a 4 mm endometrial
thickness [15].
Shallow endovascular cytotrophoblast invasion in the
spiral arteries and endothelial cell dysfunction are two key
features in the pathophysiology of preeclampsia and
HELLP syndrome [16]. Thus the question arises as to
whether the thin endometrium contributed to this problem.
However the twin gestation could have been the etiologic
factor as well as the use of donor oocytes [17, 18].
The two previous anecdotal cases of successful pregnancies with a 4 mm endometrial thickness helped this
couple decide to try fresh embryo transfer despite a very
thin endometrium. Now there are three anecdotal cases to
help some other couple make decisions, e.g., to freeze
embryos and hope for a better cycle or even the extreme
of transferring the embryos into an extremely expensive
gestational carrier. Certainly showing success with twins
in a 47-year-old woman provides a strong anecdotal
precedent for a woman faced with the dilemma of
whether to transfer embryos or not in the face of not
attaining an endometrium of sufficient thickness.
[3] Dickey D.P., Olar T.T., Carole D.N., Taylor S.N., Rye P.H.:
Endometrial pattern and thickness associated with pregnancy
outcome after assisted reproduction technologies. Hum. Reprod.,
1992, 7, 418.
[4] Sundstrom P.: Establishment of a successful pregnancy following
in vitro fertilization with an endometrial thickness of no more than
4 mm. Hum. Reprod., 1998, 13, 550.
[5] Sher G., Fisch J.D.: Vaginal sildenafil (Viagra): a preliminary
report of a novel method to improve uterine artery blood flow and
endometrial development in patients undergoing IVF. Hum.
Reprod., 2000, 15, 806.
[6] Sher G., Fisch J.D.: Effect of vaginal sildenafil on the outcome
of in vitro fertilization (IVF) after multiple IVF failures attributed
to poor endometrial development. Fertil. Steril., 2002, 78, 1073.
[7] Check J.H., Graziano V., Lee G., Nazari A., Choe J.K., Dietterich
C.: Neither sildenafil or vaginal estradiol improves endometrial
thickness in women with thin endometria after taking oral estradiol in graduating dosages. Clin. Exp. Obstet. Gynecol., 2004, 31,
99.
[8] Wada I., Hsu C.C., Williams G., Macnamee M.C., Brinsden P.R.:
The benefits of low-dose aspirin therapy in women with impaired
uterine perfusion during assisted conception. Hum. Reprod.,
1994, 9, 1954.
[9] Check J.H., Dietterich C., Lurie D., Nazari A., Chuong J.: A
matched study to determine whether low-dose aspirin without
heparin improves pregnancy rates following frozen embryo transfer and/or affects endometrial sonographic parameters. J. Assist.
Reprod. Genet., 1998,15, 579.
thawed using a single step addition and removal of cryoprotectants. Hum. Reprod. Update 2, (CD-ROM), 1997.
[11] Check J.H., Hoover L., Nazari A., OShaughnessy A., Summers
D.: The effect of assisted hatching on pregnancy rates after frozen
[12] Check J.H., Katsoff B., Choe J.K.: Embryos from women who
hyper-respond to controlled ovarian hyperstimulation do not have
lower implantation potential as determined by results of frozen
embryo transfer. In: International Proceedings of the 13th World
Congress on In Vitro Fertilization and Assisted Reproduction and
Genetics, Monduzzi Editore, 2005, 109.
[13] Check J.H., Choe J.K., Nazari A., Fox F., Swenson K.: Fresh
embryo transfer is more effective than frozen ET for donor oocyte
recipients but not for donors. Hum. Reprod., 2001, 16, 1403.
[14] Check J.H., Choe J.K., Katsoff D., Summers-Chase D., Wilson C.:
Controlled ovarian hyperstimulation adversely affects implantation following in vitro fertilization-embryo transfer. J. Assist.
Reprod. Genet., 1999, 16, 416.
[15] Check J.H., Dietterich C., Check M.L., Katz Y.: Successful delivery despite conception with a maximal endometrial thickness of 4
mm. Clin. Exp. Obstet. Gynecol., 2003, 30, 93.
[16] Roberts J.M., Redman C.W.G.: Preeclampsia: More than pregnancy-induced hypertension. Lancet, 1993, 341, 1447.
[17] Soderstrom-Anttila V., Tiitinen A., Foudila T., Hovatta O.:
Obstetric and perinatal outcome after oocyte donation: comparison with in-vitro fertilization pregnancies. Hum. Reprod., 1998,
13, 483.
[18] Salha O., Sharma V., Dada T., Nugent D., Rutherford A.J., Tomlinson A.J. et al.: The influence of donated gametes on the incidence of hypertensive disorders of pregnancy. Hum. Reprod.,
1999, 14, 2268.
References
[1] Gonen Y., Casper R.F.: Prediction of implantation by the sonogrpahic appearance of the endometrium during controlled ovarian
stimulation for in vitro fertilization (IVF). J. In Vitro Fert.
Embryo Transf., 1990, 7, 146.
[2] Check J.H., Nowroozi K., Choe J., Dietterich C.: Influence of
endometrial thickness and echo patterns on pregnancy rates during
in vitro fertilization. Fertil. Steril., 1991, 56, 1173.

7447 Old York Road
10 1167-30 -Live fetus following:1648_29 Incidence of multiple 15/11/11 14:18 Pagina 330
[789/27]
[1167/30]
330
Live fetus following embryo transfer in a woman

with diminished egg reserve whose maximal endometrial
thickness was less than 4 mm
J.H. Check, R. Cohen
Summary
Purpose: To report the thinnest peak endometrial thickness to date resulting in a viable fetus following embryo transfer. Methods:
Mild ovarian hyperstimulation was given to a 35-year-old woman with not only a family history of premature ovarian failure but she
also had diminished egg reserve. Results: She consistently could not attain more than a 4 mm endometrial thickness in graduated estrogen replacement cycles or IVF-ET cycles. She successfully conceived on her second oocyte retrieval but first embryo transfer despite
a maximum endometrial thickness of 3.7 mm; we believe this is the thinnest one to date associated with a viable pregnancy following
embryo transfer. Conclusions: Anecdotal cases are important to help couples make appropriate choices for their therapy. A physician
could simply recommend a very expensive gestational carrier. However precedents might allow a given couple to take a chance with
their ideal goal despite slim odds rather than compromise with a distant second choice.
Key words: Embryo transfer; Thin endometrium; Diminished oocyte reserve.
Introduction
In the early era of in vitro fertilization-embryo transfer
(IVF-ET) lower pregnancy rates were found with thinner
endometria on the day of injection of human chorionic
gonadotropin (hCG) [1-3]. A 10 mm thickness or greater
seemed to be an ideal level in the earlier days of IVF. In
the modern era newer technologies have led to heartier
embryos and pregnancy rates are not so markedly diminished with a peak thickness less than 10 mm.
Nevertheless, there may be some cut-off where pregnancies are not likely to occur. To date there has only
been one case published where a pregnancy was achieved
following embryo transfer with a peak endometrial thickness of 4 mm [4].
When presented with a very thin endometrium one has
the option of freezing the embryos and hoping that artificial estrogen replacement with graduating estrogen doses
will improve the thickness. However, this is not guaranteed and then one has the disadvantage of using frozenthawed embryos that at least in some IVF centers do not
have nearly the same implantation potential as fresh
embryos.
To make a decision a woman may look for anecdotal
case reports to determine if there is any evidence of successful pregnancies despite an extremely thin
endometrium especially if the endometrium has been
consistently thin. If there are no precedents, faced with
the fact that a search of the world literature failed to
reveal any reports of a live delivery in a woman with a
Revised manuscript accepted for publication November 4, 2010

XXXVIII, n. 4, 2011
peak endometrial thickness of a certain level, she may

consider using a gestational carrier. Not only is this
option extremely expensive but it denies the woman the
experience of pregnancy and delivery.
There have been no published precedents for pregnancy with an endometrial thickness less than 4 mm. The
present case report describes a viable pregnancy achieved
following IVF-ET despite a peak endometrial thickness
of only 3.7 mm.
Case Report
A 34-year-old woman with a history of Hashimotos disease
on thyroid hormone replacement presented with primary infertility of two years duration. She was advised by a previous
infertility specialist that because of pelvic adhesions from
endometriosis impairing fallopian tube function bilaterally that
she would require IVF-ET to achieve a pregnancy.
However, she also had a familial history of predilection to
diminished oocyte reserve. Her previous infertility specialist evaluated her day 3 serum FSH level and found it to be increased. She
was advised that she should consider donor oocytes.
Since our group has had extensive experience in treating
women with infertility and diminished oocyte reserve, and have
reported a good chance of success when IVF-ET is needed even
when there is only one embryo to transfer as long as a mild
ovarian hyperstimulation regimen is used, she elected to try
IVF-ET with her own oocytes [5, 6].
Her baseline day 1 serum estradiol (E2) was 28 pg/ml, with
a serum LH of 5.9 mIU/ml and a serum FSH of 15.2 mIU/ml.
In a subsequent cycle though her serum FSH was only 9.2
mIU/ml the diminished oocyte reserve was masked because of
serum FSH was brought down by her high serum E2 of 74
pg/ml. In a third evaluation cycle her serum E2 on day 3 was 80
pg/ml with a serum FSH of 8.9 mIU/ml.
Live fetus following embryo transfer in a woman with diminished egg reserve whose maximal endometrial thickness was less than 4 mm
In two observation cycles it was noted that her endometrial

thickness did not exceed 4 mm. Thus before attempting IVF she
was placed on a graduated oral and vaginal estradiol regimen to
see if under these conditions she could generate a sufficiently
thick endometrium. The purpose of this test cycle was to see if
a thin endometrium in the late follicular phase was found on the
IVF cycle was it worth freezing the embryos and transferring
the frozen-thawed embryos in a subsequent cycle with artificial
estrogen preparation. Unfortunately the lining did not exceed 4
mm despite a protracted course of 25 days of oral and vaginal
estrogen reaching 8 mg per day for the last two weeks.
The woman was advised that thin endometria provides an
additional significant negative influence on success following
embryo transfer though successful pregnancy was not unprecedented and it could be under reported [4]. In fact we informed
her of another successful pregnancy that occurred with natural
intercourse with a peak endometrial thickness of 4 mm [7]. It
was explained that her option would be traditional surrogacy
with her husbands sperm used to inseminate another woman,
to perform IVF and transfer her embryos to a gestational carrier,
adopt, use donor oocytes and a gestational carrier or proceed
with IVF-ET herself despite low odds of success, more related
to the poor endometrial development, but also related to diminished oocyte reserve.
She chose to try IVF-ET with her own eggs and with transfer back to her own uterus. Using mild ovarian hyperstimulation
she attained only one dominant follicle with a serum E2 of 266
pg/ml [5, 6]. The endometrial thickness was 4 mm. One
metaphase II oocyte was retrieved but it did not fertilize.
Having failed to get an embryo the first time she was readvised of all of her options. She again chose to try IVF-ET
with her own oocytes. In the second cycle though it started out
similar to the first one with 150 IU FSH she did go up as high
as 300 IU especially when cetrorelix 250 mcg was added with
a 14 mm follicle. Her peak serum E2 was 832 pg/ml when
10,000 units of hCG were given. This was on cycle day 14 and
her endometrial thickness was 3.7 mm. Three metaphase II eggs
were retrieved resulting in two embryos. On day 3 an 8-cell and
a 4-cell embryo with < 25% fragmentation were transferred. A
pregnancy resulted and she successfully completed the first
trimester with a live fetus. She was age 35 at the time of embryo
transfer.
Discussion
Our patient stated that an important factor in her decision on trying with her own oocytes and her own uterus
was the previous anecdotal precedents of two pregnancies
with a 4 mm endometrial thickness. At least she said she
knew it was possible [7].
She is another example of our disagreement in the conclusions from one of the leading IVF centers of the world
that if the FSH reaches 15 mIU/ml live deliveries are not
possible at any age [8]. Our data supports the concept that
there are some FSH-dependent proteins needed for
implantation that become reduced because of down-regulation of FSH receptors by increasing the already chronically elevated serum FSH even more by the high dosage
of slow clearing exogenous FSH. Such a protein has not
been identified as yet but the hypothesis would explain
the 40% clinical pregnancy rate in 65% of women attaining an embryo with a minimum of six blastomeres with
331
women whose mean FSH clearly averaged well above 15

mIU/ml and had only one embryo to transfer [5].
Because we have had successful pregnancies especially
in younger women (< age 39) who were in apparent premature menopause, we have hypothesized that there is in
general a different mechanism for oocyte depletion in
younger vs women of advanced reproductive age, i.e.,
age 45 [9-14]. The very poor pregnancy rates in women
age 45 despite IVF-ET, even in women with normal
oocyte reserve despite the transfer of normal morphologic embryos, favor the concept that with advanced
reproductive age there is a natural selection of the best
oocytes so what oocytes remain are of poor quality. Not
that they lead to poor embryo quality but embryos that
fail to result in a positive pregnancy test or live pregnancy
[7, 15]. In contrast, the relatively good pregnancy rate in
younger patients favors the hypothesis that the usual
mechanism for diminished oocyte reserve is not a more
rapid progression of oocyte atresia but related to damage
to certain geographical portions. Thus they have the same
quality of oocytes as their age peers but less quantity.
The one exception may be women with a familial
history of early ovarian failure (mother and sister). In
these cases there may be a genetic predisposition to a
more rapid atresia leading to not only fewer oocytes but
less quality oocytes. There is no proof for this hypothesis
but my experience has been a far lower pregnancy rate in
this population. The woman was made aware of this
belief but still wanted to proceed with IVF-ET with her
own eggs.
We had also made the woman aware that we had
another unpublished case of a 47-year-old woman who
successfully completed the first trimester with twins
despite a maximal endometrial thickness of 4 mm but the
source were donor oocytes. It is important to publish
these anecdotes to help women and couples make tough
decisions. Hopefully this case will encourage other colleagues having success with patients with very thin
endometria to publish their experience. It is believed this
is the first case report of a successful pregnancy with a
peak endometrial thickness of < 4 mm.
References
[1] Gonen Y., Casper R.F.: Prediction of implantation by the sonogrpahic appearance of the endometrium during controlled ovarian
stimulation for in vitro fertilization (IVF). J. In Vitro Fert.
Embryo Transf., 1990, 7, 146.
[2] Check J.H., Nowroozi K., Choe J., Dietterich C.: Influence of
endometrial thickness and echo patterns on pregnancy rates during
in vitro fertilization. Fertil. Steril., 1991, 56, 1173.
[3] Dickey D.P., Olar T.T., Carole D.N., Taylor S.N., Rye P.H.:
Endometrial pattern and thickness associated with pregnancy
outcome after assisted reproduction technologies. Hum. Reprod.,
1992, 7, 418.
[4] Sundstrom P.: Establishment of a successful pregnancy following
in vitro fertilization with an endometrial thickness of no more than
4 mm. Hum. Reprod., 1998, 13, 550.
Steril., 2007, 87, 749.
332
[6] Check J.H.: Mild ovarian stimulation. J. Assist. Reprod. Genet.

2007, 24, 621.
[7] Check J.H., Dietterich C., Check M.L., Katz Y.: Successful delivery despite conception with a maximal endometrial thickness of 4
mm. Clin. Exp. Obstet. Gynecol., 2003, 30, 93.
[8] Roberts J.E., Spandorfer S., Fasoulitotis S.J., Kashyap S., Rosenwaks Z.: Taking a basal follicle-stimulating hormone history is
essential before initiating in vitro fertilization. Fertil. Steril.,
2005, 83, 37.
[9] Check J.H., Chase J.: Ovulation induction in hypergonadotropic
amenorrhea with estrogen and human menopausal gonadotropin
therapy. Fertil. Steril., 1984, 42, 919.
[10] Check J.H., Chase J.S., Wu C.H., Adelson H.G.: Ovulation
induction and pregnancy with an estrogen-gonadotropin stimulation technique in a menopausal woman with marked hpoplastic
ovaries. Fertil. Steril., 1989, 160, 405.
[11] Check J.H., Nowroozi K., Chase J.S., Nazari A., Shapse D., Vaze
M.: Ovulation induction and pregnancies in 100 consecutive
women with hypergonadotropic amenorrhea. Fertil. Steril., 1990,
53, 811.
[12] Check M.L., Check J.H., Choe J.K., Berger G.S.: Successful
pregnancy in a 42-year-old woman with imminent ovarian failure
following ovulation induction with ethinyl estradiol without
gonadotropins and in vitro fertilization. Clin. Exp. Obstet.
Gynecol., 2002, 29, 11.
[13] Check M.L., Check J.H., Kaplan H.: Pregnancy despite imminent
ovarian failure and extremely high endogenous gonadotropins and
therapeutic strategies: Case report and review. Clin. Exp. Obstet.
Gynecol., 2004, 31, 299.
[14] Check J.H., Katsoff B.: Successful pregnancy with spontaneous
ovulation in a woman with apparent premature ovarian failure who
failed to conceive despite four transfers of embryos derived from
donated oocytes. Clin. Exp. Obstet. Gynecol., 2006, 33, 13.
[15] Check J.H., Katsoff B., Brasile D., Choe J.K., Amui J.: Pregnancy outcome following in vitro fertilization-embryo transfer
(IVF-ET) in women of more advanced reproductive age with elevated serum follicle stimulating hormone (FSH) levels. Clin. Exp.

7447 Old York Road
11 1168-30 - Speculum retention:1648_29 Incidence of multiple 15/11/11 14:21 Pagina 333
[1168/30]
333
Speculum retention during embryo transfer does not improve

pregnancy rates following embryo transfer a randomized study
J. Amui, J.H. Check, D. Brasile
Summary
Purpose: To corroborate or refute two previous studies that suggested that a technique using prolonged speculum retention may
improve pregnancy rates per embryo transfer. Methods: Women undergoing day 3 embryo transfer were randomly assigned to the conventional transfer technique vs the speculum retention technique. The speculum retention technique involves following the embryo
transfer not to withdraw the speculum but to loosen the screw in order to exert gentle pressure on the portiovaginalis of the cervix and
leave it in for seven minutes. Results: Clinical and viable pregnancy rates following the standard technique were 48.9% and 44.4%,
respectively, vs 43.8% and 37.5% with the speculum retention technique. The implantation rates were also similar - 37.6% vs 37.5%.
Conclusions: This study was unable to corroborate the benefit of speculum retention in order to improve pregnancy rates per transfer.
Key words: Speculum retention; Embryo expulsion; Embryo transfer.
Introduction
Results
A previous study found a higher pregnancy rate by

using a speculum retention technique on the day of
embryo transfer to minimize embryo expulsion [1]. A
study was presented at the 2008 Pacific Coast Reproductive Society meeting seemingly corroborating the aforementioned study [2]. One physician who had the lowest
pregnancy rates per embryo transfer among the three
rotating physicians performing weekly embryo transfers
randomly performed the embryo transfers with or without
the speculum retention and found a clinical pregnancy
rate per fresh embryo transfer of 55.7% and per frozen
embryo transfer of 41.7% vs 38.1% and 23.8%, respectively, without speculum retention [2].
In view of the marked improvement another physician
in the group who had one of the better statistics among
the physicians evaluated the speculum retention technique in a randomized manner and these data are now
presented.
The clinical pregnancy rate per transfer (viable fetus at

8 weeks) was 48.9% (22/45) with the standard technique
and 43.8% (14/32) with the speculum retention.
The viable pregnancy rate past first trimester did not
show any benefit to speculum retention either - standard
technique 44.4% (20/45) vs speculum technique
37.5% (12/32). The implantation rates were almost identical: standard technique 37.6% vs speculum technique
37.5%. All comparisons showed p > .05, chi-square
analysis.
There did not appear to be any confounding variables
in that the ages were similar (36.3 for standard and 35.8
for speculum retention and the day 3 serum FSH
(mIU/ml) was similar (9.79 standard vs 7.21 speculum
retention).

The first four days of the week (Sunday to Wednesday)
embryos were transferred using a standard technique and Thursday to Saturday the speculum retention technique during the
first rotation with this technique). These were reversed during
the second trial week and so on.
In the speculum retention technique following the embryo
transfer the screw of the vaginal speculum was loosened in
order to exert a gentle pressure on the portiovaginalis of the
cervix. The speculum was maintained for seven minutes.

XXXVIII, n. 4, 2011
Discussion
A second physician from the same group that corroborated the improved pregnancy rates by the retention
speculum technique, which theoretically could help to
prevent expulsion of the embryos, could not substantiate
any benefit [1, 2].
Interestingly the improved clinical pregnancy rates
with the physician who did the previous study in our
group using the speculum retention technique decreased
again. Further investigation found that the problem may
have been related to insertion of the embryo transfer
catheter sheath past the internal cervical os. Physician
pregnancy rates are now up to par with the rest of the
group that did not retain the speculum.
11 1168-30 - Speculum retention:1648_29 Incidence of multiple 15/11/11 14:21 Pagina 334
334
J. Amui, J.H. Check, D. Brasile
References
[1] Mansour R.: Minimizing embryo expulsion after embryo transfer:
a randomized controlled study. Hum. Reprod., 2005, 20, 170.
[2] Brasile D., Check J.H., Choe J.K., Amui J.: Retention of speculum following embryo transfer to reduce chance of embryo expulsion increases pregnancy rate per transfer. 56th Annual Meeting of
the Pacific Coast Reproductive Society, Rancho Mirage, California,
April 9-13, 2008. Fertil. Steril., 2008, 89 (suppl. 2), S14.

7447 Old York Road
AsianAmerican MultiSpecialty Summit V
Honolulu, Hawaii (USA) - February 1-4, 2012

Hilton Hawaiian Village Beach Resort & Spa
E-mail: News@SLS.org
Free of charge
Laparoscopy & Minimally Invasive Surgery
12 1171-30 - Successful pregnancy:1648_29 Incidence of multiple 15/11/11 14:23 Pagina 335
[1171/30]
335
Successful pregnancy following a single fresh embryo

transfer in a 45-year-old woman whose early follicular phase
serum follicle stimulating hormone was 29 mIU/ml
J.H. Check, J.K. Choe, R. Cohen
Summary
Purpose: To determine if a successful pregnancy is possible following in vitro fertilization embryo transfer (IVF-ET) in a woman of
advanced reproductive age with diminished egg reserve. Methods: In vitro fertilization-embryo transfer with intracytoplasmic sperm
injection (ICSI) was performed for a 45-year-old woman with a peak serum follicle stimulating hormone (FSH) level of 29 mIU/ml
and a history of failing to conceive in five previous IVF-ET cycles at a younger age. A minimal FSH stimulation protocol was used.
Results: A fresh transfer of a 7-cell embryo was performed on day 3. A successful pregnancy and delivery ensued. Conclusion: This
case report establishes a precedent that a successful pregnancy following IVF-ET is possible in a woman whose serum FSH is > 15
mIU/ml, and is age 45. Of course, there is no implication that accomplishing this again in another woman with similar circumstances
would be likely.
Key words: Advanced reproductive age; In vitro fertilization; Diminished egg reserve.
Introduction
According to a recent study from a reputable in vitro
fertilization (IVF) center when early follicular phase
serum follicle stimulating hormone (FSH) level was 15
mIU/ml, no live pregnancies resulted following a series
of IVF embryo transfers (ET) with several embryos of
good morphology, irrespective of maternal age [1]. The
authors suggested that when the serum FSH attains this
level the treatment plan should proceed directly to donor
oocytes [1].
However, there is not universal agreement with these
conclusions. In fact, one study found in women with even
a greater degree of diminished egg reserve, as evidenced
not only by serum FSH > 15 mIU/ml but by such reduced
ovarian reserve where only a single embryo was transferred, that instead of a zero percent pregnancy rate for
the 65% who had a 6-8 cell embryo, the pregnancy rate
was approximately 40% per transfer [2]. The women in
this study were aged 39.9 [2]. In another study of
women with diminished egg reserve with a mean number
of 1.06 embryos transferred, the live delivery rate was
21.7% in women aged 40-42; but there were no live
deliveries in 25 embryo transfers in women aged 43 [3].
Advanced reproductive age seems to be a more important predictor of poor pregnancy rates than early follicular phase elevation of the serum FSH [4, 5]. Most IVF
centers find that the pregnancy rate following IVF-ET in
women aged 45 is quite poor even if the early follicular phase serum FSH is normal and even if there are good
amounts of metaphase 2 eggs retrieved. Nevertheless,

XXXVIII, n. 4, 2011
because there are anecdotal reports of successful pregnancies in women age 45 with elevated serum FSH
including a 45-year-old woman who appeared to be in
overt menopause, this 45-year-old woman wanted to try
IVF with her own eggs [6-8]. She was cautioned that
these three cases did not involve IVF and that we had no
knowledge of a successful pregnancy following IVF-ET
in a 45-year-old woman whose early serum FSH was >
15 mIU/ml that had been published. She was warned that
maybe there is some advantage for embryos created from
eggs from a 45-year-old woman traversing the fallopian
tubes. Nevertheless, she wanted to try with her own eggs
and was against donor eggs.
Case Report
The woman described herein had spontaneously conceived at
the age of 39 after six months of unprotected intercourse and
had delivered a full term normal baby. Her menses were regular
but she had not used any contraception since the birth of the
child.
She did achieve a spontaneous pregnancy at age 41 but she
had a miscarriage. An infertility work-up found an elevated day
3 serum FSH and her infertility specialist advised her that a successful pregnancy with her own eggs was not possible and
advised donor oocytes. She was not interested in that treatment
option so she sought another option with our group.
The male partners semen analysis was re-checked with the
addition of antisperm antibodies and the hypoosmotic swelling
test (HOS) [9]. The sperm concentration was normal at 46.3 x
106/ml. Though the percentage of motile sperm was slightly low
at 32.0% the motile density was normal at 14.8 x 10 6/ml.
However, only 3.2% had rapid linear motion. In addition, and
more importantly, the HOS test was low at 46%. It was
explained that when the HOS score is < 50% it generally stays
336
J.H. Check, J.K. Choe, R. Cohen
low and although it allows normal oocyte fertilization and

embryo formation the embryos fail to implant [9-14]. The
couple was further advised that sometimes the defect can be
overcome by avoiding unprotected intercourse exposing the
woman only to sperm introduced by intrauterine insemination
in which the hypothesized toxic protein factor attached to the
sperm was neutralized by treatment of the sperm with the
protein digestive enzyme chymotrypsin [15, 16]. However they
were also advised that bypassing contact and attachment of
supernumerary sperm at the time of fertilization by performing
IVF with intracytoplasmic sperm injection (ICSI) would
provide a better chance of conception [17].
The woman was 41 years old a half at the initial consult
with our practice. She proceeded with IVF-ET using a low
dosage minimal stimulation protocol and despite the transfer of
several embryos she failed to conceive after five IVF-ET cycles.
She had taken a break for one and a half years because of health
problems that were initially considered to be possibly related to
amyotrophic lateral sclerosis (ALS) but symptoms spontaneously abated. The ALS diagnosis was now considered highly
unlikely and she returned to try IVF-ET again. The couple was
advised that IVF-ET has been extremely unsuccessful in
women aged 45 throughout the world even in women with
normal egg reserve. Nevertheless they wanted to still try again.
Donor oocyte or embryos were not considered an option.
At age 43 she attained her highest serum FSH at 29 mIU/ml.
Several others had been over 20 mIU/ml. In her last cycle of
IVF she did not obtain a day 3 serum FSH but instead the serum
levels were obtained on day 5. Her serum estradiol (E2) was 40
pg/ml and the FSH was 20 mIU/ml. She was first given ethinyl
estradiol 20 mcg daily (it does not cross-react in the serum E2
assay) [18]. She was started on 150 IU of recombinant FSH
beginning on day 10 following the principles of the minimal
stimulation protocol [19].
On day 5 she had four antral follicles (a 9 mm and 5 mm in
the right ovary and two that were 6 mm in the left ovary).
Recombinant FSH at 150 IU was continued at 150 IU for days
10 and 11 and was increased to 225 IU. The serum E2 at that
time was 367 pg/ml and two follicles were seen in the left ovary
of 14.7 mm and 12.3 mm. By day 14 the serum E2 reached 578
pg/ml. The serum progesterone remained low at 0.8 ng/ml and
there was no rise in the luteinizing hormone (LH) at 7 mIU/ml.
The follicle sizes were 22.3 mm and 17.3 mm. The next day the
serum E2 dropped to 462 ng/ml with a subtle rise in serum
progesterone at 1.1 ng/ml but the serum LH did not rise (6.3
mIU/ml). Human chorionic gonadotropin 10,000 units was
given. Two eggs were retrieved; one a metaphase II and one a
metaphase I. The metaphase II egg was fertilized by ICSI with
a semen specimen showing a concentration of only 15 x 106/ml
and only 14% motility. A 7-cell embryo without fragmentation
was transferred on day 3.
This 45-year-old woman conceived this cycle and delivered a
live healthy baby.
Discussion
The couple was told at their consult before the sixth
IVF cycle that their pregnancy prognosis was extremely
poor. This prognosis was predominantly related to the
female partners age of 45, her diminished egg reserve
and previous failure to conceive with five previous IVF
cycles at a younger age.
As far as a precedent was concerned we did mention
the three cases of successful pregnancy in women age 45
and over with elevated serum FSH [6-8]. However, they

were advised that we were unaware of precedents with
successful pregnancies following IVF-ET in women aged
45 with diminished egg reserve, though we were aware of
a successful pregnancy in a 42-year-old who required
IVF-ET for tubal factor who appeared to be in overt
menopause [20].
One might wonder how many women 45 advised of
very poor prognosis with elevated serum FSH 15
mIU/ml would even attempt IVF-ET. Unfortunately there
have been enough oocyte retrievals and transfers in this
circumstance to make us question whether there is something about aging that requires passage of the embryo
through the fallopian tubes. This is why this anecdotal
case is so important, i.e., establishing that successful
pregnancy is possible (though unlikely) in women
needing IVF-ET even at the age of 45 with diminished
egg reserve.
References
[1] Roberts J.E., Spandorfer S., Fasouliotis S.J., Kashyap S., Rosenwaks Z.: Taking a basal follicle-stimulating hormone history is
essential before initiating in vitro fertilization. Fertil. Steril.,
2005, 83, 37.
Steril., 2007, 87, 749.
[3] Check M.L., Check J.H., Wilson C., Choe J.K., Krotec J.:
Outcome of in vitro fertilization-embryo transfer according to
age in poor responders with elevated baseline serum follicle stimulation hormone using minimal or no gonadotropin stimulation.
[4] Check J.H., Peymer M., Lurie D.: Effect of age on pregnancy
outcome without assisted reproductive technology in women with
elevated early follicular phase serum follicle-stimulating hormone
levels. Gynecol. Obstet. Invest., 1998, 45, 217.
[5] Check J.H., Nazari P., Check M.L., Choe J.K., Liss J.R.: Prognosis following in vitro fertilization-embryo transfer (IVF-ET) in
patients with elevated day 2 or 3 serum follicle stimulating
hormone (FSH) is better in younger vs older patients. Clin. Exp.
[6] Check J.H., Check M.L., Katsoff D.: Three pregnancies despite
elevated serum FSH and advanced age: Case report. Hum.
Reprod., 2000, 15, 1709.
[7] Check J.H.: Successful pregnancy despite advanced age and elevated serum follicle stimulating hormone levels - A case report.
[8] Katsoff B., Check M.D.: Successful pregnancy in a 45-year-old
woman with elevated day 3 serum follicle stimulating hormone
and a short follicular phase. Clin. Exp. Obstet. Gynecol., 2005,
32, 97.
[9] Check J.H.: The infertile male - Diagnosis. Clin. Exp. Obstet.
Gynecol., 2006, 33, 133.
[10] Check J.H., Epstein R., Nowroozi K., Shanis B.S., Wu C.H., Bollendorf A.: The hypo osmotic swelling test as a useful adjunct to
the semen analysis to predict fertility potential. Fertil. Steril.,
1989, 52, 159.
[11] Shanis B.S., Check J.H., Bollendorf A., Lurie D.: Stability of the
hypo osmotic swelling test over time. Arch. Androl., 1992, 29,
263.
[12] Check J.H., Stumpo L., Lurie D., Benfer K., Callan C.: A comparative prospective study using matched samples to determine the
influence of subnormal hypo osmotic test scores of spermatozoa
on subsequent fertilization and pregnancy rates following in vitro
fertilization. Hum. Reprod., 1995, 10, 1197.
Successful pregnancy following a single fresh embryo transfer in a 45-year-old woman whose early follicular phase serum follicle etc. 337
[13] Katsoff D., Check M.L., Check J.H.: Evidence that sperm with
low hypoosmotic swelling scores cause embryo implantation
defects. Arch. Androl., 2000, 44, 227.
[14] Check J.H., Katsoff D., Check M.L.: Some semen abnormalities
may cause infertility by impairing implantation rather than fertilization. Med. Hypoth., 2001, 56, 653.
[15] Katsoff D., Check J.H.: Two methods of achieving pregnancies
despite subnormal hypo-osmotic swelling test scores. Fertil.
Steril., 1997, 68, 549.
[16] Check M.L., Katsoff D., Check J.H., Summers-Chase D.: Effect
of treating sperm with low hypo-osmotic swelling test scores with
chymotrypsin on pregnancy rates after conventional in vitro fertilization-embryo transfer. Fertil. Steril., 2004, 82, 741.
[17] Check J.H., Katsoff D., Check M.L., Choe J.K., Swenson K.: In
vitro fertilization with intracytoplasmic sperm injection is an
effective therapy for male factor related to subnormal hypoosmotic swelling test scores. J. Androl., 2001, 22, 261.
[18] Check J.H., Nowroozi K., Chase J.S., Nazari A., Shapse D., Vaze
M.: Ovulation induction and pregnancies in 100 consecutive
women with hypergonadotropic amenorrhea. Fertil. Steril., 1990,
53, 811.
[19] Check J.H.: Mild ovarian stimulation. J. Assist. Reprod. Genet.,
2007, 24, 621.
[20] Check M.L., Check J.H., Choe J.K., Berger G.S.: Successful
pregnancy in a 42-year-old woman with imminent ovarian failure
following ovulation induction with ethinyl estradiol without
gonadotropins and in vitro fertilization. Clin. Exp. Obstet.
Gynecol., 2002, 29, 11.

7447 Old York Road
13 1201-31 - Kiwisch von Rotterau:1648_29 Incidence of multiple 15/11/11 14:24 Pagina 338
[789/27]
[1201/31]
338
General Section
Kiwisch von Rotterau - a pioneer of European obstetrics,

gynecology and gynecopathology
H. Pickel1, O. Reich1, R.H. Young2
1
Department of Obstetrics and Gynecology, Medical Universiy of Graz, Graz (Austria)
James Homer Wright Pathology Laboratories, Department of Pathology, Messachusetts General Hospital, Boston (USA)
He whom the Gods love dies young. This quotation

from antiquity (Menander-Plautus) is not only true for
famous artists such as Raphael or composers such as
Wolfgang Amadeus Mozart and Franz Schubert, but for
many young and promising scientists such as the late
physician Franz Alexander Kiwisch Ritter von Rotterau
(Figure 1).
He died unfinished, at
the young age of 37, from
tuberculosis, an epidemic
that plagued the population
in the first half of the 19th
century [1]. He played a
major role in focusing
modern German obstetrics
and gynecology and also
was a pioneer of gynecologic pathology [2].
Franz Alexander Kiwisch Ritter von Rotterau was born
on 30 April, 1814 in the provincial town of Klattau (today
Klatovy) in the southwest of what was then the Kingdom
of Bohemia (today the Czech Republic) of the Austrian
Monarchy. His father was Ignaz Kiwisch (1783-1848),
who in his function as a high administration official was
ennobled as Ritter von Rotterau. The young Kiwisch
attended primary school in Prague and high school in
Klattau. He then went on to study philosophy and medicine at the Charles University in Prague. In Prague, he
received his doctoral degree in medicine in 1837. In 1838,
he received an additional masters degree in obstetrics,
which was common at the time, when there were three
different titles in medicine in Austria: Masters in
Surgery, Masters in Obstetrics, and Doctor of (Internal)
Medicine. In the same year, he became an assistant at the
Obstetrical Clinic in Prague [1, 3]. This institution boasted an excellent reputation at the time and was attended by
many people from abroad. As early as 1840, Kiwisch
published his first scientific work on obstetrics [4]. In the
same year, he went with friends for four months to
France, the leading country in medical science at the time.
In 1842, he took up a university lectureship for female
disorders at Prague University and was appointed head of
the newly established Clinic for Gynecology at the
General Hospital in Prague. This institution was under the
authority of the Obstetrical Clinic, but was, due to its
focus on gynecology, a novelty in European medicine at
Revised manuscript accepted for publication February 10, 2010
XXXVIII, n. 4, 2011
the time. Many people from abroad, especially physicians

from Tsarist Russia, came to visit the clinic [1, 3].
In 1843, Kiwisch married Emilie Nadherny; they had
one son and one daughter. Today, his descendants still live
in the Austrian city of Graz.
In 1845, Kiwisch moved to Wrzburg in neighboring
Bavaria to work as a Professor of Obstetrics and Head of
the School for Midwives and the Obstetrical Clinic. In
addition to a list of his scientific achievements, his assessment for this position included the following description
of him [3]: He has nice handwriting and writes fluently
both in Latin and in German. His oral skills also seem to
be very good and his public appearance not only gives
one the sense of a highly educated scholar, but a man with
a broad educational background, a feature which always
has a pleasant effect on everyone and is very welcome
and highly desired by all physicians and absolutely necessary for obstetricians due to their unique position with
regard to the gentle sex.
As Kiwisch was very well known, he was appointed
personal physician to Grand Princess Helene of the
House of Romanov, a member of the Tsars family. This
caused a conflict with his responsibilities at the medical
faculty in Wrzburg which as a result were neglected.
During his three years in Wrzburg, he finished the first
part of his epoch-making gynecological work Klinische
Vortrge ber spezielle Pathologie und Therapie der
Krankheiten des weiblichen Geschlechtes (Clinical
Lectures on the Special Pathology and Therapy of
Diseases of the Female Sex) [5]. In 1849, he published
part two of this work. The work with the young Rudolf
Virchow (1821-1902), the rising star of pathological
anatomy and histology at the time, in Wrzburg resulted
in a short-lived but productive collaboration for Kiwisch
between 1849 and 1850 [2]. This great success in his profession was followed by a series of personal setbacks: the
deaths of his father and his wife, and activation of his
latent pulmonary tuberculosis. During this time, he
received his long-awaited appointment as Professor of
Obstetrics at the Charles University in Prague in 1850*.
* The old Austrian Empire, next to the imperial capital of Vienna,
Prague, the capital of the Kingdom of Bohemia, boasted the most
important faculty of medicine. Even when the famous and primarily German-speaking Charles University (founded in 1348) was
forcedly divided into a German and a Czech university by emerging
Czech nationalism in 1882, there was still a lively exchange of
renowned physicians between Prague and Vienna and other
Austrian universities.
The relief he found in Prague in teaching and research

as well as in the form of a generously equipped clinic, was
sadly not enjoyed for long. Due to his severe illness, he
could not finish his last work, Die Geburtskunde mit
Einschluss der Lehre von den brigen Fortpflanzungsvorgngen im weiblichen Organismus (Obstetrics
including the Science of the Other Reproductive Processes
in the Female Organism [6]. In 1851, only a torso of this
work together with the first volume, an atlas volume, and
the first part of the second volume were printed. Kiwisch
died as a result of hemorrhage due to tuberculosis on 29
October, 1851 at the age of 37 [1, 3].
Kiwisch three most important publications were all
books. He also published a number of obstetric/gynecological as well as pathological/anatomical articles in different regional and international journals [1].
1) Die Krankheiten der Wchnerinnen, nach den in der
k.k. Entbindungsanstalt und im allgemeinen Krankenhaus
zu Prag gemachten Beobachtungen. 1. Band 1840, 2.
Band 1841 J. G. Calve. Prag [4].
(Diseases of women who had recently given birth
according to Observations made in the Imperial and
Royal Delivery Institution and the General Hospital in
Prague. 1. First volume 1840, second volume 1841 J. G.
Calve. Prague [4]).
Kiwisch published this work at the age of only 26. In
the foreword to this book, he expressly points out the contrast between the traditional speculative orientation of
medicine towards natural philosophy, of which Carl
Gustav Carus (1789-1869) was the most important
German proponent [7], and new medicine which was oriented towards science and pathological anatomy.
He treated the diseases of women who had recently
given birth according to the insights gained from his
wealth of observations. The first volume is dedicated to
epidemic puerperal diseases which he subsumes under
the term puerperal fever. Kiwisch divides puerperal diseases into epidemic and sporadic. However, he still
believed in the then popular concept that this disease was
caused by an atmospheric miasma and denied contagious spread (see below). The exponents of the hitherto
natural philosophy approach in medicine (see above)
repudiated this work. He was accused of introducing the
new and not yet established pathologic-anatomical point
of views of Carl von Rokitansky (1804-1878) into
Obstetrics and Gynecology [1, 3].
Until the liquidation of the German-speaking Universitas

Carolina in Prague in 1945, lecturers and professors from Prague
were frequently appointed to other German universities: for example, in the 19th century, Kiwisch and his successor, Friedrich
Wilhelm Scanzoni von Lichtenfels (1821-1891), were appointed to
Wrzburg in Bavaria [3]. In the 20th century, the famous Austrian
gynecologist Hermann Knaus (1892-1970), from Graz, co-discoverer of the then well known Knaus-Ogino contraceptive method, was
appointed Full Professor of Gynecology and Obstetrics in Prague in
1934.
339
2) Klinische Vortrge ber spezielle Pathologie und

Therapie der Krankheiten des weiblichen Geschlechtes,
in drei Bnden. J. G. Calve. Prag 1. Band 1845, 2. Band
1849, 3. Band nur 1. Teil, unvollendet [6].
(Clinical Lectures on the Special Pathology and
Therapy of Diseases of the Female Sex, in three volumes.
J. G. Calve. Prague Volume 1 1845, Volume 2, 1849,
Volume 3 only Part 1, incomplete [6]).
This work is the first scientific German work in the
field of gynecology [3]. The title had already been used
by the above-mentioned Carl Gustav Carus in 1820 for
his book on this subject [7]. In contrast to his previous
publication [4], this one was highly acclaimed by experts.
The first volume, published in 1845, was solely devoted to abnormalities of the uterus. The second volume,
published in 1849, was concerned with diseases of the
ovaries, tubes and the external sexual organs as well as
ectopic pregnancy. The third volume, which focused on
diseases of the breast, the urinary tract and diseases of
the nervous system specific to women, was completed
posthumously by Kiwischs successor in Wrzburg,
Friedrich Wilhelm Scanzoni von Lichtenfels, and published in 1855 [1].
In the foreword to the first volume Kiwisch reemphasizes the growing importance of the new pathological
anatomy of Rokitansky for gynecology. For Kiwisch, this
also included the use of microscopy, of which, he was an
early advocate, as was Hermann Lebert at around the same
time [8], of microscopic examination of uterine cancer:
The first volume systematically deals with the external
and internal examination of the patient with all the new
physical and instrumental possibilities at the time including the vaginal speculum and uterine probe. Dislocations
and deformities of the uterus are then described.
Inflammation and abnormal bleeding are given detailed
attention. Benign tumors of the uterus, the clinical picture
of tuberculosis, which was very important at the time and
puerperal fever including its symptoms, are described
extensively. Carcinoma of the uterus is featured in this
work: he notes that uterine cancer originates from the
cervix uteri in most cases. He anticipates research of the
mid-20th century, according to which cervical carcinoma
initially remains confined to the cervix uteri for a long
time without spreading longitudinally towards the corpus
uteri and then only later spreads laterally to the parametria and to the surrounding organs [9]. In contrast to
Rokitansky, Kiwisch also recorded cases of corpus carcinoma. However, the difference between cervical and corporal carcinomas remained a mystery to him. Like Lebert
[8], he was familiar with the morphology of cancer cells.
Kiwisch observed that the initial stage of uterine cancer
occurred several years before it was clinically manifest
and that he had never seen this type of cancer in virginal
individuals and before the age of 20. Very little, if anything, has changed concerning the latter observations
[10]. The symptomatology of invasive cancer and the
hopeless prognosis is well described. Kiwisch raised the
possibility of cure through surgical removal of the uterus
but notes that all attempted operations had to date failed.
340
H. Pickel, O. Reich, R.H. Young
In the second volume, Kiwisch, deals with diseases of

the remaining internal and external sexual organs: The
anatomy and physiology of the ovary is described in a
detailed way. The pathology and therapy of ovarian diseases is treated at length, then diseases of the tubes,
ectopic pregnancy and finally the pathology and therapy
of diseases of the external genitalia including venereal
diseases. In terms of the origin of ovarian cysts, the
Graafian follicle is the focus of his pathogenetic considerations. A detailed description of the clinical behavior of
simple ovarian cysts follows as well as complex cysts.
Dermoid cysts and teratomas are mentioned several
times, but their origin is thought to be the Graafian follicle. Among the complex cysts, what are known today as
serous and mucinous cystadenomas and borderline
tumors, as well as those with obvious malignant change
are dealt with. It should be mentioned that cystic ovarian
alterations had already been described by Thomas
Hodgkin in 1829 [11].
Kiwisch discusses the surgical procedures of the
Anglo-American doctors of his time, who were known as
the ovariotomists [2]. Total extirpation is considered to
be a life-threatening option and the last remedy. Only
conservative procedures like puncture are considered productive. In a detailed table, Kiwisch presents all the operations performed on ovaries up to his time including the
positive and negative outcomes. The chances of curing an
ovarian tumor at the time were 50% at most and that at a
time in which there was neither antisepsis nor asepsis and
no anesthesia. Kiwisch discusses ovarian carcinoma at
the end of his text. He differentiates medullary, fibrous
and primitive forms. At this point, a literal quotation from
his work is appropriate: Ovarian cancer is one of the
most difficult things to describe anatomically in that it
appears in such a wide variety of forms, and through complications with other degenerations it is altered in such a
way that there are continually new forms that cannot be
covered by general descriptions. In terms of cancer formations, the general characteristics are the very frequently discussed microscopic composition of the tissue, in
particular, the abundance of cells, the progressive endogenous development of cells, the thereby resulting development of the tissue, the dissolution, the penetration of
every part of the tissue and even the neighboring structures. On pages 182 and 183, Kiwisch offers a detailed
microscopic description of an ovarian tumor, apparently a
typical adenocarcinoma. In his entire oeuvre, Kiwisch
had never published such a detailed histopathological
report. At the end of this chapter, the clinical presentation
of ovarian carcinomas including the symptomatology,
prognosis and therapy are presented, although concerning
the latter point Kiwisch once again advises against radical surgery.
3) Die Geburtskunde mit Einschluss der Lehre von den
brigen Fortpflanzungsvorgngen im weiblichen
Organismus, in 2 Bnden. Erlangen, Verlag von
Ferdinand Enke 1851 [6].
1. Band: Physiologie und Ditetik, mit einem lithographierten Atlas.
2. Band: Pathologie und Therapie, unvollendet.

(Obstetrics including the Science of the Other
Reproductive Processes in the Female Organism, in 2
volumes. Erlangen, Ferdinand Enke Publishing House
1851 [6]).
1. Volume 1: Physiology and Dietetics with a
Lithographic Atlas.
2. Volume 2: Pathology and Therapy, unfinished.
In the preceding work, the Beitrge zur Geburtskunde (Contributions to Obstetrics) in 2 volumes (18461848), Kiwisch had only commented on selected obstetric questions [1]. In his last work, he attempted to produce
as complete a synopsis as possible on the knowledge of
obstetrics at the time. With a very modern systematic
approach for the time, Kiwisch presents the physiology of
the reproductive process. At the same time as the first volume, an illustrated atlas was published with anatomical
drawings and obstetric instruments.
Shortly before his untimely death, Kiwisch was working on the second volume on pathology and therapy in
obstetrics. He only managed to publish the first volume
and thus his lifes work remained unfinished. It was this
last work on obstetrics that would sustain Kiwischs high
scientific standing for years to come.
Finally, we must consider the regrettable role that
Kiwisch, still caught up in the spirit of his age, played in
obstetrics with regard to his reception of the theory of
Ignaz Philipp Semmelweis [1]:
The horror of every obstetrician, in the first half of the
19th century, was the incidence of infectious puerperal
fever in obstetrical institutions. The mortality rate at the
time was on average 4-12% and sometimes was as high
as 40%. It was during Kiwischs time in Wrzburg that
Semmelweis made the claim in Vienna in 1847 that the
cause of puerperal fever was due to the transmission of
an iatrogenic, contagious (i.e., bacterial) medium.
Semmelweis was able to significantly reduce the mortality rate of women who had recently given birth in his
institution by simple hygienic measures. The professors
of obstetrics at the time, however, repudiated
Semmelweis discovery, sometimes aggressively.
Kiwisch also rejected the contagious origin of puerperal
fever and still believed in an atmospheric origin via what
was known as a miasma (= noxious vapor). This was at
the same time when the contagious origin of cholera was
proved during the cholera epidemics in London in the
mid-19th century.
Unfortunately, in the case of puerperal fever, the
authority of Kiwisch led to this remaining a scourge of
women who had recently given birth in the Wrzburg
clinic for many years. Regrettably, Kiwischs successor,
Friedrich Wilhelm Scanzoni von Lichtenfels, had even
less understanding of the epoch-making findings of
Semmelweis. The desired change in thinking regarding
the etiological evaluation and prophylactic therapy of
contagious diseases by Semmelweis did not occur until
the acceptance of the concept of antisepsis proposed by
Joseph Lister (1827-1912) in the 1870s.
Kiwisch early on used the technical term gynecopathology in the Cannstattsche Jahresberichte ber die
Fortschritte der gesamten Medizin in allen Lndern
(Cannstatt Annual Reports on the Progress of Medicine in
Every Country), a reference journal from 1844/45 no
longer in existence [1].
Even before Kiwischs time, the comprehensive textbooks and handbooks of the Paris School from the first
half of the 19th century already contained a wealth of
details on macroscopic gynecological pathology and the
pathology of pregnancy. Among these, the work of Jean
Frdric Lobstein (1777-1835), Trait danatomie
pathologique with numerous examples from the field of
gynecopathology from 1829 to 1832, stands out. Carl von
Rokitansky devotes a large part of his work Handbuch
der speciellen pathologischen Anatomie (Handbook of
Special Pathological Anatomy), which was published in
1842, to this new speciality of pathology [2]. In terms of
gynecopathology, the first microscopic examinations
were carried out by Kiwischs contemporaries, Alfred
Donn (1801-1878) and Hermann Lebert (1813-1878), in
the 30s and the 40s of the 19th century [2, 8]. This subspecialty really emancipated itself from pathology a few
decades later through the efforts of Carl Ruge (18461926) and Robert Meyer (1864-1947) [2].
The memory of Kiwisch should be honored as he was
one of the first clinicians of the 19th century to introduce
modern pathologic-anatomical concepts into clinical
gynecology and obstetrics. Kiwisch was also one the
forerunners of the modern gynecopathology because he
recommended, as one of the first to do so, the application
of the microscope for bioptic examination of uterine (cervical) cancer. In this regard Kiwisch obviously anticipated the seminal work of Carl Ruge, the Father of gynecopathology, with his Stckchendiagnose - small piece
diagnosis [12].
References
[1] Mller B.: Franz Kiwisch von Rotterau. Inaugural-Dissertation.
Wrzburg. 1980.
[2] Dhom G.: Geschichte der Histopathologie (History of
Histopathology). New York, Springer, 2001, 607.
341
[3] Klaus K., Prenzel C.: Franz Alexander Wilhelm Kiwisch von
Rotterau. Gynk. Rdsch., 1970, 9, 155.
[4] Kiwisch F.A.: Die Krankheiten der Wchnerinnen, nach den in
der K.K. Entbindungsanstalt und im allgemeinen Krankenhaus zu
Prag gemachten Beobachtungen. 1. Band 1840, 2. Band 1841 J.
G. Calve. Prag. (Diseases of Women who had recently given Birth
according to Observations made in the Imperial and Royal Delivery Institution and the General Hospital in Prague. 1. First volume
1840, second volume 1841 J. G. Calve. Prague).
[5] Kiwisch F.A.: Klinische Vortrge ber spezielle Pathologie und
Therapie der Krankheiten des weiblichen Geschlechtes, in drei
Bnden. J.G. Calve. Prag 1. Band 1845, 2. Band 1849, 3. Band
nur 1. Teil, unvollendet. (Clinical Lectures on the Special Pathology and Therapy of Diseases of the Female Sex, in three volumes.
J. G. Calve. Prague Volume 1 1845, Volume 2 1849, Volume 3 only
Part 1, incomplete).
[6] Kiwisch F.A.: Die Geburtskunde. 1. Band Physiologie und
Ditetik mit Atlasband. 2. Band Pathologie und Therapie, unvollendet, nur 1. Heft erschienen. F. Enke. Erlangen 1851. (Obstetrics
including the Science of the Other Reproductive Processes in the
Female Organism, in 2 volumes. Erlangen, Ferdinand Enke Publishing House 1851 Volume 1: Physiology and Dietetics with a
Lithographic Atlas. Volume 2: Pathology and Therapy, unfinished).
[7] Ulrich U., Carl Gustav Carus. Frauenarzt, 2009, 50, 1075.
[8] Pickel H., Reich O., Winter R., Young R.H.: Hermann Lebert
(1813-1878): a pioneer of diagnostic pathology. Virchows Arch.,
2009, 455, 301.
[9] Bajardi F.: ber Wachstumsbeschrnkungen des Collumcarcinoms in seinem invasiven und auch prinvasiven Stadium (On the
limitations of the growth of the cervical carcinima in his invasive
and also preinvasive stages). Arch. Gynkol., 1962, 197, 407.
[10] You W., Dainty L.A., Rose G.S., Krivak T., McHale M.T., Olsen
C.H., Elkas J.C.: Gynecologic malignancies in women aged less
than 25 years. Obstet. Gynecol., 2005, 105, 1405.
[11] Hodgkin T.: On the anatomical characters of some adventitious
structures. Medico-Chirurgical Transactions, 1829, 15, 265.
[12] Dallenbach-Hellweg G., Schmidt D.: History of gynecological
pathology. XV. Dr. Carl Arnold Ruge. Int. J. Gynecol. Pathol.,
2003, 23, 83.

O. REICH, M.D.
Department of Obstetrics and Gynecology
Medical University of Graz
Auenbruggerplatz 14
A-8036 Graz (Austria)
e-mail: olaf.reich@meduni-graz.at
14 1192-30 - Induction of plasminogen:1648_29 Incidence of multiple 15/11/11 14:26 Pagina 342
[789/27]
[1192/30]
342
Induction of plasminogen activators in pregnant women

with Toxoplasma gondii infection
C.S. Chou1, M.C. Chou1, K.M. Chen2, C.Y. Lu1, S.C. Lai2,3
1
Institute of Medicine, Chung Shan Medical University

Department of Parasitology, Chung Shan Medical University
3
Clinical Laboratory, Chung Shan University Hospital, Taiwan (ROC)
2
Summary
Objective: To determine whether plasminogen activators (PAs) are involved in the pathologic process of toxoplasmosis. Materials and Methods: Out of 220 pregnant women the study included 26 with a diagnosis of toxoplasmosis: six based on seropositivity
for Toxoplasma gondii IgM and 20 based on seropositivity for T. gondii IgG. We measured serum activities and protein levels of
PAs by casein zymography and Western blotting, respectively. Results: Serum PAs were higher in healthy pregnant women than in
their healthy nonpregnant counterparts. Furthermore, serum PAs were significantly higher in pregnant women infected with T. gondii
than in their healthy counterparts. Conclusion: PAs participate in the pathogenesis of toxoplasmosis in pregnant women and may
be useful markers of T. gondii infection.
Key words: Plasminogen activators; Pregnancy; Toxoplasma gondii; tPA; uPA.
Introduction
Toxoplasma gondii is an intracellular coccidian parasite
that infects a wide variety of warm-blooded animals,
including humans, and causes toxoplasmosis, a common
zoonotic disease worldwide [1, 2]. Systemic infection follows oral ingestion and passage through the intestinal
epithelium, basement membrane, and lamina propria.
Active traversal of cellular barriers and upregulated
migratory capacity are used for tissue dissemination to
gain access to biologically restricted organs, e.g., the
brain and the placenta [3]. Specifically, T. gondii uses
proteinases to degrade the extracellular matrix (ECM)
and reach immunoprivileged sites [4, 5].
The activation of plasminogen into plasmin is mediated
by two types of activators, urokinase-type plasminogen
activator (uPA) and tissue-type plasminogen activator
(tPA) [6]. Microorganisms including bacteria, fungi and
also parasites interact with components of the fibrinolytic pathway [7]. The highly invasive pathogens Borrelia
burgdorferi [8], streptococci [9], and Yersinia pestis [10]
express plasminogen activators. These pathogenic
pathogens are capable of subverting the function of proteases, activators or inhibitors for their own benefit
including dissemination within the host and evasion of
host inflammatory immune response. Thus, several pathogenic bacterial species interfere with the mammalian
proteolytic plasminogen-plasmin system. This interference promotes ECM damage as well as bacterial spread
and organ invasion during infection [11]. PAs are associated with brain barrier disruption and pathogenesis in
helminthic infections such as angiostrongyliasis [12, 13].
uPA participates in the release of the malaria parasite
Revised manuscript accepted for publication January 7, 2011

XXXVIII, n. 4, 2011
Plasmodium falciparum from infected erythrocytes [14].

The pathophysiologic role of the plasminogen system
was deduced indirectly from correlations between levels
of its components and clinical disease states. However,
the role of PAs during T. gondii infection in pregnant
women remains poorly understood. The purpose of this
study was to determine the expression of PAs during T.
gondii infection in pregnant women.
Material and Methods
Patients and serum sampling
Out of 220 pregnant women during the third trimester of
pregnancy (38-40 weeks), the study included 26 with a diagnosis of toxoplasmosis: six based on seropositivity for T. gondii
IgM and 20 based on seropositivity for T. gondii IgG. The serum
titer was obtained using a commercially available enzymelinked immunoassay for T. gondii IgM/IgG antibody
(Euroimmun, Cardiff, UK). Further, using T. gondii IgG avidity
enzyme immunoassay (Ani Labsystems, Finland), all six IgM
seropositive samples had a low IgG avidity suggesting recent
infection. Serum was obtained from fresh blood samples drawn
from all 220 women. The Research and Ethical Review
Committees and Internal Review Board of Chung Shan Medical
University Hospital approved the protocol and procedures for
the project.
Casein zymography
The serum samples were centrifuged at 300 g for 10 min to
remove debris. Activities of PAs were determined using casein
zymography according to the method of Hou et al. [12] with
slight modifications. Briefly, the samples were diluted in a standard loading buffer containing 0.1% sodium dodecyl sulfate
(SDS) without -mercaptoethanol, and the diluted samples were
not boiled before loading on 7.5% (mass/volume) SDS-polyacrylamide gels copolymerized with 0.1% casein (Sigma, St.
Louis, MO, USA) and plasminogen (13 mg/ml, Sigma, St.
343
(b)
(a)
(6)
Relative density of PAs
(6)
(6)
HC
(c)
PC
n
ctio
Infe
(d)
Relative intensity of PAs
(6)
(6)
(6)
HC
PC
n
ctio
Infe
Figure 1. Protein levels and activities of serum plasminogen activators in pregnant women seropositive for Toxoplasma gondii IgM. (a) The protein levels of PAs were detected by Western blot assay using anti-tPA and anti-uPA,
respectively. (c) The activities of tPA and uPA were detected by casein zymography. (b, d) Quantitative analysis of the
tPA and uPA bands was performed using a computer-assisted imaging densitometer system. Sample size is shown in
parentheses and all data are presented as mean standard deviation. HC, healthy non-pregnant women; PC, healthy
pregnant women; Infection, women seropositive for T. gondii IgM. *p < 0.05 indicates a significant difference compared with healthy nonpregnant women. #p < 0.05 indicates a significant difference compared with healthy pregnant
Louis, MO). The stacking gels were 4% (mass/volume) polyacrylamide and did not contain casein and plasminogen substrate. Electrophoresis was performed in running buffer (25 mM
Tris, 250 mM glycine, 1% SDS) at room temperature at 120 V
for 1 h. After electrophoresis, the gel was washed in renaturing
buffer (2.5% Triton X-100) in a shaker for 30 min, with one
change after 30 min to remove SDS, washed two times with
double-distilled water (10 min each), incubated in reaction
buffer (50 mM Tris-HCl, pH 7.5, containing 10 mM CaCl2,
0.02% Brij-35, 0.01% NaN3) at 37C for 18 h, stained with

0.25% Coomassie Brilliant Blue R-250 (Bio-Rad, Hercules,
CA) for 1 h, and destained in 15% methanol/ 7.5% acetic acid.
The final gel appeared uniform in all regions except those to
which tPA (70 kDa), and uPA (55kDa) had migrated and
cleaved their respective substrates. Quantitative analysis of the
caseinolytic enzyme was performed with a computer-assisted
imaging densitometer system, UN-SCAN-ITTM gel Version 5.1
(Silk Scientific, Orem, UT).
344
C.S. Chou, M.C. Chou, K.M. Chen, C.Y. Lu, S.C. Lai
(a)
(b)
(20)
Relative density of PAs
(6)
(6)
HC
(c)
n
ctio
Infe
PC
(d)
Relative intensity of PAs
(20)
(6)
(6)
HC
PC
n
ctio
Infe
Figure 2. Protein levels and activities of serum plasminogen activators in pregnant women seropositive for Toxoplasma gondii IgG. (a) The protein levels of PAs were detected by Western blot assay using anti-tPA and anti-uPA,
respectively. (c) The activities of tPA and uPA were detected by casein zymography. (b, d) Quantitative analysis of the
tPA and uPA bands was performed using a computer-assisted imaging densitometer system. Sample size is shown in
parentheses and all data are presented as mean standard deviation. *p < 0.05. HC, healthy non-pregnant women; PC,
healthy pregnant women; Infection, women seropositive for T. gondii IgG. *p < 0.05 indicates a significant difference
compared with healthy nonpregnant women. #p < 0.05 indicates a significant difference compared with healthy pregnant women.
Western blotting
The protein contents of the serum samples were determined
using a protein assay kit (Bio-Rad, Hercules, CA) and bovine
serum albumin as the standard. The samples were mixed with an
equal volume of loading buffer (62.5 mM Tris-HCl, pH 6.8,
10% glycerol, 2% SDS, 5% 2-mercaptoethanol, and 0.05% bromophenol blue). The mixture was boiled for 5 min prior to electrophoresis on 10% (mass/volume) SDS polyacrylamide gel and
electrotransferred to nitrocellulose membrane overnight at a
constant current of 30 mA. Afterward, the membrane was

washed three times (30 min each) in PBS containing 0.1%
Tween 20 (PBS-T) at room temperature, allowed to react with
goat anti-human tPA or anti-human uPA polyclonal antibody
(1:1000; American Diagnostica, Stamford, CT) at 37C for 1 h,
washed three times with PBS-T, incubated with HRP-conjugated rabbit anti-goat IgG (1: 5000; Jackson ImmunoResearch
Laboratories, West Grove, PA) at 37C for 1 h to detect the
bound primary antibody, and then developed using enhanced
chemiluminescence (Amersham Biosciences, Amersham, UK)

to visualize the reactive protein. Quantitative analysis of the
caseinolytic enzyme was performed with a computer-assisted
imaging densitometer system, UN-SCAN-ITTM gel version 5.1
(Silk Scientific, Orem, UT).
Statistical analysis
Results in the different groups were compared using the nonparametric Kruskal-Wallis test followed by post-testing using
Dunns multiple comparison of means. All results are presented
as mean standard deviation. P values of < 0.05 were considered statistically significant.
Results
Protein levels and activities of PAs in serum containing
T. gondii specific IgM antibodies
Two bands (70-kDa and 55-kDa corresponding to tPA
and uPA) were detected in all samples by Western blot
analysis. Both tPA and uPA are trypsin-like serine proteinases that activate plasminogen directly. The activity of
PAs in serum with T. gondii IgM antibody was obtained
by casein zymography. The protein levels (Figure 1a, 1b)
and activities (Figure 1c, 1d) of PAs were significantly
higher (p < 0.05) in pregnant women seropositive for T.
gondii IgM than in seronegative (pregnant or nonpregnant) women.
Protein levels and activities of PAs in serum containing
T. gondii specific IgG antibody
The protein levels (Figure 2a, 2b) and activities (Figure
2c, 2d) of tPA and uPA in serum were significantly higher (p < 0.05) in pregnant women seropositive for T. gondii
IgG than in seronegative (pregnant or nonpregnant)
women.
Discussion
The plasminogen activation system is involved in the
regulation of inflammation and is used by Borrelia
species to enhance its invasiveness [8, 15]. Higher plasma
tPA levels have been reported in women infected with
human immunodeficiency virus than in normal postpartum women [16]. However, PAs represented in inflammation during pregnancy were scarcity. Here we report that
the serum levels of PAs are increased in pregnant women
seropositive for T. gondii IgM and IgG. These data suggest that PAs participate in the pathogenesis of T. gondii
infection.
Cytokines regulate the PAs expression/secretion [17].
IL-6 regulates dengue virus-induced tPA production by
endothelial cells and may have an important role in the
development of dengue hemorrhagic fever and dengue
shock syndrome [18]. Cytokines (such as IL-1, IL-12,
IL-15, TNF-, and IFN-) have been shown to be
involved in the pathogenesis of toxoplasmosis [19, 20].
Furthermore, T. gondii infection upregulates PA activity,
345
and INF- upregulates hepatic u-PA activity during infection [21]. Thus, inflammatory cytokines are increased
during toxoplasmosis. Therefore, we proposed that the
increased expression of PAs in pregnant women with toxoplasmosis might be mediated via inflammatory
cytokines.
T. gondii migrates across biological barriers to reach
immunologically privileged sites where the most severe
pathology is observed [3]. Dissemination is via two pathways: 1) active penetration of the epithelium barrier and
the ECM and 2) use of nucleated cells (e.g.,
macrophages) as Trojan horses [3, 4]. Furthermore, T.
gondii takes advantage of the motility of host cells (e.g.,
dendritic cells) to infiltrate and pass through biological
barriers (e.g., endothelial cells and ECM) in vivo [3, 22].
The crossing of biological barriers and infiltration into the
ECM by T. gondii may involve matrix metalloproteinases
(MMPs) [5]. The passage of T. gondii through vascular
basement membranes or through tissue ECM may be
facilitated by proteolytic degradation of matrix proteins.
The combined effects of PAs, plasmin, and MMPs generate a proteolytic cascade directed at ECM degradation.
Therefore, we suggest that PAs participate in ECM degradation to allow immune cell migration through the barrier and T. gondii dissemination into adjacent tissues.
Human parturition is a multi-step process involving
myometrial contraction, cervical ripening, fetal membrane rupture, and detachment of the placenta and fetal
membranes from the maternal uterus [23]. Some of these
steps require degradation or remodeling of the ECM by
proteolytic enzymes [24]. The PA cascade is thought to
play a critical role in labor-associated remodeling events,
such as fetal membrane rupture and placental separation
[25]. Increased levels of tPA and uPA antigens are found
after the third trimester of pregnancy, and levels of PAs
remain high through the first stage of labor. However, tPA
antigen levels continue to rise during the first few postpartum hours, while uPA antigen levels normalize immediately following childbirth [26]. Although PA activity
remains essentially constant during pregnancy, the fibrinolytic system changes in a complex manner [27]. In our
study, serum PA activity was higher in healthy pregnant
women than in their healthy nonpregnant counterparts.
Furthermore, serum PA activity was significantly higher
in pregnant women infected with T. gondii than in their
healthy counterparts. These results suggest that PAs are
participants in the physiologic processes required for
labor, but overexpression of PAs may cause ECM degradation in pregnant women with T. gondii infection.
Although our experiments were not designed to evaluate serum activity in pregnant women infected with T.
gondii after premature delivery or abortion, we suppose
that the toxoplasmosis-induced proteolytic cascade of
PAs is involved in premature or abortive pathophysiology.
Therefore, we suggest that serum PA levels in T. gondii
infected mothers might be used to track the risk of infection to fetal health.
In conclusion, serum PA levels are higher in pregnant
women with toxoplasmosis than in their noninfected
346
C.S. Chou, M.C. Chou, K.M. Chen, C.Y. Lu, S.C. Lai
counterparts during labor. We suppose that PAs participate in the pathogenesis of toxoplasmosis in pregnant
women and may be useful markers of T. gondii infection.
Acknowledgements
We wish to thank Cheng-You Lu, Department of Parasitology, Chung Shan Medical University, for technical assistance,
Dr. Chen Chung of San Medical College Hospital and Shin
Feshen Obstetrical and Gynecology Hospital, Dr. Chou of Chou
Obstetrical and Gynecology Hospital, Dr. Lee of Meitsun
Obstetrical and Gynecology Hospital, and Dr. Tasi of Tasi
Obstetrical and Gynecology Hospital, for samples.
References
[1] Sabin A.B., Olitsky P.K.: Toxoplasma and obligate intracellular
parasitism. Science, 1937, 85, 336.
[2] Tenter A.M., Heckeroth A.R., Weiss L.M.: Toxoplasma gondii:
from animals to humans. Int. J. Parasitol., 2000, 30, 1217.
[3] Barragan A., Sibley L.D.: Transepithelial migration of
Toxoplasma gondii is linked to parasite motility and virulence. J.
Exp. Med., 2002, 195, 1625.
[4] Da Gama L.M., Ribeiro-Gomes F.L., Guimares U. Jr., Arnholdt,
A.C.: Reduction in adhesiveness to extracellular matrix components, modulation of adhesion molecules and in vivo migration of
murine macrophages infected with Toxoplasma gondii. Microbes.
Infect., 2004, 6, 1287.
[5] Buache E., Garnotel R., Aubert D., Gillery P., Villena I.: Reduced
secretion and expression of gelatinase profile in Toxoplasma
gondii-infected human monocytic cells. Biochem. Biophys. Res.
Commun., 2007, 359, 298.
[6] Astrup T., Sterndorff I.: The plasminogen activator in animal tissue. Acta Physiol. Scand., 1956, 36, 250.
[7] Bergmann S., Hammerschmidt S.: Fibrinolysis and host response
in bacterial infections. Thromb Haemost., 2007, 98, 512.
[8] Coleman J.L., Roemer E.J., Benach J.L.: Plasmin-coated Borrelia
burgdorferi degrades soluble and insoluble components of the
mammalian extracellular matrix. Infect. Immun., 1999, 67, 3929.
[9] Sun H., Ringdahl U., Homeister J.W., Fay W.P., Engleberg N.C.,
Yang A.Y. et al.: Plasminogen is a critical host pathogenicity factor for group A. streptococcal infection. Science, 2004, 305, 1283.
[10] Cowan C., Jones H.A., Kaya Y.H., Perry R.D., Straley S.C.:
Invasion of epithelial cells by Yersinia pestis: evidence for a Y.
pestis-specific invasin. Infect. Immun., 2000, 68, 4523.
[11] Lhteenmki K., Edelman S., Korhonen T.K.: Bacterial metastasis: the host plasminogen system in bacterial invasion. Trends
Microbiol., 2005, 13, 79.
[12] Hou R.F., Tu W.C., Lee H.H., Chen K.M., Chou H.L., Lai, S.C.:
Elevation of plasminogen activators in cerebrospinal fluid of mice
with eosinophilic meningitis caused by Angiostrongylus cantonensis. Int. J. Parasitol., 2004, 34, 1355.
[13] Chen K.M., Liu J.Y., Lai S.C., Hsu L.S., Lee, H.H.: Association
of plasminogen activators and matrix metalloproteinase-9 proteolytic cascade with blood-CNS barrier damage of angiostrongyliasis. Int. J. Exp. Pathol., 2006, 87, 113.
[14] Roggwiller E., Fricaud A.C., Blisnick T., Braun-Breton C.: Host
urokinase-type plasminogen activator participates in the release of
malaria merozoites from infected erythrocytes. Mol. Biochem.
Parasitol., 1997, 86, 49.
[15] Del Rosso M., Fibbi G., Pucci M., Margheri F., Serrati S.: The
plasminogen activation system in inflammation. Front. Biosci.,
2008, 13, 4667.
[16] de Andrade C.M., Duarte G., Quintana S.M., Montes M.B., Toloi
M.R.: Effect of antiretroviral therapy on hemostasis in Brazilian
pregnant women with HIV infection. Blood Coagul. Fibrinolysis
2007, 18, 769.
[17] Plesner T., Behrendt N., Ploug M.: Structure, function and expression on blood and bone marrow cells of the urokinase-type plasminogen activator receptor, uPAR. Stem Cells, 1997, 15, 398.
[18] Huang Y.H., Lei H.Y., Liu H.S., Lin Y.S., Chen S.H., Liu C.C., Yeh
T.M.: Tissue plasminogen activator induced by dengue virus infection of human endothelial cells. J. Med. Virol., 2003, 70, 610.
[19] Denkers E.Y., Gazzinelli R.T.: Regulation and function of T-cellmediated immunity during Toxoplasma gondii infection. Clin.
Microbiol. Rev., 1998, 11, 569.
[20] Kang K.N., Choi I.U., Shin D.W., Lee Y.H.: Cytokine and antibody responses of reactivated murine toxoplasmosis upon administration of dexamathasone. Korean J. Parasitol., 2006, 44, 209.
[21] Mullarky I.K., Szaba F.M., Winchel C.G., Parent M.A., Kummer
L.W., Mackman N. et al.: In situ assays demonstrate that interferon-gamma suppresses infection-stimulated hepatic fibrin deposition by promoting fibrinolysis. Blood Coagul. Fibrinolysis 2006,
4, 1580.
[22] Lambert H., Hitziger N., Dellacasa I., Svensson M., Barragan A.:
Induction of dendritic cell migration upon Toxoplasma gondii
infection potentiates parasite dissemination. Cell Microbiol.,
2006, 8, 1611.
[23] Li W., Alfaidy N., Challis J.R.: Expression of extracellular matrix
metalloproteinase inducer in human placenta and fetal membranes
at term labor. J. Clin. Endocrinol. Metab., 2004, 89, 2897.
[24] Woessner J.F. Jr.: Matrix metalloproteinases and their inhibitors
in connective tissue remodeling. FASEB J., 1991, 5, 2145.
[25] Tsatas D., Baker M.S., Moses E.K., Rice G.E.: Gene expression
of plasminogen activation cascade components in human term gestational tissues with labour onset. Mol. Hum. Reprod., 1998, 4,
101.
[26] Shimada H., Takashima E., Soma M., Murakami M., Maeda Y.,
Kasakura S. et al.: Source of increased plasminogen activators
during pregnancy and puerperium. Thromb Res., 1989, 54, 91.
[27] Kruithof E.K., Tran-Thang C., Gudinchet A., Hauert J., Nicoloso
G., Genton C. et al.: Fibrinolysis in pregnancy: a study of plasminogen activator inhibitors. Blood, 1987, 69, 460.

SHIH-CHAN LAI, M.D.
Department of Parasitology
Chung Shan Medical University
110, Section 1, Chien-Kuo North
Road, Taichung 402, Taiwan (ROC)
e-mail: shih@csmu.edu.tw
15 1141-30 - Effects of inherited:1648_29 Incidence of multiple 15/11/11 14:28 Pagina 347
[1141/30]
347
Effects of inherited trombophilia in women

with recurrent pregnancy loss
Z. Habibovic1, B. Zeybek1, C. Sanhal1, Z. Eroglu, E. Karaca3, M. Ulukus1
1
Department of Obstetrics and Gynecology, 2Department of Medical Biology, 3Department of Genetics

Ege University School of Medicine, Bornova, Izmir (Turkey)
Summary
Purpose of Investigation: To evaluate the prevalence and effects of inherited thrombophilia caused by factor V Leiden, prothrombin
G20210A and methylenetetrahydrofolate reductase (MTHFR) C677T mutations in women with recurrent pregnancy loss. Methods: A
study group of 97 women with recurrent miscarriages and a control group of 71 healthy pregnant women were included in the study.
Genotype analyses for factor V Leiden, prothrombin G20210A and MTHFR C677T polymorphisms were performed by real-time polymerase chain reaction (RT-PCR). Results: The frequency of factor V Leiden, prothrombin G20210A and MTHFR C677T mutations
were similar in both the study and control group. There were eight patients (8.2%) who had more than one gene mutation in the study
group and one patient in the control group (1.4%). This difference was not statistically significant. Study group patients (n = 97) were
compared in terms of the number of miscarriages and the abortion week, in addition to being a carrier of factor V Leiden and MTHFR
C677T gene mutations. No statistically significant correlation was found between being a factor V Leiden and MTHFR C677T mutation carrier with either the number of miscarriages or the abortion week. Conclusion: Factor V Leiden, prothrombin G20210A and
MTHFR C677T gene mutations are not individually related with recurrent pregnancy loss. However, combined gene mutation status
may be associated with recurrent miscarriages.
Key words: Recurrent pregnancy loss; Factor V Leiden; Prothrombin; MTHFR.
Introduction
Recurrent pregnancy loss (RPL) is traditionally defined

as three or more consecutive miscarriages before the 20th
week of pregnancy. According to this definition, RPL
occurs in one of 100 pregnancies [1]. This frequency
increases to 5% when it is defined as two or more pregnancy losses [2, 3]. Parental chromosomal anomalies,
uterine anomalies, endocrine disorders, infections,
immunological factors, acquired or inherited thrombophilia, and maternal chronic diseases contribute to
approximately 50% of cases. However, in the remaining
50% the etiology is unknown [4].
As pregnancy is a hypercoagulable state, secondary to
an increase in coagulation factors and a reduction in naturally occurring anticoagulants, thrombophilia may exaggerate this hypercoagulability and diminish uteroplacental circulation. For this reason, maternal thrombophilias
(factor V Leiden, prothrombin, methylenetetrahydrofolate reductase (MTHFR) C677T mutations, and deficiencies of protein C and protein S) may be related to adverse
pregnancy outcomes and significant pathologies in
obstetrics [5]. When the prevalence of gene mutations for
factor V Leiden, prothrombin and MTHFR were compared among women with RPL, and without any miscarriage, results were conflicting [6-9].
The aim of this study was to identify the possible role
of factor V Leiden, prothrombin G20210A and MTHFR
C677T gene mutations in patients with RPL in the
Western region of Turkey.
In this study we examined 97 patients with RPL and 77

patients without RPL in the period between January 2006 and
May 2009. The criterion to accept patients as cases of RPL was
two or more miscarriages before the 20th week of gestation.
Women with anatomic, autoimmune, hormonal, or chromosomal abnormalities, or antiphospholipid antibody syndrome were
excluded.
The control group consisted of 71 patients (18-37 years old)
who had given birth at least once without any problems during
pregnancy, who had a maximum of one abortion in their history,
and were without any personal or familial history of thromboembolism.
Before inclusion in the study, all the patients underwent physical examination, blood pressure measurement, and hematological and urinary examination to exclude chronic hypertension,
chronic nephropathy and other major systemic diseases. None
of the women who had previous thromboembolic diseases or
family history were included in the study.
All patients, whether in the study or control group, were
examined for factor V Leiden, prothrombin G20210A, and
MTHFR C677T mutations. For DNA isolation, peripheral
blood was collected in EDTA tubes with the consent of all participating women. Genotype analysis was performed by realtime (online) polymerase chain reaction (RT-PCR).
Revised manuscript accepted for publication August 2, 2010

XXXVIII, n. 4, 2011
Factor V Leiden (G1691A) and prothrombin (G20210A)

mutations
Genomic DNA was extracted from peripheral leukocytes of
the subjects using the High Pure PCR Template Preparation Kit
(Roche Applied Science; Mannheim, Germany). All patients
were tested for the presence of factor V Leiden and prothrombin G20210A mutations on the Lightcycler system using the
commercial LightCycler Factor V Leiden G1691A and Prothrombin G20210A Mutation Detection Kits, respectively
(Roche Diagnostics; Mannheim, Germany).
348
Z. Habibovic, B. Zeybek, C. Sanhal, Z. Eroglu, E. Karaca, M. Ulukus
Genotyping of the different alleles for the factor V Leiden

mutation was done according to the specific melting temperature (Tm) of the resulting amplicons. In this analysis a wildtype
genotype with two copies of the G allele (G/G) showed a single
melting peak at 65C, a mutant genotype with two copies of the
A allele (A/A) also showed a single melting peak but at 57C,
and a heterozygous genotype with both alleles (G/A) showed
two melting peaks at 65C and 57C.
Similarly, specific Tm of the resulting amplicons identified
different alleles of the prothrombin G20210A mutation. In this
analysis a wildtype genotype with two copies of the G allele
(G/G) showed a single melting peak at 59C, a mutant genotype
with two copies of the A allele (A/A) also showed a single
melting peak but at 49C, and a heterozygous genotype with
both alleles (G/A) showed two melting peaks at 59C and 49C.
Table 1. Factor V Leiden and prothrombin G20210A gene

mutation status in both groups.
Factor V Leiden
Prothrombin G20210A
Normal Heterozygote A allele p value Normal Heterozygote

genotype
genotype
carrier
genotype genotype
Study
86
9
2
94
3
group (88.7%) (9.2%) (2.1%)
(96.9%) (3.1%)
(n = 97)
n.s.
Control 64
6
1
70
1
group (90.1%) (8.5%) (1.4%)
(98.6%) (1.4%)
(n = 71)
A allele
carrier
p value
3
(3.1%)
n.s.
1
(1.4%)
n.s. = non significant.
Table 2. MTHFR C677T gene mutation status in both groups.

MTHFR C677T
MTHFR (C677T) mutation

For the detection of the C677T polymorphism at the MTHFR
gene, specific primer probes were used together with the LightCycler-DNA Master Hybridization Probes Kit (Roche Applied
Science; Mannheim, Germany). Experiments were carried out
on the LightCycler system (Roche Applied Science;
Mannheim, Germany) according to the protocol of Charalampos Aslandis and Gerd Schmitz (Institute for Clinical Chemistry
and Laboratory Medicine, University of Regensburg, Regensburg, Germany). Specific Tm of the resulting amplicons identified polymorphic alleles. In this analysis individuals with two
copies of the C allele (C/C) showed a single melting peak at
63.1C, individuals with two copies of the T allele (T/T) also
showed a single melting peak but at 54.6C, and individuals
with both alleles (C/T) showed two melting peaks at 54.6C and
63.1C.
All statistical analyses were performed using Microsoft SPSS
11.0 version. Continuous variables were assessed using the
Students t-test. A chi-square test was applied to detect the statistical differences between genetic mutations in the RPL group
and control group. Data are presented as the mean SD. Differences were considered to be significant at p < 0.05.
Results
The mean age of the study group (n = 97) was 30.6
5.8 (20-43 years old) and that of the control group (n =
71) was 28.2 5.2 (19-38 years old). There was a statistically significant difference between the mean ages of
the two groups (p < 0.05). The number of abortions in the
study group (n = 97) was 2.9 1.2 (2-7) on average. The
mean abortion week of the study group was 8.4 2.9
(weeks 4-19), whereas it was 7.1 1 (weeks 6-9) in the
control group. Twenty-nine patients had miscarriages in
the second trimester. However, it was found that 26 of
these patients also had at least one first-trimester loss.
There was no statistically significant difference between
the two groups in terms of abortion week .
In terms of the factor V Leiden gene, within the study
group (n = 97) 86 patients (88.7%) had normal genotypes
(GG), nine (9.2%) had heterozygote (GA) genotypes, and
two patients (2.1%) had homozygote (AA) genotypes. In
the control group (n = 71) 64 patients (90.1%) had
normal genotypes, six patients (8.5%) had heterozygote
Normal
(CC) genotype
Study group
46
(n = 97)
(47.4%)
Control group
34
(n = 71)
(47.9%)
p value
n.s.
Heterozygote
(CT) genotype
Homozygote
(TT) genotype
T allele carrier
31
(32%)
30
(42.3%)
n.s.
20
(20.6%)
7
(9.9%)
n.s.
51
(52.6%)
37
(52.1%)
n.s.
Table 3. Combined gene mutation status in both groups.

Combined gene mutation
Study group (n = 97)

8 (8.2%)
Control group (n = 71)

1 (1.4%)
n.s.
genotypes, and one patient (1.4%) had a homozygote

genotype. There was no statistically significant difference
between the two groups in terms of being a carrier of the
factor V Leiden mutation (Table 1).
In terms of the prothrombin G20210A gene mutation,
gene mutation carrier status was identified in three
patients (3.1%) in the study group (n = 97), whereas a
heterozygote gene mutation was found in one patient
(1.4%) in the control group (n = 71). No statistically significant difference was found between the two groups in
terms of carrier status for the prothrombin G20210A gene
mutation (Table 1).
In terms of the MTHFR C677T gene mutation, in the
study group (n = 97) 46 patients (47.4%) had normal
(CC) genotypes, 31 patients had (32%) heterozygote
(CT) genotypes, and 20 patients (20.6%) had homozygote (TT) genotypes. In the control group (n = 71) 34
patients (47.9%) had normal genotypes, 30 patients
(42.3%) had heterozygote genotypes, and seven patients
(9.9%) had homozygote genotypes. There was no statistically significant difference between the groups in terms
of MTHFR C677T gene mutation carrier status (Table 2).
It was found that eight patients (8.2%) in the study
group (n = 97), and one patient (1.4%) in the control
group were carriers of multiple gene mutations. This difference was not statistically significant (Table 3).
Study group patients (n = 97) were compared in terms
of the number of miscarriages and the abortion week, as
well as carrier status of the factor V Leiden mutation. In
Effects of inherited trombophilia in women with recurrent pregnancy loss
Table 4. Number of abortions and abortion weeks for factor

V Leiden A allele carriers and MTHFR C677T T allele
carriers within study group.
Factor V Leiden
A allele
carriers
(n = 11)
Non
carriers
(n = 86)
Number of
miscarriages
(mean SD) 3.3 1.5 2.8 1.2
Abortion
week
(mean SD) 8.6 2.5 8.5 2.3
Prothrombin G20210A
p value
T allele
carriers
(n = 51)
Non
carriers
(n = 46)
p value
n.s.
2.9 1.1
2.9 1.3
n.s.
n.s.
8.7 2.4
8.4 2.2
n.s.
the 86 non-carrier patients the average number of miscarriages was 2.8 1.2 and the mean abortion week was 8.5
2.3, while the average number of miscarriages for the
11 patients with A allele carrier status was 3.3 1.5 and
the mean abortion week was 8.6 2.5. Accordingly, there
was no statistically significant correlation between being
a carrier of the factor V Leiden mutation with either the
number of miscarriages or the abortion week (Table 4).
Study group patients (n = 97) were compared in terms
of the number of miscarriages and the abortion week, as
well as being a carrier of the MTHFR C677T gene mutation. In the 46 non-carrier patients the average number of
abortions was 2.9 1.3 and the mean abortion week was
8.4 2.2, while the average number of abortions for the
51 patients with T allele carrier status was 2.9 1.1 and
the mean abortion week was 8.7 2.4. Accordingly, no
statistically significant correlation was found between
being a MTHFR C677T mutation carrier with either the
number of miscarriages or the abortion week (Table 4).
Discussion
Factor V Leiden, prothrombin G20210A, and MTHFR
C677T mutations, which are known to increase the risk
of thrombosis, are thought to play a role in RPL and in
the etiology of late pregnancy complications [10, 11]. In
the literature, there are case control studies investigating
the relationship between factor V Leiden mutation and
RPL that are similar to our study in terms of study design
and patient selection. Although some of these studies
have shown a link between factor V Leiden mutation and
RPL [12, 13], a significant number of studies has also
failed to identify such a relationship [8, 14].
In a meta-analyses, the factor V Leiden mutation was
found to be associated with RPL and these women were
found to be at higher risk of pregnancy loss in the second
compared with the first trimester (OR 7.83, 95% CI 2.8321.67 and OR 2.01, 95% CI 1.13-3.58, respectively) [15].
This finding was supported by another meta-analysis by
Robertson et al. [16] (OR 4.12; 95% CI 1.93-8.81 and
OR 1.91; 95% CI 1.01-3.61, respectively). However, in a
study by Rai et al. [17], which comprises one of the
largest patient populations among the studies conducted
to this point, 905 unselected patients with RPL and 150
349
control cases were examined and it was concluded that

there was no relationship between the factor V Leiden
mutation and RPL. In our study, carrier status of factor V
Leiden mutation was found to be 11.3% in the study
group and 9.9% in the control group and these rates were
not considered statistically significant.
As is the case with factor V Leiden, there are numerous studies that have investigated the effects of the prothrombin G20210A mutation on RPL and found that prothrombin G20210A heterozygosity increases the risk of
RPL from 2-6.5 times [15, 16]. On the other hand,
Brenner et al. [18], Wramsby et al. [19], and Kutteh et al.
[20] conducted three case-control studies examining the
relationship between the prothrombin G20210A mutation
and RPL, and reported that the mutation did not increase
the risk of pregnancy loss. In our study, although the difference was not statistically significant, carrier status of
the prothrombin G20210A mutation was found to be
3.1% in the study group whereas it was 1.4% in the
control group.
The results of studies on the effects of the MTHFR
C677T gene mutation on unexplained RPL remain contradictory. These conflicting results may be attributed to
the number of patients included in the studies, and the
variability of selection criteria for study and control
group cases, as well as differences in ethnic and geographical distribution of the T allele. The majority of
researchers agree that the MTHFR C677T heterozygote
mutation does not lead to pregnancy loss. However, Martinelli et al. [21] and Nelen et al. [22] reported that the
MTHFR C677T homozygote mutation leads to mild
hyperhomocysteinaemia, and that it may increase the risk
of pregnancy loss by 2-3 times. In a study by Jivraj et al.
[23], 714 women were selected for the case group and
136 women were selected for the control group. The rate
of carrier status of the MTHFR C677T mutation was the
same (32%) in both groups. While achieving these
results, Jivraj et al. [23] did not evaluate the heterozygote
and homozygote MTHFR C677T mutation separately. In
a meta-analysis (26 case-controlled studies, 2120 RPL
cases and 2949 controls), Ren et al. [24] stated that
women with RPL have three times more homozygote
MTHFR C677T mutations and that this is significant
with regards to RPL. However Rey et al. [15] could not
find any relation between the MTHFR homozygote mutation and RPL. Meta-analyses by Robertson et al. [16] and
Nelen et al. [25] also showed that hyperhomocysteinaemia was strongly associated with RPL (OR 6.25;
95% CI, 1.37-28.42 and OR 4.2; 95% CI, 2.0-8.8 respectively). According to all these studies, it could be concluded that hyperhomocysteinaemia plays the major role
in RPL instead of MTHFR gene mutation.
In a study investigating the relationship between RPL
and combined thrombophilic mutations, conducted by
Sotiriadis et al. [26], 88 patients with RPL were compared to 88 controls. The relationship between combined
thrombophilic mutations and RPL was found to be statistically nonsignificant. Our study supports Sotiriadis et
al., as we have found combined gene mutations are not
350
Z. Habibovic, B. Zeybek, C. Sanhal, Z. Eroglu, E. Karaca, M. Ulukus
statistically significant in terms of RPL, however, the frequency was higher (8.2% vs 1.4%). In a study by Coulam
et al. [27], 150 women with a history of RPL and 20
fertile control were examined for ten thrombophilic gene
mutations. They concluded that while none of the specific
thrombophilic gene mutations appears to be a risk factor
for RPL, when taken together the total number of mutations is a significant risk.
Conclusion
Although the number of cases is not adequate to make
definitive comments, our results suggest that factor V
Leiden, prothrombin G20210A and MTHFR C677T gene
mutations are not individually related with RPL.
However, combined gene mutation status may be associated with RPL as the frequency was higher (8.2% vs
1.4%). Further studies with larger series are needed to
clarify this issue.
References
[1] Laird S.M., Tuckerman E.M., Cork B.A., Linjawi S., Blakemore
A.I., Li T.C.: A review of immune cells and molecules in women
with recurrent miscarriage. Hum. Reprod. Update, 2003, 9, 163.
[2] Hogge W.A., Byrnes A.L., Lanasa M.C., Surti U.: The clinical
use of karyotyping spontaneous abortions. Am. J. Obstet.
Gynecol., 2003, 189, 397.
[3] The American College of Obstetricians and Gynecologists. Management of recurrent early pregnancy loss. Washington, DC: The
American College of Obstetricians and Gynecologists, 2001.
ACOG Practice Bulletin No. 24.
[4] Strobino B., Fox H.E., Kline J., Stein Z., Susser M., Warburton D.:
Characteristics of women with recurrent spontaneous abortions
and women with favourable reproductive histories. Am. J. Public
Health, 1982, 76, 986.
[5] Preston F.E., Rosendaal F.R., Walker I.D., Briet E., Berntorp E.,
Conard J. et al.: Increased fetal loss in women with heritable
thrombophilia. Lancet, 1996, 348, 913.
[6] Sarig G., Younis J.S., Hoffman R., Lanir N., Blumenfeld Z.,
Brenner B.: Thrombophilia is common in women with idiopathic
pregnancy loss and is associated with late pregnancy wastage.
Fertil. Steril., 2002, 77, 342.
[7] Reznikoff-Etievan M.F., Cayol V., Carbonne B., Robert A., Coulet
F., Milliez J.: Factor V Leiden and G20210A prothrombin mutations are risk factors for very early recurrent miscarriage. BJOG,
2001, 108, 1251.
[8] Dizon-Townson D.S., Kinney S., Branch D.W., Ward K.: The
factor V Leiden mutation is not a common cause of recurrent miscarriage. J. Reprod. Immunol., 1997, 34, 217.
[9] Pickering W., Marriott K., Regan L.: G20210A prothrombin gene
mutation: prevalence in a recurrent miscarriage population. Clin.
Appl. Thromb Hemost., 2001, 7, 25.
[10] Rai R., Shlebak A., Cohen H., Backos M., Holmes Z., Marriott K.
et al.: Factor V Leiden and acquired activated protein C resistance among 1000 women with recurrent miscarriage. Hum.
Reprod., 2001, 16, 961.
[11] Meinardi J.R., Middeldorp S., de Kam P.J., Koopman M.M., van
Pampus E.C., Hamulyak K. et al.: Increased risk for fetal loss in
carriers of the factor V Leiden mutation. Ann. Intern. Med., 1999,
130, 736.
[12] Younis J.S., Brenner B., Ohel G., Tal J., Lanir N., Ben-Ami M.:
Activated protein C resistance and Factor V Leiden mutation can
be associated with first as well as second-trimester recurrent pregnancy loss. Am. J. Reprod. Immunol., 2000, 43, 31.
[13] Foka Z.J., Lambropoulas A.F., Saravelos H., Karas G.B., Karavida
A., Agorastos T. et al.: Factor V Leiden and Prothrombin
G20210A mutations, but not methylenetetrahydrofolate reductase
C677T, are associated with recurrent miscarriages. Hum.
Reprod., 2000, 15, 458.
[14] Balach J., Reverter J.C., Fabregues F., Tassies D., Rafel M., Creus
M. et al.: First-trimester abortion is not associated with activated
protein C resistance. Hum. Reprod., 1997, 12, 1094.
[15] Rey E., Kahn S.R., David M., Shrier I.: Thrombophilic disorders
and fetal loss: a meta-analysis. Lancet, 2003, 361, 901.
[16] Robertson L., Wu O., Langhorne P., Twaddle S., Clark P., Lowe
G.D. et al.: Thrombophilia in pregnancy: a systematic review.
Br. J. Haematol., 2006, 132, 171.
[17] Rai R., Shlebak A., Cohen H., Backos M., Holmes Z., Marriott K.
et al.: Factor V Leiden and acquired activated protein C resistance among 1000 women with recurrent miscarriage. Hum.
Reprod., 2001, 16, 961.
[18] Brenner B., Sarig G., Weiner Z., Younis J., Blumenfeld Z., Lanir
N.: Thrombophilic polymorphisms are common in women with
fetal loss without apparent cause. Thromb. Haemost., 1999, 82,
6.
[19] Wramsby M.L., Sten-Linder M., Bremme K.: Primary habitual
abortions are associated with high frequency of factor V Leiden
mutation. Fertil. Steril., 2000, 74, 987.
[20] Kutteh W.H., Park V.M., Deitcher S.R.: Hypercoagulable state
mutation analysis in white patients with early first trimester recurrent pregnancy loss. Fertil. Steril., 1999, 71, 1048.
[21] Martinelli I., Taioli E., Cetin I., Marinoni A., Gerosa S., Villa M.V.
et al.: Mutations in coagulation factors in women with unexplained late fetal loss. N. Engl. J. Med., 2000, 343, 1015.
[22] Nelen W.L., Bulten J., Steegers E.A., Blom H.J., Hanselaar A.G.,
Eskes T.K.: Maternal homocysteine and chorionic vascularization
in recurrent early pregnancy loss. Hum. Reprod., 2000, 15, 954.
[23] Jivraj S., Rai R., Underwood J., Regan L.: Genetic thrombophilic
mutations among couples with recurrent miscariage. Hum.
Reprod., 2006, 21, 1161.
[24] Ren A., Wang J.: Methylenetetrahydrofolate reductase C677T
polymorphism and the risk of unexplained recurrent pregnancy
loss: a meta-analysis. Fertil. Steril., 2006, 86, 1716.
[25] Nelen W.L., Blom H.J., Steegers E.A., den Heijer M., Eskes T.K.:
Hyperhomocysteinemia and recurrent early pregnancy loss: a
meta-analysis. Fertil. Steril., 2000, 74, 1196.
[26] Sotiriadis A., Vartholomatos G., Pavlou M., Kolaitis N., Dova L.,
Stefos T. et al.: Combined thrombophilic mutations in women
with unexplained recurrent miscarriage. Am. J. Reprod. Immunol., 2007, 57, 133.
[27] Coulam C.B., Jeyendran R.S., Fishel L.A., Roussev R.: Multiple
thrombophilic gene mutations rather than specific gene mutations
are risk factors for recurrent miscarriage. Am. J. Reprod.
Immunol., 2006, 55, 360.

B. ZEYBEK, M.D.
Ege University School of Medicine
35100 Bornova, Izmir (Turkey)
e-mail: bzeybek@yahoo.com;
e-mail: burak.zeybek@ege.edu.tr
16 1156-30 - Infectious respiratory:1648_29 Incidence of multiple 15/11/11 14:30 Pagina 351
[1156/30]
351
Infectious respiratory diseases in pregnancy - results of a

15-year study in Seoul
Joo Yeon Cheung, Sung Shine Shim, Yookyung Kim
Department of Radiology, Mokdong Hospital, Ewha Womans University School of Medicine, Seoul (Korea)
Summary
Purpose: To determine the incidence, clinical course, and outcomes of infectious disease during pregnancy. Methods: A retrospective review was performed of pregnant woman with infectious lung diseases including pneumonia and active tuberculosis. Demographic, clinical data and radiologic findings were collected for all the cases identified. Results: During the study period, our hospital
had 14,603 pregnancies. Among these, eight patients (55/100,000) had pneumonia and two (14/100,000) had active pulmonary tuberculosis. The median interval between onset of symptoms and disgnosis was 8.8 days for pneumonia and 41 days for tuberculosis. All
the pneumonia patients recovered, and death during the study period occurred in one patient with active tuberculosis. Conclusion: The
incidence of pneumonia during pregnancy was not higher than that of non-pregnant women and the patients evidenced complete recovery. The incidence of tuberculosis was a higher incidence than reported in developed countries and could cause diagnostic delays and
progress to acute respiratory failure. Therefore, clinicians should be aware of the potential for nonspecific presentation of tuberculosis
in pregnancy and should consider a diagnosis in women particularly in endemic areas.
Key words: Lung; Pregnancy; Infection.
Introduction
Pregnancy is a physiological change which renders a
woman more susceptible to a variety of pulmonary disorders. Several manuscripts have reported on pulmonary
diseases of pregnancy, including conditions specific to
pregnancy and diseases of non-specific causes.
Pulmonary complications owing to non-pregnancy-specific conditions are known to be the leading cause of
death and poor prognosis; among these, infectious respiratory diseases are an essential cause of morbidity and
mortality in pregnant women [1-3]. The majority of these
respiratory diseases included pneumonia and tuberculosis, especially in endemic regions. Several reviews and
studies concerning pneumonia and tuberculosis during
pregnancy have already been conducted [4-7]. Pregnant
patients with infectious disease have been found to be significantly more likely to evidence nonspecific symptoms
and to experience delays in obtaining chest radiographs
than non-pregnant women; even with regard to tuberculosis, up to 20% of pregnant women are asymptomatic. On
the other hand, reported infant and maternal mortality
from untreated active tuberculosis is generally reported as
between 30%-40%, despite the fact that mortality due to
pneumonia was in a range similar to that of communityacquired pneumonia (CAP) in non-pregnant patients [8,
9]. Therefore, clinicians and radiologists should attempt
to gain a better understanding of the incidence of these
diseases in large series and clinical courses, as well as
image findings. In this article, we have assessed the incidence of infectious respiratory disease (pneumonia,
tuberculosis) in pregnancy for 15 years at our institute,
and describe the correlation of the clinical course with the
initial and follow-up chest radiological images.
Revised manuscript accepted for publication September 30, 2010
XXXVIII, n. 4, 2011

Setting
Our institute is an 850-bed district general hospital. The

hospital serves a population of approximately 500,000 in
the territory of Yangcheon-gu. The notification rate of
tuberculosis in Korea in 2008 was 70.3/100,000. The hospital notifies approximately 2,600 pneumonia patients
annually and 380 tuberculosis patients annually. The
obstetric unit performed approximately 1,100
deliveries/year from 1995-2003 and 800 deliveries/year
from 2004-2009 with a recent apparent decrease in the
fertility rate in Korea.
Patients
Over a 15-year period spanning November 1994 to

November 2009, pregnant women who were cared for at
our institute were retrospectively investigated. In this
study, patients with pneumonia and active tuberculosis
(TB) during pregnancy were selected. The incidence, disease progression, and its effects on delivery were evaluated by reviewing the patients medical records and radiologic studies. A total of 14,603 delivery cases and 13,015
pregnant women presented at our hospital for 15 years.
Among these, ten women (10 cases) were identified who
had pneumonia and active TB during pregnancy.
Results
During the 15-year period, our hospital had 14,603
pregnancies, and the total number of pregnant women
was 13,015. Among these, ten women (68/100,000) had
pregnancy-related infectious respiratory diseases, including pneumonia (n = 8) and active pulmonary tuberculosis
(n = 2) in our hospital. The mean age was 32 years (range
352
28-36 years). All cases were initially diagnosed during

pregnancy without any exacerbation of pre-existing disease. They had no past or familial histories or chronic
medical condition. Mean gestational age at the time of
symptom onset was 26 weeks (range 3-37 weeks) and
mean gestational age at the time of diagnosis was 28
weeks (range 4-39 weeks). Mean gestational age at the
time of delivery was 36 weeks (range 15-40 weeks) and
two women were still pregnant during the study period
(32 weeks and 36 weeks) without significant medical and
radiological problems. One woman with pneumonia
delivered before 37 weeks of gestation by cesarean section due to high fever, and one woman with active pulmonary TB had a spontaneous abortion at a gestational
age of 15 weeks; however, none of the patients in the
pneumonia group delivered prior to 34 weeks of gestation. All women delivered by normal spontaneous vaginal
deliveries except for the previously mentioned patient
with pneumonia, who delivered by cesarean section.
Death due to pregnancy-related infectious disease during
the study period occurred in one patient with active TB.
The details of each case and disease including incidence,
symptoms, gestational age at symptom onset, and diagnosis are presented in Tables 1 and 2. Patient outcomes of
pregnancy and infectious disease are provided in Table 3.
Pneumonia
Eight patients (55/100,000) had pneumonia during
pregnancy. The median interval between onset of symptoms and disgnosis of pneumonia was 8.8 days. Among
these patients, two women had Mycoplasma pneumonia
infections confirmed by serum Ab test. A gram-negative
bacillus was cultured from the patients blood in one case.
In the other cases, microorganisms were not confirmed
from blood or sputum cultures, but could be diagnosed as
pneumonia by clinical symptoms, laboratory findings,
and chest radiography. All the pneumonia patients recovered without significant compliance with commonly used
antibiotics in pregnancy (category A and B) and the mean
recovery time was 9.7 days from the day of diagnosis.
Table 1. Incidence of pneumonia and pulmonary

tuberculosis during pregnancy.
Disease
Pneumonia
Active pulmonary
tuberculosis
No. of patients (%)
No. of cases (%)
8 (0.061)
8 (0.055)
2 (0.015)
2 (0.014)
Table 2. Clinical symptoms, gestation at onset, and

gestation at diagnosis of ten patients with infectious
respiratory disease during pregnancy.
Disease
Case
Age
Clinical symptoms
Gestation at onset of symptoms
1
2
3
4
5
6
7
36
34
33
28
32
30
28
36 weeks
3 weeks
35 weeks
21 weeks
26 weeks
37 weeks
38 weeks
4 weeks
36 weeks
21 weeks
28 weeks
39 weeks
8
9
10
30
36
32
Cough
Cough, dyspnea
Cough, fever
Cough, fever
Fever
Cough, fever
Fever, dyspnea,
chest pain
Cough
Fever
Fever
31 weeks
33 weeks
33 weeks
8 weeks
33 weeks
33 weeks
39 weeks
13 weeks
Pneumonia
Active
pulmonary
tuberculosis
Gestation at
diagnosis
Table 3. Outcome of pregnancy and infectious respiratory

diseases during pregnancy.
Disease
Case Type of
delivery
1
2*
3
Pneumonia 4
5
6
7
8*
Active
9
pulmonary 10
tuberculosis
NVD
C/S
unknown
NVD
NVD
NVD (twin)
35 weeks
8 weeks
Outcome of pregnancy Clinical outcome

(gestation at delivery,
weeks)
Full term (40)
Full term (37)

unknown
Full term (40)
Full term (39)
Full term (38)
Full term (40)
Spontaenous
abortion (15)
Treated for 1 week

Treated for 2 weeks
Treated for 2 weeks
unknown
Treated for 5 days
Treated for 1 week
Treated for 2 weeks
Treated for 1 week
Treated for 6 months
Death due to ARDS,
DIC, and renal failure
*; women on pregnancy during study period, NVD = normal virginal delivery, C/S =
cesarean section, ARDS = acute respiratory distress syndrome, DIC = disseminated
intravascular coagulation.
Active pulmonary tuberculosis

Two women (14/100,000) had active pulmonary TB
during pregnancy. They had a mild fever during the mean
41 days prior to admission (42 days and 40 days, respectively), but the diagnosis of TB was delayed without adequate treatment. One of these patients was diagnosed with
miliary TB at a gestational age of 13 weeks by chest
roentgenography and computed tomography (CT) scan,
and had an abrupt spontaneous abortion at a gestational
age of 15 weeks. Her condition worsened soon after abortion with combined pneumonia, acute renal failure, hepatic failure, DIC, ARDS, and she finally expired within 18
days of diagnosis from TB. The other woman had no significant symptoms except intermittent mild fever, and TB
was identified at a gestational age of 39 weeks and three
days due to abnormalities on chest roentgenography and
CT scan. In the result of the sputum study, the growth of
Mycobacterium tuberculosis was reported. She delivered
a baby on the next day with a spontaneous virginal pattern

without induction, and recovered after six months of
treatment with Pyrazinamide, Rifampicin, Isoniazid, and
Ethambutol.
Discussion
Our study involved a series of patients who developed
infectious pulmonary complications including TB in
pregnancy, reported in a tuberculosis-endemic area. An
accurate estimate of the incidence of pneumonia during
pregnancy is somewhat difficult to obtain. The few studies of pneumonia in pregnancy conducted thus far mostly
include small numbers of cases, and evidence marked
variations in incidence over the years, with values of
0.44-8.5 per 1,000 deliveries [10, 11]. In the 1970s and
early 1980s, reduced incidence was reported with 0.44-
Infectious respiratory diseases in pregnancy - results of a 15-year study in Seoul
353
Fig. 1
Fig. 2
Figure 1. On simple chest roentgenography diffuse ground

glass opacities in both lungs can be seen. Right-sided aortic arch
is also seen.
Figure 2. Axial image of chest HRCT scan (1 mm in thickness) shows miliary nodules with diffuse bilateral ground glass
attenuated lesions.
0.78 per 1,000 deliveries in comparison with the results

noted in the years prior to 1965 (6.3-8.5 per 1000 deliveries), presumably due to advanced antibiotics and
improvements in obstetric care [4, 6]. Recently, an incidence of 1.1-2.7 per 1,000 deliveries has been reported,
and this increase in incidence may be reflective of the
higher proportion of pregnant women with chronic medical conditions [12]. The results of our study demonstrated an incidence of pneumonia at 0.55 per 1,000 deliveries, which is lower than in many other contemporary
reports. However, these results were obtained from pregnant women who did not use drugs and were HIV-negative; therefore, these results are not representative or
applicable to the general population.
Some studies have compared pregnant women with
pneumonia and pregnant women without pneumonia in
order to establish risk factors associated with the development of pneumonia and the effects of pneumonia on pregnancy. However, there have been no studies in which pneumonia in pregnant and non-pregnant women has been
directly compared. Hence, there is currently no information
as to whether pneumonia is any different in pregnant
women and non-pregnant adults. There is certainly no convincing evidence to suggest that the documented changes
in the immune system result in clinically significant
immunosuppression with increased susceptibility to respiratory tract infection. Therefore, pregnancy is generally not
regarded as a risk factor for pneumonia, and its incidence
in pregnancy has been reported in recent studies not to differ from that in non-pregnant adults [13, 14].
There have been no detailed studies specifically focusing on the microbial agents involved in pneumonia during
pregnancy. In bacterial and atypical pathogens,
Streptococcus pneumonia is the most common organism
identified, followed by Hemophilus influenza.
Mycoplasma pneumonia might be expected to be an additional common pathogen, particularly in this age group.
Pneumonia has been cited as the third most frequent

cause of indirect obstetric death in North America.
However, recent studies have reported a maternal mortality of 1-4%, which approximates a mortality of 0-4%
from pneumonia in hospitalized non-pregnant adults. In
our series, only one patient permitted a cesarean section
to be conducted due to aggravated fever with pneumonia
however, the patient recovered completely seven days
after delivery. The others were well controlled with
antibiotics for a mean 9.7 days after normal vaginal deliveries, without complications. This result corresponds well
with their results showing very low mortality from pneumonia in pregnancy.
Recent publications have described series of cases of
TB in pregnancy within various populations, but no
large-series data have been published thus far in endemic areas, to the best of our knowledge. Approximately
two million deaths occurred from TB worldwide in
1997, 98% of them in developing countries. In South
Korea, the incidence of active TB was reported to be
approximately 70.3/100,000 persons in 2008 [15]. This
is still much higher than in the US, where the value was
6.8/100,000 population between 1993 and 1998. In our
series, two cases of TB developed in 15 years, and this
result was consistent with an incidence of 14 per
100,000 people, which is higher than reported in developed countries, but lower than the data from results
including all ages and all regions in Korea. This discrepancy with a total incidence in Korea is most probably the
result of differences in the study populations. All of our
patients were < 40 years of age, had no history of corticosteroid use, HIV-infection, or other comorbidities,
including diabetes mellitus and chronic renal disease.
Another possible contributory factor might be that
Yangcheon-gu in Seoul, which is served by our hospital,
was deemed the nation`s best tuberculosis-controlled
city in 2008.
354
It is a matter of great interest to consider whether pregnancy is an independent risk factor for developing TB and
progression to acute respiratory failure. The question of
pregnancy as a risk factor for TB has been preivously
debated. The one deceased patient in the TB group was
the only case in which the patient died as the result of
infectious complications during the study period. The
radiologic findings of this patient showed a miliary pattern. A true estimate of the incidence of non-miliary TB
versus miliary TB during pregnancy is difficult to obtain.
As a predictor of miliary TB, one recent study indicated
that age < 30 years, HIV infection, and corticosteroid use
were strong independent predictors of miliary TB [16].
Our patient had a family history of TB with her father;
however, there were no other risk factors, including history of diabetes mellitus or immunodepressive conditions,
including HIV infection. It is difficult to describe pregnancy as a risk factor or poor prognostic factor in TB
because our results were obtained from only two cases;
however, although pregnancy is not thought to change the
course of TB, TB clearly poses a risk to the pregnant
woman and her fetus. A larger series on studies of this
topic are clearly warranted.
Two patients with TB who, because they were pregnant,
were subjected to regular medical reviews. The fact that
these patients had symptoms of TB for over 40 days
before diagnosis is clearly a cause for concern. We identified a variety of reasons for this delay, including nonspecific symptoms and tendency to defer radiological
investigations during pregnancy. Up to 20% of pregnant
women with TB have been shown to be asymptomatic
[17]. In one study, a group of pregnant patients with pulmonary TB were significantly more likely to be asymptomatic at the time of diagnosis[18]. In another, pregnant
patients with TB were significantly more likely to evidence non-specific symptoms and also to experience
delays in obtaining chest radiographs, as compared to
non-pregnant women with TB [19].
Conclusion
The incidence of pneumonia in this study was 0.55 per
1,000 deliveries, which is not higher than that of nonpregnant women and the patients evidenced recovery
without compliance within a mean of 9.7 days. Diagnosis
and management strategies for non-pregnant adults can,
therefore, also be applied to pregnant women, thus
addressing possible toxicity to the fetus. The incidence of
TB was 0.14 per 1,000 deliveries in this study, which was
a higher incidence than reported in developed countries.
Moreover, TB during pregnancy can cause diagnostic
delays, and may progress to acute respiratory failure.
Therefore, clinicians and radiologists should be aware of
the potential for nonspecific presentation of TB in pregnancy and should consider such a diagnosis in women,
particularly in areas in which the prevalence of TB is
high.
References
[1] Cohen R., Talwar A., Efferen L.S.: Exacerbation of underlying
pulmonary disease in pregnancy. Crit. Care Clin., 2004, 20, 713.
[2] Lapinsky S.E.: Cardiopulmonary complications of pregnancy.
Crit. Care Med., 2005, 33, 1616.
[3] Pereira A., Krieger B.P.: Pulmonary complications of pregnancy.
Clin. Chest. Med., 2004, 25, 299.
[4] Benedetti T.J., Valle R., Ledger W.J.: Antepartum pneumonia in
pregnancy. Am. J. Obstet. Gynecol., 1982, 144, 413.
[5] Maccato M.L.: Pneumonia and pulmonary tuberculosis in pregnancy. Obstet. Gynecol. Clin. North Am., 1989, 16, 417.
[6] Madinger N.E., Greenspoon J.S., Ellrodt A.G.: Pneumonia during
pregnancy: has modern technology improved maternal and fetal
outcome?. Am. J. Obstet. Gynecol., 1989, 161, 657.
[7] Richey S.D., Roberts S.W., Ramin K.D., Ramin S.M.,
Cunningham F.G.: Pneumonia complicating pregnancy. Obstet.
Gynecol., 1994, 84, 525.
[8] Schaefer G., Zervoudakis I.A., Fuchs F.F., David S.: Pregnancy
and pulmonary tuberculosis. Obstet. Gynecol., 1975, 46, 706.
[9] Simpson J.C., Macfarlane J.T., Watson J., Woodhead M.A.: A
national confidential enquiry into community acquired pneumonia
deaths in young adults in England and Wales. British Thoracic
Society Research Committee and Public Health Laboratory
Service. Thorax, 2000, 55, 1040.
[10] Hopwood H.G. Jr.: Pneumonia in pregnancy. Obstet. Gynecol.,
1965, 25, 875.
[11] Shariatzadeh M.R., Marrie T.J.: Pneumonia during pregnancy.
Am. J. Med., 2006, 119, 872.
[12] Berkowitz K., LaSala A.: Risk factors associated with the increasing prevalence of pneumonia during pregnancy. Am. J. Obstet.
Gynecol., 1990, 163, 981.
[13] Lim W.S., Macfarlane J.T., Colthorpe C.L.: Pneumonia and pregnancy. Thorax, 2001, 56, 398.
[14] Ramsey P.S., Ramin K.D.: Pneumonia in pregnancy. Obstet.
Gynecol. Clin. North Am., 2001, 28, 553.
[15] World Health Organization. Global tuberculosis control: surveillance, planning, financing WHO report 2007.
[16] Jin S.M., Lee H.J., Park E.A., Lee H.Y., Lee S.M., Yang S.C. et al.:
Frequency and predictors of miliary tuberculosis in patients with
miliary pulmonary nodules in South Korea: a retrospective cohort
study. BMC infectious diseases, 2008, 8, 160.
[17] Good J.T. Jr., Iseman M.D., Davidson P.T., Lakshminarayan S.,
Sahn S.A.: Tuberculosis in association with pregnancy. Am. J.
Obstet. Gynecol., 1981, 140, 492.
[18] Carter E.J., Mates S.: Tuberculosis during pregnancy. The Rhode
Island experience, 1987 to 1991. Chest, 1994, 106, 1466.
[19] Doveren R.F., Block R.: Tuberculosis and pregnancy a provincial study (1990-1996). The Netherlands J. Med., 1998, 52, 100.

S.S. SHIM, M.D.
Department of Radiology
Mokdong Hospital
Ewha Womans University School of Medicine
911-1 Mok-6-dong Yangcheon-gu
Seoul 158-710 (Republic of Korea)
e-mail: sinisim@ewha.ac.kr
17 1211-31 - Serum osteoprotegerin:1648_29 Incidence of multiple 15/11/11 14:32 Pagina 355
[1211/31]
355
Serum osteoprotegerin correlates with age and bone mass

in postmenopausal, but not in fertile age women
G. Mainini, M. Incoronato, L. Urso, C. Scaffa
Fondazione IRCCS SDN, Naples (Italy)
Summary
Purpose of investigation: Osteoprotegerin (OPG) and receptor activator of nuclear factor B ligand (RANKL) are bone turnover
modulators expressed by osteoblasts. The aim of this study was to assess the relationship between the circulating OPG/RANKL
system, age and bone mass, in fertile age and postmenopausal women. Methods: In this cross-sectional observational study on 48
patients (fertile age, n = 22; postmenopause, n = 26), we investigated the correlation between serum OPG and RANKL, age and
bone mineral density (BMD). Serum concentrations of OPG and RANKL were determined by enzyme-linked immunosorbent assay
(ELISA); estimate BMD evaluation was performed with heel quantitative ultrasonometry (QUS). Results: Serum OPG significantly
increased (p = 0.003) and serum RANKL significantly decreased (p = 0.002), in the postmenopausal group compared to fertile age
women. A significant correlation of serum OPG with age (rs = 0.39, p = 0.047) and BMD (rs = 0.45, p = 0.023) in postmenopausal
women, and between RANKL and BMD (rs = 0.48, p = 0.024) in fertile age was found. Conclusion: These data demonstrate in
vivo that the OPG/RANKL system is significantly associated with menopausal status and could play a role in postmenopausal osteoporosis.
Key words: Osteoprotegerin; RANKL; Menopause; Osteoporosis.
Introduction
The decrease in estrogen circulating levels during
menopausal hormonal switch represents the most important cause of bone loss, with a predominance of osteoclast mediated resorption and high incidence of osteoporosis [1, 2].
The bone mass balance is under estrogen influence
because of double activity: one, direct, mediated by
receptors present on the bone cell [3-5], the other, indirect and delayed, modulating calcium metabolism at the
level of the intestine, kidneys and parathyroids [6]. Nevertheless, estrogens prevent bone loss also by regulating
several cytokines that modulate osteoclastic bone resorption, including interleukin-1 (IL-1), interleukin-6 (IL6), osteoprotegerin (OPG), and receptor activator of
nuclear factor B (RANK) ligand (RANKL) by cells of
osteoblastic lineage [7].
OPG is a soluble glycoprotein, expressed by osteoblasts,
that acts as a decoy receptor for RANKL blocking the
process of osteoclast differentiation and modulating the
apoptosis process in these cells; moreover, OPG is a negative regulator of osteoclast mediated bone resorption [8, 9].
The role of the OPG/RANKL system in physiological
bone remodelling has been well characterised [10-12], and
in vitro and in vivo studies have demonstrated that estrogens and raloxifene prevent bone loss also by stimulating
OPG production by osteoblasts [4, 5, 13, 14]. On the other
hand, the most recent literature review reports conflicting
results on the correlation of serum levels of OPG and
RANKL with age, menopausal status and bone mineral
density (BMD) [15-17].

XXXVIII, n. 4, 2011
The aim of this study was to assess the relationship, if

one exists, between serum OPG and RANKL levels, age
and bone mass in fertile age and postmenopausal women
to have a better definition of the role of the OPG/RANKL
system in postmenopausal osteoporosis.
Patients and Methods
Study groups. A cohort of consecutive women (n = 48)
referred to the Fondazione IRCCS SDN of Naples were
enrolled for this cross-sectional study and divided into two
groups: group F (fertile age women, n = 22), group M (postmenopausal women, n = 26).
The patients were selected according to the following inclusion criteria: age 30 years for group F, clinical and hormonal
diagnosis of postmenopause for group M (serum estradiol levels
< 110 pmol/l, serum FSH levels > 30 IU/l). Exclusion criteria
were: body mass index (BMI) 30, bone disorders except
osteoporosis, use of hormone replacement therapy (HRT) or
other bone-active agents less than six months before enrollment.
Biochemical measurements. Serum levels of OPG and
RANKL and BMD were measured on the entire study population. OPG/RANKL ratio was also calculated.
Serum OPG and RANKL evaluation was performed with a
blood sample obtained by venipuncture, immediately separated
and stored at 20C. Serum levels were measured by enzymelinked immunosorbent assay (ELISA) as pmol/l (Human Osteoprotegerin ELISA, Human sRANKL ELISA; Biovendor, Brno,
Czech Republic): detection limit 0.13 pmol/l, intra- and interassay coefficients of variation (CVs) 4.5% and 5.5%, respectively,
for OPG; detection limit 0.2 pmol/l, intra- and interassay CVs
8.70% and 9.19%, respectively, for RANKL.
BMD estimate was performed with a heel quantitative ultrasonometry (QUS) (Sahara; Hologic, Bedford, USA) measured
on the nondominant foot. Ultrasound frequency of 0.6 MHz was
used to measure estimated BMD as g/cm2 and speed of sound
(SoS) as m/s: CVs 3% for BMD (absolute precision 0.014
g/cm2) and 0.22% for SoS (absolute precision 3.4 m/s).
356
Statistical analysis. All values are depicted as the mean

values standard deviation (SD). Due to the nonparametric data
and small population, the statistical significance was calculated
by the Mann-Whitney test and the correlation analysis was performed using the Spearman correlation test (coefficient rs). The
value p < 0.05 was regarded as significant.
Results
The mean age in group F was 43.3 7.2 years and the
BMI 25.4 4.5 kg/m2; in group M, the mean age was
60.6 6.7 years and the BMI 28.0 3.6 kg/m2 (p < 0.05).
Serum levels of OPG and RANKL achieved the detection level in all assays with the following mean values:
serum OPG was 3.66 1.57 pmo/l in group F and significantly increased to 4.60 1.19 pmo/l in group M (p =
0.003); serum RANKL was 317.07 177.64 pmo/l in
group F and significantly decreased to 181.78 88.41
pmo/l in group M (p = 0.002). Concerning bone assessment, the QUS estimated BMD was 0.555 0.127 g/cm2
and 0.449 0.135 g/cm2 in group F and M, respectively
(p = 0.002). A complete description of characteristics of
the subjects and clinical findings was reported in Table 1.
Correlations between OPG and RANKL serum levels,
age and BMD are fully reported in Tables 2 and 3: a significant correlation of serum OPG with age (rs = 0.39, p
= 0.047) and BMD (r s = 0.45, p = 0.023) in postmenopausal women (Figures 1 and 2), and between
RANKL and BMD (rs = 0.48, p = 0.024) in fertile age
was found. No other significance was achieved in the correlation between circulating OPG and RANKL, age and
BMD in the two study groups (Tables 2-3).
Table 1. Characteristics of the subjects and clinical findings

by study group (mean S.D.).
Group F
(n = 22)
Ages (year)
43.3 7.2
25.4 4.5
BMI (kg/m2)
Age of menopause (years)
Duration of menopause (years)
Serum OPG (pmol/l)

3.66 1.57
Serum RANKL (pmol/l)
317.07 177.64
OPG / RANKL Ratio
0.015 0.010
2
QUS estimate BMD (g/cm ) 0.555 0.127
QUS SoS (m/s)
1556.1 36.5
Group M
(n = 26)
p
value
60.6 6.7
28.0 3.6
49.2 3.8
11.5 8.8
4.60 1.19
181.78 88.41
0.033 0.026
0.449 0.135
1528.0 34.1
< 0.001
0.012
0.003
0.002
< 0.001
0.002
0.002
BMI, body mass index; OPG, osteoprotegerin; RANKL, receptor activator of nuclear
factor B ligand; QUS, quantitative ultrasonometry; BMD, bone mineral density; SoS,
speed of sound.
Table 2. Spearman correlation between OPG and RANKL

serum levels and age by study group.
Group F
(n = 22)
r
p
value
value
Serum OPG
Serum RANKL
OPG / RANKL ratio
+0.31
0.07
+0.21
0.159
0.766
0.340
Group M
(n = 26)
r
value
p
value
+0.39
0.00
+0.17
0.047
0.995
0.395
OPG, osteoprotegerin; RANKL, receptor activator of nuclear factor B ligand.
Table 3. Spearman correlation between OPG and RANKL

serum levels and estimate BMD by study group.
Group F
(n = 22)
r
p
value
value
Serum OPG
Serum RANKL
OPG / RANKL ratio
+0.10
+0.48
0.32
0.658
0.024
0.146
Group M
(n = 26)
r
value
p
value
+0.45
+0.13
+0.09
0.023
0.522
0.649
OPG, osteoprotegerin; RANKL, receptor activator of nuclear factor B ligand;

QUS, quantitative ultrasonometry; BMD, bone mineral density.
Discussion
An increase in active osteoclast pool size, with
increased bone resorption and decreased bone mass,
occurs in many osteopathic disorders, including postmenopausal osteoporosis. Estrogen decrease of
menopausal transition inhibits mature osteoblasts and
osteocytes and promotes osteoblastic apoptosis [18].
Moreover, this hormonal deficit interferes with osteoclastic lineage increasing its recruitment and activation due to
the stimulation of osteoblast cytokines release: IL-1, IL6, TNF- [19, 20]. Interference of osteoclastic activity
acts also through a reduction of TGF- and OPG production, and the identification in the mid to late 1990s of the
OPG/RANKL system clarified the role played by
osteoblasts in osteoclastogenesis [21-26].
The importance of OPG in bone metabolism is suggested by the positive correlation between gene production of OPG [9] and bone mass increase in animal models
[1, 27]. In humans, OPG seems to be implicated in the
pathogenesis of postmenopausal osteoporosis [28] and
other metabolic diseases characterized by bone loss [29],
but the link between OPG levels, menopausal status and
BMD is still under debate.
There is general agreement that OPG levels increase
after menopause [10, 30-34], even if other studies showed
no significant differences among premenopausal, postmenopausal, or estrogen-replete postmenopausal women

[35].
Some authors state that circulating OPG levels reflect
the antiresorptive activity in bone [10], and serum OPG
levels have been found to be positively related to BMD
and negatively related with bone resorption in postmenopausal women [32, 36, 37], even if increases in conditions of postmenopausal osteoporosis have been
reported with a negative correlation to BMD [28, 30, 33,
38, 39]; unrelated to BMD for other authors [31, 40]. In
382 healthy postmenopausal women, circulating levels of
OPG were significantly associated with age, and, at multivariate analysis, age and OPG were the independent
determinants for BMD [41]. In a population-based study
of 2,134 women, BMD was negatively associated with
OPG at baseline, and in postmenopausal women not on
hormone replacement therapy, bone loss increased with
increasing OPG, whereas no relationship was found in
men, premenopausal women, or postmenopausal women
on HRT [39].
Serum RANKL levels have also been investigated in
postmenopausal women and reported not to be associated
with menopausal status, HRT or BMD [32, 35, 42].
Serum osteoprotegerin correlates with age and bone mass in postmenopausal, but not in fertile age women
357
Fig. 1
Fig. 2
Age (yrs)
Figure 1. Spearman correlation between OPG serum levels and age in the postmenopausal group (n = 26).
Figure 2. Spearman correlation between OPG serum levels and estimate BMD in the postmenopausal group (n = 26).
These contradictory findings may relate to differences

in study design, methodology, or other aspects influencing the measurements of these factors. Moreover, circulating OPG levels are dependent on several factors and
paracrine mechanisms involved in osteoporosis genesis
and on non-skeletal sources [19, 30, 43].
In our experience, the comparison of a postmenopausal
group with a control group of fertile age women showed
a significant variation in OPG (increase) and RANKL
(decrease) serum levels (p = 0.003 and p = 0.002, respectively), according to other evidence [10, 30, 34] and to the
hypothesis that elevation of serum OPG along with age
might be a compensatory mechanism against accelerated
bone resorption, while decreased levels of serum RANKL
might be helpful for restoring reduced bone formation
[44]. Moreover, our data revealed a significant correlation
of serum OPG with age (p = 0.047) and BMD (p = 0.023)
in postmenopausal women, and between RANKL and
BMD (p = 0.024) in fertile age, while no other significance was achieved in the correlation between circulating
OPG and RANKL, age and BMD in either study group.
Then, although limited by a small population, this comparative study shows that serum OPG correlates with age
and bone mass in postmenopausal women compared to
the fertile age group; these findings are in accord with
other studies about correlation with age [10, 30, 43, 45]
and BMD [32, 36, 37], although in other experiences a
significant association between serum OPG and bone
mass was not found [30, 43, 45].
BMD has been measured with an ultrasound method,
heel QUS measured on the nondominant foot [46-49], not
considered as the gold standard in the diagnosis of postmenopausal osteoporosis, but able to estimate bone
density decreases and predict the risk of fractures in
respect to the conventional DXA technique [50-55].
Conclusion
In conclusion, our results confirm the hypothesis that
the OPG/RANKL system plays a role in bone resorption
and menopausal status probably modulates this role. In
particular, these findings might improve the definition of

the role of OPG/RANKL system in postmenopausal
osteoporosis, opening a therapeutic awareness and application of OPG-modulating drugs [56]: OPG-inducing
drugs, as estrogens [57], raloxifene [14], bisphosphonates
[58], strontium ranelate [59], teriparatide [60]; OPGmimicking drugs (anti-RANKL drugs), as recombinant
OPG [61] and monoclonal antibody denosumab [62].
References
[1] Luisetto G., Zangari M., Tizian L., Nardi A., Ramazzina E., Adami
S. et al.: Influence of aging and menopause in determining vertebral and distal forearm bone loss in adult healthy women. Bone
Miner., 1993, 22, 9.
[2] Riggs B.L., Khosla S., Atkinson E.J., Dunstan C.R., Melton L.J.
III: Evidence that type I osteoporosis results from enhanced
responsiveness of bone to estrogen deficiency. Osteoporos Int.,
2003, 14, 728.
[3] Bord S., Ireland D.C., Beavan S.R., Compston J.E.: The effects
of estrogen on osteoprotegerin, RANKL, and estrogen receptor
expression in human osteoblasts. Bone, 2003, 32, 136.
[4] Viereck V., Grndker C., Blaschke S., Niederkleine B., Siggelkow
H., Frosch K.H. et al.: Raloxifene concurrently stimulates osteoprotegerin and inhibits interleukin-6 production by human trabecular osteoblasts. J. Clin. Endocrinol. Metab., 2003, 88, 4206.
[5] Taranta A., Brama M., Teti A., De Luca V., Scandurra R., Spera G.
et al.: The selective estrogen receptor modulator raloxifene regulates osteoclast and osteoblast activity in vitro. Bone, 2002, 30,
368.
[6] Oleksik A.M., Duong T., Pliester N., Asma G., Popp-Snijders C.,
Lips P.: Effects of the selective estrogen receptor modulator,
raloxifene on the somatotropic axis insulin-glucose homeostasis.
J. Clin. Endocrinol. Metab., 2001, 86, 2763.
[7] Compston J.E.: Sex steroids and bone. Physiol. Rev., 2001, 81,
419.
[8] Cheung J., Mak Y.T., Papaioannoul S., Evans B.A.J., Fogelman I.,
Hampson G.: Interleukin-6 (IL-6), IL-1, receptor activator of
nuclear factor kB ligand (RANKL) and osteoprotegerin production by human osteoblastic cells: comparison of the effects of
17beta-oestradiol and raloxifene. J. Endocrinol., 2003, 177, 423.
[9] Liao E.Y., Luo X.H., Su X.: Comparison of the effects of 17betaE2 and progesterone on the expression of osteoprotegerin in
normal human osteoblast-like cells. J. Endocrinol. Invest., 2002,
25, 785.
[10] Oh K.W., Rhee E.J., Lee W.Y., Kim S.W., Oh E.S., Baek K.H. et
al.: The relationship between circulating osteoprotegerin levels
and bone mineral metabolism in healthy women. Clin.
Endocrinol. (Oxf.), 2004, 61, 244.
358
[11] Hofbauer L.C., Kuhne C.A., Viereck V.: The

OPG/RANKL/RANK system in metabolic bone diseases. J. Musculoskelet Neuronal Interact., 2004, 4, 268.
[12] Theoleyre S., Wittrant Y., Tat S.K., Fortun Y., Redini F., Heymann
D.: The molecular triad OPG/RANK/RANKL: involvement in
the orchestration of pathophysiological bone remodeling.
Cytokine Growth Factor Rev., 2004, 15, 457.
[13] Bashir A., Mak Y.T., Sankaralingam S., Cheung J., McGowan
N.W., Grigoriadis A.E. et al.: Changes in RANKL/OPG/RANK
gene expression in peripheral mononuclear cells following treatment with estrogen or raloxifene. Steroids, 2005, 70, 847.
[14] Messalli E.M., Mainini G., Scaffa C., Cafiero A., Cobellis L.,
Salzillo P.L. et al.: Raloxifene therapy interacts with serum
osteoprotegerin in postmenopausal women. Maturitas, 2007, 56,
38.
[15] Reid P., Holen I.: Pathophysiological roles of osteoprotegerin
(OPG). Eur. J. Cell. Biol., 2009, 88, 1.
[16] Kostenuik P.J.: Osteoprotegerin and RANKL regulate bone
resorption, density, geometry and strength. Curr. Opin. Pharmacol., 2005, 5, 618.
[17] Kearns A.E., Khosla S., Kostenuik P.J.: Receptor activator of
nuclear factor kB ligand and osteoprotegerin regulation of bone
remodeling in health and disease. Endocr. Rev., 2008, 29, 155.
[18] Xing L., Boyce B.F.: Regulation of apoptosis in osteoclasts and
osteoblastic cells. Biochem. Biophys. Res. Commun., 2005, 328,
709.
[19] Koka S., Petro T.M., Reinhardt R.A.: Estrogen inhibits interleukin-1 beta-induced interleukin-6 production by human
osteoblastlike cells. J. Interferon Cytokine Res., 1998, 18, 479.
[20] Secreto F.J., Grover A., Pacurari M., Rice M.B., Kantorow M.,
Bidwai A.P. et al.: Estrogen potentiates the combined effects of
transforming growth factor-beta and tumor necrosis factor-alfa on
adult human osteoblastlike cell prostaglandin E2 biosynthesis.
Calcif. Tissue Int., 2003, 73, 565.
[21] Lacey D.L., Timms E., Tan H.L., Kelley M.J., Dunstan C.R.,
Burgess T. et al.: Osteoprotegerin ligand is a cytokine that regulates osteoclast differentiation and activation. Cell, 1998, 93, 165.
[22] Hsu H, Lacey DL, Dunstan CR, Solovyev I, Colombero A, Timms
E, et al.: Tumor necrosis factor receptor family member RANK
mediates osteoclast differentiation and activation induced by
osteoprotegerin ligand. Proc. Natl. Acad. Sci USA, 1999, 96,
3540.
[23] Simonet W.S., Lacey D.L., Dunstan C.R., Kelley M., Chang M.S.,
Lthy R. et al.: Osteoprotegerin: a novel secreted protein
involved in the regulation of bone density. Cell, 1997, 89, 309.
[24] Li J., Sarosi I., Yan X.Q., Morony S., Capparelli C., Tan H.L. et
al.: RANK is the intrinsic hematopoietic cell surface receptor
that controls osteoclastogenesis and regulation of bone mass and
calcium metabolism. Proc. Natl. Acad. Sci USA, 2000, 97, 1566.
[25] Wada T., Nakashima T., Hiroshi N., Penninger J.M.: RANKLRANK signaling in osteoclastogenesis and bone disease. Trends
Mol. Med., 2006, 12, 17.
[26] Vega D., Maalouf N.M., Sakhaee K.: Clinical review: the role of
receptor activator of nuclear factor-kappaB (RANK)/RANK
ligand/osteoprotegerin: clinical implications. J. Clin. Endocrinol.
Metab., 2007, 92, 4514.
[27] Mizuno A., Amizuka N., Irie K., Murakami A., Fujise N., Kanno
T. et al.: Severe osteoporosis in mice lacking osteoclastogenesis
inhibitory factor/osteoprotegerin. Biochem. Biophys. Res.
Commun., 1998, 247, 610.
[28] Yano K., Tsuda E., Washida N., Kobayashi F., Goto M., Harada A.
et al.: Immunological characterization of circulating osteoprotegerin/osteoclastogenesis inhibitory factor: increased serum concentrations in postmenopausal women with osteoporosis. J. Bone
Miner Res., 1999, 14, 518.
[29] Ueland T., Bollerslev J., Godang K., Muller F., Froland S.S.,
Aukrust P.: Increased serum osteoprotegerin in disorders characterized by persistent immune activation or glucocorticoid excesspossible role in bone homeostasis. Eur. J. Endocrinol., 2001,
145, 685.
[30] Kudlacek S., Schneider B., Woloszczuk W., Pietschmann P.,
Willvonseder R., Austrian Study Group on Normative Values of
Bone Metabolism: Serum levels of osteoprotegerin increase with
age in healthy adult population. Bone, 2003, 32, 681.
[31] Khosla S., Arrighi H.M., Melton L., Atkinson E.J., OFallon
W.M., Dunstan C. et al.: Correlates of osteoprotegerin levels in
women and men. Osteoporos Int., 2002, 13, 394.
[32] Mezquita-Raya P., de la Higuera M., Garca D.F., Alonso G., RuizRequena M.E., de Dios L.J. et al.: The contribution of serum
osteoprotegerin to bone mass and vertebral fractures in postmenopausal women. Osteoporos. Int., 2005, 16, 1368.
[33] Trofimov S., Pantsulaia I., Kobyliansky E., Livshits G.: Circulating levels of receptor activator of nuclear factor-kB ligand/osteoprotegerin/macrophage-colony stimulating factor in a presumably
healthy human population. Eur. J. Endocrinol., 2004, 150, 305.
[34] Mazziotti G., Sorvillo F., Piscopo M., Cioffi M., Pilla P., Biondi B.
et al.: Recombinant human TSH modulates in vivo C-telopeptides
of type-1 collagen and bone alkaline phosphatase, but not osteoprotegerin production in postmenopausal women monitored for differentiated thyroid carcinoma. J. Bone Miner. Res., 2005, 20, 480.
[35] Eghbali-Fatourechi G., Khosla S., Sanyal A., Boyle W.J., Lacey
D.L., Riggs B.L.: Role of RANK ligand in mediating increased
bone resorption in early postmenopausal women. J. Clin. Invest.,
2003, 111, 1221.
[36] Rogers A., Saleh G., Hannon R.A., Greenfield D., Eastell R.: Circulating estradiol and osteoprotegerin as determinants of bone
turnover and bone density in postmenopausal women. J. Clin.
Endocrinol. Metab., 2002, 87, 4470.
[37] Fahrleitner-Pammer A., Dobnig H., Piswanger-Soelkner C.,
Bonelli C., Dimai H.P., Leb G. et al.: Osteoprotegerin serum
levels in women: correlation with age, bone mass, bone turnover
and fracture status. Wien Klin Wochenschr., 2003, 115, 291.
[38] Abrahamsen B., Hjelmborg J., Kostenuik P.J., Stilgren L.S., Kyvik
K., Adamu S. et al.: Circulating amounts of osteoprotegerin and
RANK ligand: Genetic influence and relationship with BMD
assessed in female twins. Bone, 2005, 36, 727.
[39] Jrgensen L., Vik A., Emaus N., Brox J., Hansen J.B., Mathiesen
E. et al.: Bone loss in relation to serum levels of osteoprotegerin
and nuclear factor-kappaB ligand: the Troms Study. Osteoporos. Int., 2010, 21, 931.
[40] Indridason O.S., Franzson L., Sigurdsson G.: Serum osteoprotegerin and its relationship with bone mineral density and markers
of bone turnover. Osteoporos. Int., 2005, 16, 417.
[41] Nabipour I., Larijani B., Vahdat K., Assadi M., Jafari S.M., Ahmadi
E. et al.: Relationships among serum receptor of nuclear factorkappaB ligand, osteoprotegerin, high-sensitivity C-reactive protein,
and bone mineral density in postmenopausal women: osteoimmunity versus osteoinflammatory. Menopause, 2009, 16, 950.
[42] Schett G., Kiechl S., Redlich K., Oberhollenzer F., Weger S.,
Egger G. et al.: Soluble RANKL and risk of nontraumatic fracture. JAMA, 2004, 291, 1108.
[43] Han K.O., Choi J.T., Choi H.A., Moon I.G., Yim C.H., Park W.K.
et al.: The changes in circulating osteoprotegerin after hormone
therapy in postmenopausal women and their relationship with
oestrogen responsiveness on bone. Clin. Endocrinol. (Oxf.),
2005, 62, 349.
[44] Liu J.M., Zhao H.Y., Ning G., Zhao Y.J., Chen Y., Zhang L.Z. et
al.: The relationships between changes of serum osteoprotegerin,
nuclear factor-kappa B ligand receptor activator, and age,
menopause, bone biochemical markers and bone mineral densities
in women aged 20-75. Zhonghua Nei Ke Za Zhi, 2004, 43, 447.
[45] Uemura H., Yasui T., Miyatani Y., Yamada M., Hiyoshi M.,
Arisawa K. et al.: Circulating profile of osteoprotegerin and
soluble receptor activator of nuclear factor B ligand in postmenopausal women. J. Endocrinol. Invest., 2008, 31, 163.
[46] Langton C.M., Langton D.K.: Male and female reference data for
ultrasound measurement of the calcaneus within the UK adult population. Br. J. Radiol., 1997, 70, 580.
[47] Ingle B.M., Sherwood K.E., Eastell R.: Comparison of two
methods for measuring ultrasound properties of the heel in postmenopausal women. Osteoporos. Int., 2001, 12, 500.
[48] Hans D., Rizzoli R., Thiebaud D., Lippuner K., Allaoua S., Genton
L. et al.: Reference data in a Swiss population. J. Clin. Densitom., 2001, 4, 291.
[49] Louis O., Kaufman L., Osteaux M.: Quantitative ultrasound of
the calcaneus with parametric imaging: correlation with bone
mineral density at different sites and with anthropometric data in
menopausal women. Eur. J. Radiol., 2000, 35, 65.
Serum osteoprotegerin correlates with age and bone mass in postmenopausal, but not in fertile age women
[50] Von Stetten E., Ouellet H., Wilson K., Steiger P., Stein J.A.:
European caucasian female reference values for the Sahara clinical bone sonometer. Bedford (USA), Hologic Inc., 1998.
[51] Ponteggia L., Di Cato M., Ponteggia F., Pica M., Puxeddu A.,
Coaccioli S.: Evaluation of the peak bone mass by quantitative
heel ultrasound in young women of the centre of Italy. Reumatismo, 2003, 55, 34.
[52] He Y.Q., Fan B., Hans D., Li J., Wu C.Y., Njeh C.F. et al.: Assessment of a new quantitative ultrasound calcaneus measurement:
precision and discrimination of hip fractures in elderly women
compared with dual X-ray absorptiometry. Osteoporos. Int.,
2000, 11, 354.
[53] Gler C.C.: Quantitative ultrasound techniques for the assessment of osteoporosis: expert agreement on current status. J. Bone
Miner. Res., 1997, 12, 1280.
[54] Adami S., Bertoldo F., Brandi M.L., Cepollaro C., Filipponi P.,
Fiore E. et al.: Guidelines for the diagnosis, prevention and treatment of osteoporosis. Reumatismo, 2009, 61, 260.
[55] Cummings S.R., Bates D., Black D.M.: Clinical use of bone densitometry: scientific review. JAMA, 2002, 288, 1889.
[56] Messalli E.M., Scaffa C.: New perspectives in the management
of osteoporosis: the OPG/RANK/RANKL system. In: Mattingly
B.E., Pillare A.C. (eds.), Osteoporosis: Etiology, Diagnosis and
Treatment; New York (USA), Nova Science Publishers Inc., 2009,
143.
[57] Kim J.G., Kim J.H., Lee D.O., Kim H., Kim J.Y., Suh C.S. et al.:
Changes in the serum levels of osteoprotegerin and soluble receptor activator for nuclear factor kappaB ligand after estrogenprogestogen therapy and their relationships with changes in bone
mass in postmenopausal women. Menopause, 2008, 15, 357.
359
[58] Reyes-Garca R., Muoz-Torres M., Garca D.F., Mezquita-Raya

P., Garca Salcedo J.A., de Dios Luna J.: Effects of alendronate
treatment on serum levels of osteoprotegerin and total receptor
activator of nuclear factor kappaB in women with postmenopausal
osteoporosis. Menopause, 2010, 17, 140.
[59] Brennan T.C., Rybchyn M.S., Green W., Atwa S., Conigrave A.D.,
Mason R.S.: Osteoblasts play key roles in the mechanisms of
action of strontium ranelate. Br. J. Pharmacol., 2009, 157, 1291.
[60] Anastasilakis A.D., Goulis D.G., Polyzos S.A., Gerou S., Pavlidou
V., Koukoulis G. et al.: Acute changes in serum osteoprotegerin
and receptor activator for nuclear factor-kappaB ligand levels in
women with established osteoporosis treated with teriparatide.
Eur. J. Endocrinol., 2008, 158, 411.
[61] Bekker P.J., Holloway D., Nakanishi A., Arrighi M., Leese P.T.,
Dunstan C.R.: The effect of a single dose of osteoprotegerin in
postmenopausal women. J. Bone Miner. Res., 2001, 16, 348.
[62] McClung M.R., Lewiecki E.M., Cohen S.B., Bolognese M.A.,
Woodson G.C., Moffett A.H. et al.: AMG 162 Bone Loss Study
Group. Denosumab in postmenopausal women with low bone
mineral density. N. Engl. J. Med., 2006, 354, 821.

G. MAININI, Ph.D., M.D.
Via Diaz, 77
80055 Portici, Naples (Italy)
e-mail: giampaolomainini@libero.it
18 1176-30 - Clinical effects of :1648_29 Incidence of multiple 15/11/11 14:36 Pagina 360
[789/27]
[1176/30]
360
Clinical effects of transvaginal vesicovaginal fistula repair

surgery mediated by the Foley catheter (64 cases)
L. Bing-shu, H. Li, W. Qin, H. Min, C. Yan-xiang
Department of Obstetrics and Gynecology, Renmin HospitalWuhan University, Wuhan, Hubei (China)
Summary
Objective: To investigate the clinical effects and superiority of transvaginal vesicovaginal fistula (VVF) repair surgery mediated by
the Foley catheter. Patients and Methods: We retrospectively reviewed the case notes of 129 patients with vesicovaginal fistulas who
received surgery in our hospital; 68 patients received VVF repair surgery mediated by the Foley catheter (modified group), and 61
patients received traditional transvaginal VVF repair surgery (traditional group). Results: The success rate of the primary operation,
mean operation time, mean intraoperative blood loss, mean postoperative hospitalization time, and rate of patients with postoperative
urine leakage were significantly different between the modified group and traditional group. However, the mean bladder capacity, postoperative recovery time of self-miction, and postoperative wound infection rate were not significantly different between the groups.
Conclusions: Transvaginal VVF repair surgery mediated by the Foley catheter had a higher success rate, shorter operation time, less
blood loss and sooner recovery time postoperatively. Therefore, it should be applied in clinics generally.
Key words: Vesicovaginal; Urinary fistula; Foley catheter.
Introduction
Vesicovaginal fistula (VVF) is the most common urogenital fistula; once one is diagnosed almost all patients
must undergo surgery. Despite the advances in medical
care, VVF continues to be a distressful problem, particularly in some poor and undeveloped countries that do not
have adequate obstetric assistance. Nonetheless, urogenital fistula is a worldwide problem even in wealthy countries where it is mainly related to hysterectomy [1]. With
the develepment of urogenital fistula repair surgery, the
success rate has been improved, but the failture rate
remains as high as 15% or more [2]. The high failure rate
is the main problem in treating urogenital fistula, therefore improving the success rate of surgery is critical. We
have been carrying out VVF repair surgery mediated by
the Foley catheter based on the traditional transvaginal
VVF repair surgery in our hospital since 2002. The Foley
catheter is used so masterly that it expands the operative
view and improves the success rate of surgery. Therefore,
it should be applied in clinics generally.
Clinical data
We retrospectively evaluated cases and follow-up data of 129
patients with VVF in our hospital between January 2002 and
November 2009. Out of the 129 patients, 68 patients were
treated by VVF repair surgery mediated by the Foley catheter
(modified group). The mean age of the patients with urogenital
fistulae was 41 12 (range 25 to 70 years). The etiology of
cases was as follows: 22 cases were secondary to uterine cervix
cancer radical correction, ten cases received ovarian cancer

XXXVIII, n. 4, 2011
cytoreductive surgery, 16 cases had total abdominal hysterectomy, eight cases underwent vaginal hysterectomy, eight cases
had cesarean section, three cases were due to dystocia, and one
case had an abortion; the diameter of the fistula was less than 3
cm. In 11 cases the diameter of the fistulae was more than 2 cm
while duration of the fistula varied from three months to 35
months (median 24 months). Out of the 129 patients, 61 patients
were treated by traditional transvaginal VVF repair surgery (traditional group). The mean age of the patients with urogenital
fistulae was 42 12 (range 26 to 72 years). Twenty cases were
secondary to uterine cervix cancer radical correction, six cases
underwent ovarian cancer cytoreductive surgery, 16 cases had
total abdominal hysterectomy, eight cases had vaginal hysterectomy, eight cases had cesarean section, two cases were due to
dystocia, and one case was because of trauma; the diameter of the
fistula was less than 3 cm, the number of fistulae was > 2 in 11
cases, and the duration of the fistulae varied from three months
to 31 years (median 21 months). None of the patients were suffering from diabetes, hypertension or other chronic diseases that
may have influenced wound healing, and all of them underwent
surgery for the first time.
Self-miction, urine leakage and bladder capacity of the
patients were followed-up in the outpatient department or inpatient department at one month, three months and 12 months
after surgery. Although four cases in the modified group could
not be followed-up, the follow-up rate was 94.12% (64/68);
three patients in the traditional group could not be followed-up,
thus the follow-up rate was 95.08% (58/61).
The diagnosis and exclusion standard of VVF: all patients
were evaluated by medical history, the time and clinical situation of leaking urine, gynecological examination and physical
examination (including bladder filling with methylene blue to
demonstrate the fistula tract). If the patient had the typical clinical situation of leakage or the fistula could be found by vaginal
examination, it could be diagnosed. If it was difficult to be diagnosed, the following auxiliary examinations were done: urinalysis, ureteral examination, voiding cystouretrography, intravenous urography (IVU), cystoscopy and nephrogram.
Success outcomes of surgery included healing of the postoperative fistulae negative methylene blue test after removal of the
Clinical effects of transvaginal vesicovaginal fistula repair surgery mediated by the Foley catheter (64 cases)
bladder catheter and disappearance of urine leakage. Bladder

storage, voiding function and urodynamic examination were in
the normal range after follow-up of three to six months.
Operation method
The vaginal fistula repair surgery mediated by Foley catheter
The patient was operated in the dorsal lithotomic position
after epidural anesthesia. Diluted methylene blue solution (250300 ml) was injected via a catheter. A Foley catheter was
inserted into the bladder through the vaginal fistula (if the
fistula was too small to be inserted with the Foley catheter,
blood vessel forceps were used to enlarge the fistula under the
guidance of methylene blue stain and exploring needle). Gas (2
ml) was inserted so that the erocyst could be filled in the
bladder, dragging the Foley catheter slightly outward to press
and expose the fistula more clearly, which also could support
the bladder wall near the fistula to implement the next procedure. A cystoscope was used to observe the bladder shape,
fistula size, location and number, to judge whether there were
vesical calculus, surrounding tissue scar formation and the
neighboring anatomical relationship, especially the ureteral
orifice situation. The vaginal wall surrounding the edge of the
fistula was cut (about 0.2-0.3 cm) with a small sickle knife dissociating the vaginal wall outside about 0.3-0.5 cm, removing
the old fistula scar tissue (including the bladder and vaginal
tissue and even previous sutures). Continuous half purse-string
sutures for the bladder fascia and muscle above and under the
fistula with 0/3 absorbable catgut were done. After deflation the
Foley catheter was dragged outside and a knot was tied between
the over and under thread.
Traditional transvaginal vesicovaginal fistula repair surgery [3]
361
Table 1. Patient characteristics in the two groups (n = 129).

General health
state
Modified
group
Traditional
group
Age
41 12
42 12
Fistula size
1.68 0.82 1.61 0.80
Single fistula
57
52
Mutiple fistulae
11
9
t value / 2
value
p value
0.551
0.431
0.582
0.667
0.049
0.824
Table 2. Etiology of vesicovaginal in the two different

groups.
Etiology
No. of cases
Ratio (%)
42
32.56%
16
32
16
16
5
1
1
129
12.41%
24.80%
12.41%
12.41%
3.87%
0.77%
0.77%
100.00%
Radical correction
of uterine cervix cancer
Radical correction
of ovarian cancer
Complete hysterectomy
Vaginal hysterectomy
Cesarean section
Dystocia
Artificial abortion
Trauma
Total
Table 3. Comparion of the two different operations (n

=122).
Modified group
Time of
operation (min)
Bleeding
volume (ml)
Traditional group T value
85 8.1
109 23.4
p value
116 19.5 12.51 0.001

175 60.2 8.10
0.001
The method was the same as the above method, except for
using a Foley catheter.
SPSS 13.0 software was used for statistical analysis. Data were
analyzed by the chi-square test and Fishers exact tests, and measurement data were were compared using t tests. Non-normal distribution data were compared using the nonparametric tests; p <
0.05 was considered to indicate statistical significance.
Results
Comparison between the two groups of patients
We did t-testing for age and fistula size of the two
groups, and found that there were no significant differences (Table 1). Chi-square tests for fistula number of the
two patients groups showed that there were also no significant differences between the two groups, as shown in
Table 1. We also did two samples of the rank sum test for
the two groups duration; Wilcoxon W statistic was
3724.000 there was no significant difference between
the two groups duration (p = 0.253).
Etiolgical factors for the VVF
The etiolgical factors for the VVF in this study are
shown in Table 2. The factors of gynecological surgery
(87%) were prominent for most patients, of which radical

correction of the uterine cervix cancer was responsible for
32.56%, radical correction of ovarian cancer was responsible for 12.41%, complete hysterectomy was responsible
for 24.80%, and vaginal hysterectomy was responsible
for 12.41%. The factors for obstetrical surgery (17.05%)
were insignificant, of which cesarean section was responsible for 12.41%, dystocia for 3.87%, artificial abortion
for 0.77%, and trauma was responsible for 0.77%.
Comparion of therapeutic effect
The mean operation time was 85 8.1 min, ranging
from 70 to 100 min. Mean intraoperative blood loss was
109 23.4 ml, ranging from 80 to 150 min in the modified group, but the mean operation time was 116 19.5
min (ranging from 90 to 150 min), and mean intraoperative blood loss was 175 60.2 ml (ranging from 100 to
300 min). There was a significant difference between the
two groups (p < 0.001) (Table 3).
Comparion of hospitalization and recovery are shown
in Table 4. Mean self-miction recovery time of the
patients in the modified group was 10 1.8 days, ranging
from 7 to 14 days. Mean postoperative hospitalization
time was 13 1.8 days, ranging from 10 to 17 days.
362
L. Bing-shu, H. Li, W. Qin, H. Min, C. Yan-xiang
Table 4. Comparion of patient hospitalization and recovery

time (x s, n = 122).
Mean self-urination
recovery time (d)
Mean postoperative
hospitalization time (d)
Rate of urine leakage
Rate of incision infection
Modified
group
Traditional
group
t value / 2
value
p
value
10 1.8
17 2.08
21.30
0.000
13 1.8
3.13%
(2/64)
1.56%
(1/64)
20 2.1
15.52%
(9/58)
8.62%
(4/58)
19.03
4.873
0.000
0.027
1.908
0.167
Table 5. The comparion of the postoperative further

situation (x s, n = 122).
Modified
group
Traditional
group
2
value
Mean bladder capacity (ml) 378 52.6 389 54.4 1.165

Success rate
96.88%
84.48% 5.696
of primary operation
(62/64)
(49/58)
p
value
0.246
0.017
However the mean self-miction recovery time of the

patients in the traditional surgical group was 17 2.1
days, ranging from 14 to 21 days. Mean postoperative
hospitalization time was 20 2.1 days, ranging from 17
to 24 days. There were significant differences between
the two groups (p < 0.001). Two cases could not be operated successfully in the modified group and urine leaking
occurred postoperatively; the rate was 3.13% (2/64).
However, nine cases could not be operated successfully in
the traditional group and had urine leaking postoperatively; the rate was 15.52% (9/64), and there was a significant
difference (p < 0.05). The rate of incision infection was
1.56% (1/64) in the modified group, and the rate of incision infection was 8.62% (4/58), but there was no significant difference.
Comparion of the postoperative period is shown in Table
5. Mean bladder capacity in the modified group was 378
52.6 ml, but it was 389 54.4 ml in the traditional group,
and there were no significant differences. The success rate
of primary surgery in the modified group was 96.88%
(62/64) and it was 84.48% (49/58) in the traditional group,
and there was a significant difference (p < 0.05).
Discussion
Surgery for VVF
If the fistula of the patient is very small without infection, and the surrounding tissue is healthy without ureteral involvement or radiotherapy, it can be treated by an
indwelling catheter or fulguration of the fistulous orifice,
and the patients should receive antibiotics [4, 5]. However
only 2% patients with VVF can be cured [6] with continuous urethral catheterization; four weeks later if the fistula has not closed, it would be impossible to close it [7];
which could improve the life quality of the patients and
prepare them for further surgery.
Most patients should receive surgery that is performed
Figure 1. Illustration of transvaginal vesicovaginal fistula

repair surgery mediated by a Foley catheter.
by abdominal, vaginal, or a combined approach. Raashid

et al. [8] found that whether transabdominal or transvaginal, the success rate of VVF repair surgery was only 87%.
Many factors influence the surgery repair it can be
achieved by the vaginal or abdominal approach and
depends on the surgeons experience as well as local factors like size, location, and previous radiotherapy.
In recent years, several reports have been designed supporting new procedures for vesico-vaginal fistula repair
[9, 10]. With the development of laparoscopic minimally
invasive surgery, we can repair an urogenital fistula using
laparoscopy. Melamud et al. reported that they had done
the first VVF repair by robot-assisted laparoscopy in 2005
[12]. Subsequently, Nabi and Hemal reported they had
completed the first case of vesico-vaginal fistula repair
successfully for the first time by laparoscopy [13].
Laparoscopy not only has the same benefits as traditional transabdominal surgery, but also own the benefit of
less trauma and fewer postoperative complications.
However it was considered so difficult that it could not be
applied clinically in general [13-15].
Most VVF is in the medium or lower position fistula,
and can be repaired by the vaginal approach. The vaginal
approach is minimally invasive with short-term hospitalization, lower costs, more esthetic, fewer complications,
less blood loss and better results [16]. The vaginal
approach also allows a high cure rate, short recovery, and
does not require any sophisticated material. The vaginal
approach could also be avoided through the previous surgical field, and even if it fails, it can be repaired repeatedly. It is welcomed by the women popularly. Thus the vaginal approach is the first choice for all patients with VVF.
Unique innovations of the operation
The difficulty of traditional transvaginal VVF repair
surgery is to accurately label and successfully repair the
Clinical effects of transvaginal vesicovaginal fistula repair surgery mediated by the Foley catheter (64 cases)
fistula. However there is a small operative view, poor

exposure and unclear patch level by the vaginal approach.
It also has the disadvantage that the fistula can not be
dragged down if it is difficult to find the fistula. In addition, inflammation of the tissuse surrounding the fistula
makes the tissue adhere and scar. Thus it is difficult to distinguish the stump hole and fistula. These would make
urogenital fistula repair more difficult and these are the
keys to failure of traditional urogenital fistula repair surgery.
This innovational operation with insertion of a Foley
catheter directly into the bladder via the vaginal
approach, filling gas into the aerocyst to support the fistula in the bladder, can broaden the operation view, clearly
explore the fistula under the direction of a Foley catheter
and exactly and quickly distinguish the fistula and stump
hole. After the aerocyst supports the fistula, it makes the
surrounding tissue maintain a certain tension, and fully
separates the bladder or vaginal tissue surrounding the
fistula. It would allow the organizational structured layers
of the bladder/vagina to be clearer and could be beneficial
by cutting the scar tissue of the bladder or vagina surrounding the fistula hole. It could also ensure the fistula
surrounding tissue blood supply and promote fistula healing. The scar is the key factor to influence the effect of
surgery.
The first surgery is the best time to repair the fistula and
it should be carefully planned and performed to reach the
highest cure rate. This study found that the primary success rate of traditional transvaginal VVF repair was only
84.48% (49/58), which is similar to the literature [1]. The
primary success rate (96.88% vs 84.48%, p < 0.05), mean
operation time (85 8.1 min vs 116 19.5 min, p <
0.001), mean intraoperative blood loss (109 23.4 ml vs
175 60.2 ml, p < 0.001), mean postoperative hospitalization (13 1.8d vs 20 2.1d, p < 0.001), rate of postoperative urine leakage postoperatively (3.13% (2/64) vs
15.52% (9/58), p < 0.05) differed for the modified and
traditional group and these differences were significant.
However, the mean bladder capacity (378 52.6 ml vs
389 54.4 ml), postoperative self-miction recovery time
(10 1.8d vs 17 2.1d), and rate of postoperative wound
infection (1.56% (1/64) vs 8.62% (4/58) between the
modified group and traditional group were not significantly different.
Therefore, the VVF repair surgery mediated by the
Foley catheter has a higher success rate, shorter operation
time, less blood loss and quicker postoperative recovery.
Thus the VVF repair method is superior and should be
363
applied in clinics generally. In addition, we successfully

repaired one case of rectovaginal fistula mediated by the
Foley catheter but whether it could be applied to repair
rectovaginal fistulas needs further study.
References
[1] Mattingly R.F., Thompson J.D.: Te Lindes operative gynecology. Philadelphia, J.B. Lippincott, 1985.
[2] Blaivas J.G., Heritz Z.M., Romanzi L.I.: Early versus late repair
of vesicovaginal fistulas: vaginal and abdominal approaches. J.
Urol., 1995, 153, 1110.
[3] Raz S.: Atlas of Transvaginal Surgery. Philadelphia, WB Saunders, 2002.
[4] Davits R.J., Miranda S.I.: Conservative treatment of vesico
vaginal fistulas by bladder drainage alone. Br. J. Urol., 1991, 68,
155.
[5] Stovski M.D., Ignatoff J.M., Blum M.D., Nanninga J.B., OConnor V.J., Kursh E.D.: Use of eletrocoagulation in the treatment of
vesicovaginal fistulas. J. Urol., 1994, 152, 1443.
[6] Woo H.H., Rosario D.J., Chapple C.R.: The treatment of vesicovaginal fistua. Eur. Urol.,1996, 29, 1.
[7] Chapple C., Turner-Warwick R.: Vesicovaginal fistula. BJU Int.,
2005, 95, 193.
[8] Raashid Y., Tmajeed T., Majeed N., Shahzad N.: Iatrogenic vesicovaginal fistula. J. Coll. Physicians Surg. Pak., 2010, 20, 436.
[9] Hemal A.K., Kolla S.B., Wandhwa P.: Robotic reconstruction for
recent supra-trigonal vesicovaginal fistulas. J. Urol., 2008, 180,
981.
[10] Cohen B.L., Gousse A.E.: Current techniques or vesicovaginal
fistulas repair: surgical pearls to optimize cure rate. Curr. Urol.
Rep., 2007, 8, 413.
[11] Hemal A.K., Kumar R., Nabi G.: Laparoscopic repair of vesicouterine fistula: a point of technique. J. Urol., 2001, 165, 1167.
[12] Melamud O., Elehel L., Turbow B., Shanberg A.: Laparoscopic
vesicovaginal fistula repair with robotic reconstruction. Urology,
2005, 65, 163.
[13] Nabi G., Hemal A.K.: Laparoscopy repair of vesicovaginal fistula
and right nephrectomy for nonfunctioning kidney in a single
session. J. Endourol., 2001, 15, 801.
[14] Nezhat C.H., Nezhat F., Nezhat C., Rottenberg H.: Laparoscopic
repair of vesicovaginal fistula: a case report. Obstet. Gynaecol.,
1994, 83, 899.
[15] Alonso y Gregorio S., Alvarez Maestro M., Cabrera Castillo P.M.,
Hidalgo Togores L., de la Pea Barthel J.J.: Laparoscopic repair
of the vesicovaginal fistula (laparoscopic OConnor repair). Actas
Urol. Esp., 2009, 33, 1133.
[16] Eilber K.S., Kavaler E., Rodrguez L.V., Rosenblum N., Raz S.:
Ten-year experience with transvaginal vesicovaginal fistula repair
using tissue interposition. J. Urol., 2003, 169, 1033.

H. LI, M.D.
Renmin Hospital
Medical College of Wuhan University
Wuhan 430060 (China)
e-mail: hongli66609088@yahoo.com.cn
19 1261-31 - Evaluation of clinical:1648_29 Incidence of multiple 15/11/11 14:38 Pagina 364
[789/27]
[1261/31]
364
Evaluation of clinical and cytogenetic fndings on 1,068

second-trimester amniocenteses in Southeast Turkey
M. Balkan1, H. Akbas1, S. Kalkanli1, M.N. Sakar2, M. Fidanboy1, M.N. Alp1, T. Budak1
1
Department of Medical Biology and Genetics, Medical Faculty, 2Department of Gynecology and Obstetrics
Medical Faculty, University of Dicle, Diyarbakir (Turkey)
Summary
Objective: To investigate the indications of amniocentesis for the detection of chromosomal abnormalities among a sample of
patients in Southeast Turkey. Material and Methods: Between 2004 and 2007, 1,068 second-trimester amniocentesis tests were performed in the Medical Biology and Genetics Department Laboratory at Dicle University. Amniotic fluids were cultured by using
long-term tissue culture for prenatal diagnosis with cytogenetic analysis. The clinical and cytogenetic findings on 1,068 secondtrimester amniocenteses were analyzed. The indications, the proportions of karyotypes according to indications and complications
were summarized. Results: Among the 1,068 amniocentesis cases, the maternal age between 35 and 39 years was the most common
age group (34.5%). Of the clinical indications abnormal maternal serum screening results were the most common indication for
amniocentesis (37.6%). Of 52 cases (4.9%) with detected chromosomal aberrations, 39 were numeric (27 trisomies, 10 sex chromosome aberrations and two triploidies) and 13 were structural (2 reciprocal translocations, 2 Robertsonian translocations and 6
inversions). The highest detection rate of chromosome aberrations was in cases undergoing amniocentesis for abnormal maternal
serum screening combined with abnormal ultrasound (US) findings (8.0%). Conclusion: This study suggests that complementary
measures, such as routine antenatal US and maternal serum screening, should be added to increase the efficiency of genetic amniocentesis. Therefore, the study could be used for the establishment of a database for genetic counseling.
Key words: Amniocentesis; Chromosome aberrations; Genetic counseling; Prenatal diagnosis.
Introduction
Prenatal diagnosis with cytogenetic analysis, such as
chorionic villus sampling, amniocentesis and cordocentesis has been recognized for more than 20 years as a safe
and reliable method for couples at increased risk of
giving birth to a child with a clinically significant chromosomal abnormality [1-4]. Of these methods, amniocentesis for chromosomal abnormalities remains the most
common invasive prenatal diagnostic procedure today [216]. Accurate risk estimates for chromosomal abnormalities are important tools for the physician or obstetrician,
who would need to make referrals to a prenatal genetic
center [9]. The discovery of an abnormality allows the
option of termination or, later in the pregnancy, more
suitable obstetric management [8].
The most common indications for prenatal diagnosis
with cytogenetic analysis include advanced maternal age
(AMA), abnormal biochemical markers in the maternal
serum, previous chromosomal abnormality and prenatal
structural rearrangements [5-8, 10-15]. This study investigated the indications for amniocentesis for the detection
of chromosomal abnormalities among a sample of
patients in Southeast Turkey. Between 2004 and 2007,
1,068 amniocentesis tests were performed in the Medical
Biology and Genetic Department Laboratory of Dicle
University.
Revised manuscript accepted for publication May 31, 2011

XXXVIII, n. 4, 2011

Study setting and population
The cytogenetic findings from 1,068 second-trimester amniocentesis cases obtained between 2004 and 2007 were reviewed.
Amniocenteses were performed in various medical sites, but the
majority (90%) were carried out at the Department of Gynecology and Obstetrics, Dicle University Hospital in the city of
Diyarbakir, Southeast Anatolia Region of Turkey.
All samples were analyzed for cytogenetic analyses in the
Medical Biology and Genetics Department Laboratory at Dicle
University. The laboratory provides a prenatal service to obstetrics-gynecology departments of different hospitals in Diyarbakr
and its surrounding provinces in Southeast Turkey. The laboratory appraisal of the amniotic fluid was the responsibility of the
Department of Human Genetics. The findings in these cases are
summarized in the Results section.
A detailed interview was conducted with all couples before
amniocentesis, and a detailed medical history was obtained. The
complications and risks of amniocentesis were explained to the
family in detail. The risk of abortion due to the procedure was
also explained to the families. They were informed that, if an
abnormality was identified, a legal termination of pregnancy
could be offered. Informed consent for genetic testing was
obtained from all patients.
The main indications for amniocentesis with cytogenetic
analysis in this study included; AMA, that is, if the mother was
35 years old at the expected date of confinement; abnormal
screening markers ( -fetoprotein, human chorionic
gonadotropin, and/or unsaturated estriol) in maternal serum;
abnormal ultrasound (US) findings; previous fetus/child with
chromosomal aberrations; previous abnormal and/or mentally
retarded child, previous neonatal death or stillbirth; maternal
anxiety.
Evaluation of clinical and cytogenetic fndings on 1,068 second-trimester amniocenteses in Southeast Turkey
Cultures and harvesting and cytogenetic analysis
Table 1. Age distribution.
The amniotic fluids were cultured by using long term tissue

culture in three different flasks containing 2.5-3 ml of medium
Bioamf (Biological Industries, Israel) as the basal medium supplemented with Bioamf supplement (Biological Industries), 1%
200 mm L-glutamine (Gibco, New York, USA), 100 U/ml penicillin (Biological Industries), and 100 g/ml streptomycin (Biological Industries), using the technique described earlier [17].
Cultures were harvested when colonies were sufficient (at least
15 colonies), 9-14 days after seeding. Chromosomes were prepared in the usual manner. Routine diagnosis was based on
examination of GTG-banded chromosome from at least 20 cultured metaphase cells from a minimum of two independent
culture dishes. In some cases, chromosomes analyses were performed by using both the GTG-banding and Ag-NOR chromosome-banding techniques. In the cases of mosaic karyotypes,
30-100 metaphase spreads were analyzed. The karyotypes were
described according to the International System for Chromosome Nomenclature [18].
All chromosomal abnormalities detected by karyotype analysis have been classified into numerical and structural abnormalities. Chromosomal variants that are not clinically significant,
such as enlarged heterochromatin on various chromosomes and
enlarged satellites, were not included. Frequencies of observed
chromosomal abnormalities were then calculated for each indication and considered second trimester risk estimates.
Maternal age
(years)
Genetic counseling
*US anomaly identified at the time of pre-amnio US?
Genetic counseling was provided by obstetricians to all

couples before the amniocenteses were performed in the Department of Gynecology and Obstetrics. Those patients that were
identified as having pregnancies with chromosomal anomalies
received post-amniocentesis genetic counseling in the Department of Medical Biology and Genetics. Our prenatal genetic
counseling center was established in 1994 to serve patients [19].
The couples in this study were informed of the nature of the
study, and the signatures of the couples for their informed
consent were obtained. All of the patients interviewed clearly
understood that the research was independent of their care, and
that their participation in the study would not affect their care
in any way. All protocols were IRB approved. None of the
patients declined to participate.
Results
As previously stated, 1,068 second-trimester amniocentesis cases were analyzed at the cytogenetics lab in our prenatal genetic center between 2004 and 2007. After receiving genetic counseling, cases were selected to undergo a
prenatal cytogenetic study. The majority of the women in
our study had completed formal education. Of the 1,068
women; 398 (37.3%) had graduated from a university; 249
(23.3%) from a high school; 210 (19.7%) from a primary
school, and 211 (19.8%) had no formal education.
Of the 1,068 women who had amniocentesis, 34.5% (n
= 368) had a maternal age between 35 and 39 years,
which was the most common age group, followed by age
30-34 (23.6%, 252), 25-29 (20.2%, 216), older than 40
(13,3%, 142), 20-24 (6.5%, 70), and 19 years or younger
(1.9%, 20) (Table 1).
The gestational ages at the time when the amniocentesis was performed were: 15 weeks in 5% of cases, 16
19
20-24
25-29
30-34
35-39
40
Total
365
Amniocenteses
(n)
20
70
216
252
368
142
1068
1.9
6.5
20.2
23.6
34.5
13.3
100.0
Table 2. Number of amniocenteses cytogenetically analyzed

according to indication.
Indication
Amniocenteses
(n)
Advanced maternal age (AMA) ( 35)

Abnormal maternal serum screenings results
Abnormal ultrasonographic (US) findings
Previous fetus/child with chromosomal aberrations
Previous abnormal and/or mentally retarded child
Previous neonatal death or stillbirth
Maternal anxiety
Abnormal maternal serum screening + AMA
Abnormal maternal serum screening +
Abnormal US findings*
AMA + Abnormal US findings
Total
Proportion
(%)
266
402
78
34
32
21
35
149
24.9
37.6
7.3
3.2
3.0
2.0
3.3
14.0
25
26
1068
2.3
2.4
100.0
Table 3. Types and frequencies of chromosomal abnormalities.

Karyotypes
Numerical abnormalities
Autosomal abnormalities
Trisomy 21
Trisomy 18
Trisomy 13
Triploidy
Sex chromosome abnormalities
Turner syndrome
Classic
Mosaica
Klinefelter syndrome
Triple X syndrome
Structural rearrangements
Reciprocal translocation
Robertsonian translocationb
Inversion
Deletion
Supernumerary marker chromosome
Total
Number (n)
39
27
20
5
2
2
10
5
4
1
3
2
13
2
2
6
2
1
52
75
51.9
38.5
9.6
3.8
3.8
19.2
9.6
7.7
1.9
5.8
3.8
25
3.8
3.8
11.5
3.8
1.9
100.0
45,X/46,XX;
One of the Robertsonian translocations was unbalanced: 46,XX,+13,der(13;14)
(q10;q10).
weeks in 28%, 17 weeks in 33%, 18 weeks in 14%, 19

weeks in 7%, 20 weeks in 4%, 21 weeks in 2%, 22 weeks
in 3%, 23 weeks in 2% and 24 weeks in 2%.
The indications for the amniocenteses are shown in
Table 2. Among these, the most common clinical indication for amniocentesis was abnormal maternal serum
screening results (37.6%), followed by AMA (24.9%),
abnormal maternal serum screening combined with AMA
(14.0%), abnormal US findings (7.3%), maternal anxiety
366
M. Balkan, H. Akbas, S. Kalkanli, M.N. Sakar, M. Fidanboy, M.N. Alp, T. Budak
Table 4. Types and frequencies of chromosome abnormalities according to the indications.

Indications
Total number
(n)
Chromosomal
abnormalities n (%)
AMA ( 35)
266
19 (7.1%)
Abnormal maternal serum screenings results
402
12 (3.0%)
Abnormal US findings
78
6 (7.7%)
Previous fetus/child with chromosomal aberrations
34
2(5.9%)
Previous abnormal and/or mentally retarded child

Previous neonatal death or stillbirth
Maternal anxiety
Abnormal maternal serum screening + AMA
32
21
35
149
1
1
1
6
Abnormal maternal serum screening +

Abnormal US findings
AMA + Abnormal US findings
25
2 (8.0%)
26
2 (7.7%)
1068
52
Total
(3.2%)
(4.8%)
(2.9%)
(4.0%)
Type of abnormalities
(n)
Trisomy 21 (11)
Trisomy 18 (2)
Trisomy 13 (1)
Turner (2)
Klinefelter (1)
Triple X Syndrome (1)
46,XY,inv(9)(p13q13) (1)*
Trisomy 21 (6)
Klinefelter (2)
Turner (2)
46,XY,inv(9)(p11q11) (1)**
46,XY,inv(9)(p11q13) (1)*
Trisomy 18 (1)
Trisomy 21(1)
Trisomy 13 (1)
Triploidy (1)
46,XY,del(18)(p?) (1)*
Triple X Syndrome (1)
46,XY, t(3;7)(q24;q36) (1)a
46,XY,inv(9)(p11q13) (1)*
46,XY,inv(9)(p11q13) (1)*
45,XY,der(13;14)(q10;q10) (1)b
46,XY,inv(9)(p11q11) (1)**
Trisomy 21 (1)
Turner (1)
46,XY, t(3;18)(p23;p11) (1)c
46,XY,del(18)(p?) (1) (1)*
Trisomy 18 (2)
Triploidy (1)
46,XX,+13,der(13;14)(q10;q10) (1)d
Trisomy 21 (1)
47,__,+mar (22) (1)*
de novo reciprocal translocation, b de novo Robertsonian translocation, c familial reciprocal translocation in association with a balanced paternal reciprocal translocation,
d
familial Robertsonian translocation in association with a balanced maternal reciprocal translocation, *de novo cases, **familial cases.
(3.3%), previous fetus/child with chromosomal aberrations (3.2%), previous abnormal and/or mentally retarded
child (3.0%), AMA combined with abnormal US findings
(2.4%), abnormal maternal serum screening combined
with abnormal US findings (2.3%), and previous neonatal death or stillbirth (2.0%).
In 1,068 of our cases, except six, cells were able to be
grown in culture (99.4%). The frequencies by classification for chromosomal abnormalities are shown in Table 3.
Of the 1,068 amniocenteses, 1,016 cases (95.1%) showed
normal diploidy and 52 cases (4.9%) showed chromosomal abnormalities. Among these chromosomal abnormalities, numerical and structural abnormalities were seen in
39 and 13 cases, respectively. The majority of chromosomal abnormalities were autosomal trisomies (51.9%,
27/52). Trisomy 21 syndrome was the most common
abnormality (38.5%, 20/52). Edward syndrome and Patau
syndrome were found in five and two cases, respectively.
Triploidy syndrome was found in two cases (69, XXY
and 69, XXX). In cases with sex chromosomal abnormalities (10 cases), five cases had Turner syndrome (4 classic
and 1 mosaic), three Klinefelter syndrome (classic), and
two triple X syndrome. Total structural rearrangements

were found in 13 cases (25.0%, 13/52). Among structural
chromosomal rearrangements, reciprocal translocations
were detected in two cases and Robertsonian translocations in two cases. One of the Robertsonian translocations was unbalanced (trisomy 13). Marker chromosome
was found in one case, deletions in two cases and inversions were present in six cases.
Table 4 gives the frequencies of chromosome abnormalities according to the indications. Of 25 cases with
abnormal maternal serum screening combined with
abnormal US findings, two cases resulted in chromosomal abnormalities, which showed the highest positive
predictive value (8.0%) among indications, followed by
abnormal US findings (7.7%), AMA combined with
abnormal US findings (7.7%), AMA (7.1%), previous
fetus/child with chromosomal aberrations (5.9%), previous neonatal death or stillbirth (4.8%), abnormal maternal serum screening combined with AMA (4.0%), previous abnormal and/or mentally retarded child (3.2%),
abnormal maternal serum screenings results (3%), and
maternal anxiety (2.9%).
Evaluation of clinical and cytogenetic fndings on 1,068 second-trimester amniocenteses in Southeast Turkey
Discussion
Prenatal diagnosis has become a major aid in genetic
counseling, and thus several important areas of technology have evolved, such as cytogenetic prenatal diagnosis,
by using analysis of cultured cells from the amniotic fluid
at mid-trimester. Because of its high reliability and safety
record with the lowest fetal loss and embryonic damage,
amniocentesis has become the most common practice for
prenatal diagnosis [13, 19]. This technique was established in 1989 in Turkey and in 1994 in our department.
The reports on prenatal diagnosis of amniocentesis have
revealed that the incidence of chromosomal abnormalities
ranges between 1.0% and 6.7% [5, 6, 8-16]. In this study,
it was found that 4.9% of 1,068 cases had chromosomal
abnormalities, which was similar to the data of Kromberg
et al. [16] (4.9%) and Acar et al. [2] (5.2%). The wide variation in incidence of chromosome abnormalities may have
accounted for changes in cytogenetic technology, sensitivity of US, advent and utilization of maternal serum screening, gestational age at diagnosis, etc.
Prenatal diagnosis by chromosomal analysis has been
increasingly used in obstetric practices for the diagnosis
and treatment between 15 and 18 gestational weeks since
it became available using amniocentesis in 1967 [5]. In
the 1980s, amniocentesis was used primarily for those in
advanced maternal age groups, at least 35 years old [5].
So far, other recent reports have still shown that prenatal
diagnosis of chromosomal disorders has been performed
mainly for pregnancies at an AMA [8-10, 13, 20]. In the
present study it was determined that abnormal maternal
serum screening was the most common indication for
amniocentesis, followed by AMA (Table 2). This finding
was similar to the results of previous studies [5, 13, 2123]. Maternal serum marker screening has been accepted
as the prominent indication for amniocentesis among
obstetricians over time [5, 9]. In particular, this test has
made remarkable progress both as a routine prenatal
screening program and a detection technique in our
center. The cost of abnormal maternal serum screening
was paid by the patient herself if she did not have health
insurance, or covered by private insurance, or funded by
a state-supported agency in Turkey.
It has earlier been reported that abnormal US findings
showed the highest detection rate for chromosomal
abnormalities in prenatal diagnosis, at ranges between
5.3% and 8.9% [5, 8, 9, 14]. In the present study, abnormal maternal serum screening combined with abnormal
US findings, AMA combined with abnormal US findings
and abnormal US findings showed the highest positive
predictive values among the clinical indications, at 8%,
7.7%, and 7.6% respectively (Table 4). Today, highly sensitive US technology can detect many fetal anomalies,
which eventually necessitate amniocentesis.
In cases with maternal anxiety, there should be a proper
diagnosis in consideration of psychiatric stress which
could affect the family [5]. This study found 35 women
(3.3%) who requested amniocentesis due to the indications above (Table 2).
367
Among numerical autosomal abnormalities, Trisomy

21 syndrome was the most common abnormality found in
our study (Table 3). This result is similar to some previous results reported in the literature [5, 6, 8, 9, 13, 15]. In
addition, in the present study it was found that the prevalence of Trisomy 21 cases (1.9%) among all the study
population slowly increased from the results of previous
studies [5, 9, 13-15, 24], which might be due to a remarkable progress in the maternal serum screening test and US
techniques.
Turner syndrome was the most common of the sex
chromosomal abnormalities in our study (Table 3).
Although the phenotype varies from normal female to
full manifestations of Turner syndrome, it has been
reported that the abnormal phenotypic rate of prenatally
diagnosed cases is about 14% at birth [5]. Some authors
have concluded that the dynamics surrounding sex aneuploidies with a low risk of an abnormal clinical phenotype probably differ from those surrounding Down syndrome and aneuploidies in which a severe clinical
phenotype is expected [25]. In addition, it has been
demonstrated in long-term follow-up studies that the
postnatal development of cases with sex chromosome
aneuploidies is mostly normal [25, 26]. These types of
empirical evidence are likely to have influenced genetic
counseling strategies.
Translocations were present in four fetuses, including
two Robertsonian translocations and two reciprocal
translocations (Table 3). One of the Robertsonian translocations was balanced and de novo: 45,XY,der(13;14)
(q10;q10 and the other case was unbalanced and familial:
46,XX,+13,der(13;14)(q10;q10) in association with a
balanced maternal Robertsonian translocation. Of the two
reciprocal translocations, one case was de novo: 46,XY,
t(3;7)(q24;q36) and the other case was familial translocation: 46,XY, t(3;18)(p23;p11) in association with a balanced paternal reciprocal translocation (Table 4). The
problem is entirely different in parents carrying a translocation [15]. As is well known, there is information about
the de novo translocations as in the carrier whose risk of
having an aneuploid live birth lies in the medium range,
5%-10% and in the highest range, 35%. This risk is, of
course, very variable as it depends on the breakpoints of
each translocation. Some translocations are indeed lethal
for the embryo when unbalanced and will never be
observed, while others are not as damaging [15]. Families in our study were informed about these risks.
Inversion 9 was identified in 11.5% (6/52) (Table 3).
These karyotypes were generally considered normal variants without phenotypic effects on the individuals carrying these aberrations [27]. Nevertheless, there have been
also debates on the association between these karyotypes
and various clinical problems. The prevalence of inversion chromosome 9 in a normal population was reported
as 1.65%, and higher incidence in aborted fetuses with
normal karyotype (3.31%) and couples with a history of
more than two spontaneous first trimester abortions
(3.19%) [28]. In another study, there were patients having
inv(9) accompanied by delayed development or mental
368
M. Balkan, H. Akbas, S. Kalkanli, M.N. Sakar, M. Fidanboy, M.N. Alp, T. Budak
retardation (25.0%), congenital anomaly (23.1%), giving

birth to babies with an inv(9) (15.4%) and habitual abortion (7.7%) [27]. However it was not possible to confirm
whether inv(9) was responsible for these clinical findings.
In summary, prenatal diagnosis by amniocentesis in the
past was performed mainly for AMA. However, due to
the development of maternal serum markers and sensitive
US technology, the indications for amniocentesis are
changing. For daily practice, our data corroborates the
importance of prenatal diagnosis in light of the well
defined indication categories, offering amniocentesis to
mothers in order to evaluate prognosis and to give accurate information concerning the child to be born and the
risk for further pregnancies.
References
[1] Ndumbe F.M., Navti O., Chilaka V.N., Konje J.C.: Prenatal diagnosis in the first trimester of pregnancy. Obstet. Gynecol. Surv.,
2008, 63, 317.
[2] Acar A., Balci O., Gezginci K., Onder C., Capar M., Zamani A. et
al.: Evaluation of the results of cordocentesis. Taiwan J. Obstet.
Gynecol., 2007, 46, 405.
[3] Savac S., Yksel S., Yesilada E., Kaygusuz E., Glbay G.: Prenatal diagnosis evaluation at medical biology and genetic Department Laboratory of Inn University for two years. Inn
niversitesi Tp Fakltesi Dergisi, 2008, 15, 19.
[4] Yldrm G., Gngrdk K., Gl A., Aslan H., Ceylan Y.,
Gedikbas A.: Results of cordocentesis at our department: evaluation of 260 cases. J. Turk. Ger. Gynecol. Assoc., 2008, 9, 224.
[5] Han S.H., An J.W., Jeong G.Y., Yoon H.R., Lee A., Yang Y.H. et
al.: Clinical and cytogenetic findings on 31,615 mid-trimester
amniocenteses. Korean J. Lab. Med., 2008, 28, 378.
[6] Daniilidis A., Karydas H., Zournatzi V., Tantanasis T., Giannoulis
C., Tzafettas J.: A four-year retrospective study of amniocentesis:
one centre. Hippokratia, 2008, 12, 113.
[7] Odabas A.R., Yksel H., Demircan S., Temocin K., Bal F., Yapc
S. et al.: The results of second trmester genetc amniocentess
procedure: adnan menderes Unversity Experience with the results
of 22 Centers in Turkey. Turkiye Klinikleri J. Gynecol. Obstet.,
2007, 17, 196.
[8] Tseng J.J., Chou M.M., Lo F.C., Lai H.Y., Chen M.H., Ho E.S.:
Detection of chromosome aberrations in the second trimester
using genetic amniocentesis: experience during 1995-2004.
Taiwan J. Obstet. Gynecol., 2006, 45, 39.
[9] Karaoguz M.Y., Bal F., Yakut T., Ercelen N.O., Ergun M.A.,
Gokcen A.B. et al.: Cytogenetic results of amniocentesis materials: incidence of abnormal karyotypes in the Turkish collaborative
study. Genet. Couns., 2006, 17, 219.
[10] Turhan N.O., Eren U., Seckin N.C.: Second-trimester genetic
amniocentesis: 5-year experience. Arch. Gynecol. Obstet., 2005,
271, 19.
[11] Gunduz C., Cogulu O., Cankaya T., Bora E., Karaca E., Alpman
A. et al.: Trends in cytogenetic prenatal diagnosis in a reference
hospital in Izmir/Turkey: a comparative study for four years.
Genet. Couns., 2004, 15, 53.
[12] Park I.Y., Shin J.C., Kim S.C., Ahn H.Y., Moon H.B., Park C.H.
et al.: Cytogenetic analysis in 3,503 cases of midtrimester amniocentesis: CUMC experience (II). Korean J. Obstet. Gynecol.,
2004, 47, 96.
[13] Park S.Y., Kim J.W., Kim Y.M., Lee M.H., Lee B.Y. et al.: Frequencies of fetal chromosomal abnormalities at prenatal diagnosis: 10 years experiences in a single institution. J. Korean Med.
Sci., 2001, 16, 290.
[14] Yang Y.H., Ju K.S., Kim S.B., Cho Y.H., Lee J.H., Lee S.H. et al.:
The Korean collaborative study on 11,000 prenatal genetic
amniocentesis. Yonsei Med. J., 1999, 40, 460.
[15] Caron L., Tihy F., Dallaire L.: Frequencies of chromosomal
abnormalities at amniocentesis: over 20 years of cytogenetic
analyses in one laboratory. Am. J. Med. Gene., 1999, 82, 149.
[16] Kromberg J.G., Bernstein R., Jacobson M.J., Rosendorff J.,
Jenkins T.: A decade of mid-trimester amniocentesis in Johannesburg. Prenatal diagnosis, problems and counselling. S. Afr. Med.
J., 1989, 76, 344.
[17] Verma R.S., Babu A.T.: Issue culture techniques and chromosome preparation. In: Verma R.S., and Babu A. (eds.). Human
Chromosomes Principles and Techniques. 2nd edition, New York:
McGraw-Hill, 1995, 6.
[18] ISCN 2005. An International System for Human Cytogenetic
Nomenclature (Cytogenetic & Genome Research). Shaffer L.G.,
Tomnerup N., Basel, Karger, 2005.
[19] Balkan M., Akbas H., Isi H., Oral D., Turkyilmaz A., Kalkanli S.
et al.: Cytogenetic analysis of 4216 patients referred for suspected chromosomal abnormalities in Southeast Turkey. Genet.
Mol. Res., 2010, 11, 1094.
[20] Kessler R.G., Sanseverino M.T.V., Leistner-Segal S., Magalhes
J.A.A., Giugliani R.: Prenatal diagnosis of fetal chromosomal
abnormalities: Report of an 18-year experience in a Brazilian
public hospital. Gen. Mol. Biol., 2008, 31, 829.
[21] Marthin T., Liedgren S., Hammar M.: Transplacental needle
passage and other risk factors associated with second trimester
amniocentesis. Acta Obstet. Gynecol. Scand., 1997, 76, 728.
[22] Tongsong T., Wanapirak C., Sirivatanapa P.: Amniocentesis
related fetal loss; a cohort study. Obstet. Gynecol., 1998, 92, 64.
[23] Sener K.T., Durak B., Tanir H.M., Tepeli E., Kaya M., Artan S.:
Results of amniocentesis in 7 years period in Eskisehir
Osmangazi University. Perinatol., 2006, 14, 170.
[24] Marical H., Douet-Guilbert N., Bages K., Collet M., Le Bris M.J.,
Morel F. et al.: Second-trimester prenatal screening for trisomy
21 using biochemical markers: a 7-year experience in one cytogenetic laboratory. Prenat. Diagn., 2006, 26, 308.
[25] Quadrelli R., Quadrelli A., Mechoso B., Laufer M., Jaumandreu
C., Vaglio A.: Parental decisions to abort or continue a pregnancy
following prenatal diagnosis of chromosomal abnormalities in a
setting where termination of pregnancy is not legally available.
Prenatal. Diagnosis, 2007, 27, 228.
[26] Brun J., Gangbo F., Wen Z.Q., Galant K., Taine L., MaugeyLaulom B.: Prenatal diagnosis and management of sex chromosome aneuploidy: a report on 98 cases. Prenatal. Diagnosis,
2004, 24, 213.
[27] Kim S.S., Jung S.C., Kim H.J., Moon H.R., Lee J.S.: Chromosome abnormalities in a referred population for suspected chromosomal aberrations: a report of 4117 cases. J. Korean Med. Sci.,
1999, 14, 373.
[28] Yamada K.: Population studies of INV(9) chromosomes in 4,300
Japanese: incidence, sex difference and clinical significance. Jpn.
J. Hum. Genet., 1992, 37, 293.

M. BALKAN, Ph.D.
Department of Medical Biology
and Genetics,
Medical Faculty University of Dicle
21280, Diyarbakr (Turkey)
e-mail: balkanmah@gmail.com
mahbal@dicle.edu.tr
20 1180-30 - Distribution of etiological:1648_29 Incidence of multiple 15/11/11 14:40 Pagina 369
[1180/30]
369
Distribution of etiological factors of

hypergonadotropic amenorrhea
H. Meden-Vrtovec1, K. Gerak1, D. Frani2
1
Department of Obstetrics and Gynecology, University Medical Centre Ljubljana, Ljubljana

2
Gynecology Outpatient Clinic Dr. Frani, Rogaka Slatina (Slovenia)
Summary
Objective: To describe the etiology of hypergonadotropic amenorrhea (HA) and outline the subgroup of infertile women that might
achieve pregnancy with their own eggs despite premature ovarian failure. Methods: In this retrospective study we enrolled 70 women
aged 32.5 5.71 years. After a detailed history of the disease, measurements of follicle-stimulating hormone, estradiol, prolactin and
thyroid-stimulating hormone levels, determination of the karyotype and fragile X premutation syndrome, and a quick ACTH test, estrogen-progestin replacement therapy was introduced. Results: In 17 of the 70 women, HA was due to chromosomal abnormalities, in 16
to extensive gynecologic surgery, in ten to oral contraceptive use, in four to chemo- and radiotherapy; in 23 HA was idiopathic. After
estrogen-progestin replacement therapy, three women with idiopathic HA conceived and delivered healthy babies. Conclusion: Estrogen-progestin replacement therapy in pharmacological doses might be beneficial to women with idiopathic HA, having normal prolactin levels, adrenal and thyroid function, and a normal karyotype.
Key words: Estrogen-progestin treatment; Hypergonadotropic amenorrhea; Pregnancy.
Introduction
Etiologies of hypergonadotropic amenorrhea (HA) in

the reproductive period are diverse; if HA occurs before
the age of 40, it is defined as premature ovarian failure
(POF). The diagnosis of POF is made in around 10% of
patients complaining of secondary amenorrhea [1].
The terminology used to categorize patients with POF
has led to considerable confusion regarding etiologic factors. Friedman et al. [2] proposed a classification of primary ovarian failure. The initial division is between
women with an intact number of immature follicles
(gonadotropin-resistant ovarian syndrome) and women
with premature follicular depletion. Those with follicular
depletion are further divided regarding their chromosomal complement. Chromosomally abnormal women represent a complete unit, whereas normal subjects with 46
XX karyotype are divided into those having familial,
immunologic, iatrogenic, infectious or secondary to systemic diseases or idiopathic etiology.
Therapeutic efforts to restore ovarian function have
been focused on 46 XX subjects with follicular depletion
and on those with gonadotropin-resistant ovary syndrome
[3]; as for chromosomally abnormal subjects, there have
been anecdotic reports of accidental pregnancies achieved
with estrogen treatment [4].
The aim of this study was to describe the etiology of
hypergonadotropic amenorrhea (HA) in women referred
to our outpatient infertility clinic. Our further aim was to
identify a group of women without any known or proven
reason for HA (idiopathic HA), and within this group a
subgroup of those that could achieve pregnancy with their
own eggs.
In this observational uncontrolled retrospective study we

enrolled 70 hypergonadotropic women seeking infertility treatment in the outpatient clinic of the Department of Obstetrics
and Gynecology, University Medical Centre Ljubljana, in the
time period 2002-2007. To find etiologic factors of amenorrhea,
the women underwent determinations of the levels of follicular
stimulating hormone (FSH), estradiol (E 2 ), prolactin and
thyroid-stimulating hormone (TSH), and karyotyping and
fragile X premutation analysis.
In all women serum FSH and E2 levels were checked twice
in a time lapse of two of three months.
Determinations of the analyzed hormones were performed on
the fully automated analyzer LIAISON, Dia Sorin, Saluggia,
Italy) with a quantitative direct competitive chemiluminescence
immunoassay (CLIA). Each test is a modified two-step (sandwich principle) assay where a specific antibody to the measured
hormone is bound to magnetic particles.
Normal values for follicular phase FSH range between 3.5
and 9.2 IU/l, for E2 between 0.17 and 0.41 nmol/l, for prolactin
between 6.2 and 23.5 g/l, and for TSH between 0.3 and 3.6
mU/l.
Karyotyping and the analysis of the fragile X premutation
were performed according to standard procedures [5].
In all the women vaginal ultrasound (US) examination was
repeated two to three times by an independent observer to
assess antral follicle count and to exclude or confirm ovarian
resistance syndrome. In all the enrolled women no follicles
were registered; the endometrial thickness was < 4 mm.
Since the E2 level in all women was far below the normal
range and US endometrial thickness was less than 4 mm, a
progesterone withdrawal test was not performed.
The mean womens age was 32.5 5.71 years (range: 19-40
years), and the duration of amenorrhea ranged from 1-15 years.
Prior to enrollment in the study and the confirmed diagnosis,
the women had been receiving either continuous or discontinuous HRT regimen or oral contraceptives.
After a close examination of the history data, complete hormonal determinations, karyotyping and fragile X premutation

XXXVIII, n. 4, 2011
370
H. Meden-Vrtovec, K. Gerak, D. Frani
analysis, and after a confirmed diagnosis of HA, estrogen-progestin replacement therapy consisting of a daily dose of estradiol
valerate 2 mg and norgestrel 0.5 mg was introduced.
The study was approved by the national medical ethics committee and each woman signed an informed consent before
entering the study.
Karyotypes of the women that conceived were normal;

also, these women had no history of any risk for the
development of HA. One conceived while waiting for
oocyte donation, and two during the time period when
deciding either on oocyte donation program or adoption.
Table 3. Clinical data on babies.
Results
Mother
(initials)
Babys sex
Birth weight
Apgar score
Pediatric estimation
The womens history data showed that among the 70

enrolled women 16 had undergone extensive pelvic or
ovarian surgery, ten had used oral contraceptives (OC) for
more than two years prior to onset of amenorrhea, and
four had had chemo- and radiotherapy for malignant disease.
Karyotyping revealed that 17 women had chromosomal
abnormalities.
HDB
(twins)
KKD
KS
Male
Male
Male
Female
3,020
2,990
3,770
3,450
9
8
9
9
Normal
Normal
Normal
Normal
Table 1. Presumed etiology of hypergonadotropic amenorrhea.

Diagnosis (n)
n (%)
Extensive surgery
Endometriosis (8)
Viscerolysis OWR (8)
> 2 years (10)
Hodgkins disease (3)
Leukemia (1)
45XO (7)
46XY (2)
Mosaicism (8)
16 (22.9)
Genetic
10 (14.3)
4 (5.7)
17 (24.3)
Total
Ten to 12 months after delivery FSH levels were measured in the three women again demonstrating hypergonadotropic FSH (HDB: 90.5 and 92.9 IU/l; KKD: 49.6
and 65.8 IU/l; KS: 62.1 and 71.2 IU/l).
Discussion
Etiology
OC
Radio-, chemotherapy
g
g
g
g
47 (67.2)
OC = oral contraception; OWR = ovarian wedge resection.
On the basis of the womens history data and karyotyping, etiologic factors were established in 47 of the 70
women (67.1%). In the remaining 23 women (32.8%) no
history data of toxic, infectious, medicamentous,
endocrine or environmental risk factors could be identified; these women were therefore classified as having
idiopathic HA. After estrogen-progestin replacement
therapy, three of the 23 women (13.3%) with idiopathic
HA conceived and delivered healthy babies.
In the three women that conceived FSH levels before
pregnancy were found elevated and estrogen levels
decreased. Thyroid function assessed by TSH determination was found to be normal in all three patients, and so
were prolactin plasma concentrations (Table 2).
Table 2. Clinical data on women who conceived.
Patient
initials
Age
(years)
Duration of
amenorrhea
FSH
(IU/l)
E2
(nmol/l)
PRL
(g/l)
TSH
(mU/l)
HDB
KKD
KS
35
21
35
1 year
1.5 years
1 year
109.98
93. 88
73. 69
0.04
0.07
0.09
19
16
12
0.5
2.1
0.9
E2 = estradiol, FSH = follicle-stimulating hormone, PRL = prolactin, TSH =

thyroid-stimulating hormone.
During pregnancy no hormonal support was offered,

and the three women delivered healthy babies; one of the
women had twins.
Beyond ovum donation there has been no proven effective therapy in patients with HA to achieve pregnancy.
The etiology of the disorder is heterogeneous and by
selecting the patients according to the known causative
factors, a group of those with possible fertility perspectives could be identified. The aim of this study was to
describe the etiology of HA and identify the subgroup of
infertile women that could benefit from estrogen-progestin replacement therapy, and define their characteristics.
According to Powell et al. [6] chromosomal abnormalities are detected in 40-50% of women with HA. In our
group we registered only 24% of chromosomal abnormalities, which is likely due to the selected group of women
seeking infertility treatment. Women with chromosomal
abnormalities (monosomy X, mosaicism, polysomy X)
may have ovarian function preserved at least for a limited
period of time [4]. In these women early diagnosis is of
outmost importance as it offers a possibility of cryopreservation of ovarian tissue for future fertility [7].
Several reports have identified the women with HA
among fragile X premutation carriers with a familial history of premature ovarian failure (POF) [8]. Sherman,
using the combined information from women interviewed
at the age of 40 years, estimated the rate of POF among
fragile X premutation carriers to be 21% [9]. The frequency of fragile X premutation carriers among women
with sporadic POF has been found to range between 1.6
and 3.3% [8, 10]. In Slovene women with sporadic POF,
evaluated at the Department of Obstetrics and
Gynecology Ljubljana between 1991 and 2001, the fragile X premutation was found in 4.8% of the screened
women (4/83 women) [5].
No case of fragile X premutation was registered among
the women enrolled in this study.
Iatrogenic damage of ovarian tissue encompasses cytotoxic treatment used in leukemia and Hodgkins disease,
and extensive ovarian or pelvic surgery. Long term use of
OC may hide the signs of ovarian insufficiency and post-
Distribution of etiological factors of hypergonadotropic amenorrhea
pone the possibility of early diagnosis and treatment.

Cytotoxic-induced ovarian failure is notable for occasional spontaneous remission, although approximately one
half of all women receiving 400-500 rads to ovaries over
four to six weeks will develop permanent ovarian failure
[11, 12].
A case report by Menashe et al. [13] of a patient who
conceived spontaneously on three occasions resulting in a
live-birth infant is a proof that gonadal failure following
chemotherapy may not be permanent.
In our group of women with HA, three had undergone
treatment for Hodgkins disease and one for leukemia. In
these women the hypergonadotropic condition persisted
for more than ten years, which renders the possibilities of
spontaneous remission and reverse of ovarian function
most unlikely.
Extensive pelvic surgery with direct ovarian damage or
resection may lead to premature depletion of ovarian follicles, ovarian cortical damage, and hence a functional
loss in the ovarian reserve [14].
We registered 16 cases of HA after surgery; in eight HA
occurred after extensive surgery of pelvic and ovarian
endometriosis, and in eight after extensive viscerolysis
with ovarian wedge resection. We speculate that surgical
procedures were too aggressive to preserve the ovarian
function. In cases of removed or destroyed ovarian tissue
no treatment for infertility can be considered, therefore
these women are offered hormonal replacement therapy,
oocyte donation or adoption.
Following OC use, women often experience some delay
in resuming normal menses, but according to most studies [15] less than 1% fail to begin menstruating regularly
within six months. About one-half of these will develop
post pill amenorrhea resulting from a disruption of the
normal hypothalamic-pituitary-ovarian function. In evaluating the women with post pill amenorrhea it is important to rule out hyperprolactinemia, weight changes and
POF. The medical history of women with post pill amenorrhea should be thoroughly analyzed focusing on menstrual cycle regularity before OC treatment is prescribed.
In our series of HA women, ten had used OC for more
than two years. According to the data from the literature
there appears to be no correlation between the duration of
OC use and the occurrence of amenorrhea [15].
Women with menstrual cycle irregularities should be
checked for the basic hormone levels, i.e. FSH, LH, PRL
and TSH, before they are prescribed OC. The ten OC
users in our series had had irregular menstrual cycles and
had been prescribed OC without searching for the cause
of irregularities: six had been prescribed OC to abolish
menstrual irregularities, and four for the prevention of
unwanted pregnancy. This situation clearly indicates the
importance of considering the indications and contraindications prior to OC prescription.
Between 10% and 30% of women with HA have a concurrent autoimmune disease, the most common being
hypothyroidism. In all our women the thyroid function
was assessed, and the results were normal. HA has also
been reported to be associated with myasthenia gravis,
371
systemic lupus erythematosus, rheumatoid arthritis and

Chrons disease [16].
Another autoimmune disorder that affects ovarian function is Addisons disease. We previously reported a case
of a woman with Addisons disease that developed POF
and hypothyroidism [17]. After estrogen-gestagen
replacement therapy, and treatment with thyroid hormones and corticosteroids, she conceived and delivered a
healthy baby. Additionally, autoimmune lymphocytic
oophoritis was also reported in association with adrenal
insufficiency (Addisons disease) as steroidogenic cell
immunity [16].
In a large proportion of women the cause of HA is not
identifiable. It seems likely that occult viral oophoritis
might account for many of these cases [18].
In their systematic review on therapeutic interventions
to restore ovarian function, Van Kasteren and Schoemaker
[19] evaluated 52 case reports, eight observational studies, nine uncontrolled studies and seven controlled trials.
Due to a strong variability in study design, patient selection and type of intervention, it was not possible to combine the data of seven controlled studies to perform a
meta-analysis. According to their conclusions there was
no evidence that any treatment could enhance pregnancy
rate. However, anecdotal reports of pregnancies that
occurred in women with HA during treatment with estrogens or estrogens and gestagens [20-22] provide evidence
for a possible recruitment of residual oocytes should they
exist.
Achievement of three pregnancies in our series of
women with idiopathic HA after estrogen-progestin treatment is in accordance with the statements that estrogen or
estrogen and progestin treatment may be beneficial in
some types of HA. Differentiation among different types
of HA is essential when deciding on the introduction of
therapeutic interventions. At present a promising predictor of ovarian reserve is anti Mullerian hormone level
determination exceeding conventional analytes testing
with FSH and inhibin B. In the future it could become a
screening test to detect the women with residual oocytes.
In the era of assisted reproduction which covers nearly
all cases of severe infertility, infertility due to HA can be
overcome with an oocyte donation program. A great
majority of women wishing pregnancy enter these procedures, but there are still some who wish to have their own
genetic child. Therefore, it seems reasonable to identify
those women with HA that may benefit from hormonal
treatment. Based on our results these are the ones with
idiopathic HA, normal prolactin levels and adrenal and
thyroid function, with normal karyotype, and with no history of extensive pelvic surgery.
Young women with HA should be offered higher doses
of estrogen replacement therapy than women in their
fifties. Not only to cope with vasomotor symptoms but
also to increase target tissue responsiveness by increasing
the concentration of its own receptor and that of the intracellular progestin and androgen receptor [23]. In addition,
the efficacy of estrogen treatment depends also on the
time of initiation of therapy. Our results are in agreement
372
H. Meden-Vrtovec, K. Gerak, D. Frani
with the results of Lin and Yu [24], who, based on 126 HA

cases, found a significantly better efficacy of estrogen
treatment among the cases with amenorrhea lasting less
than one year as compared to those lasting longer than
one year.
In conclusion, we have to emphasize that women with
HA who wish to conceive with their own eggs should be
properly investigated of the etiology of the disease. A
selected group of women, apparently those with idiopathic HA that have no extensive pelvic surgery in their history, and have normal prolactin levels, thyroid and adrenal
functions, and a normal karyotype, should be offered
immediate estrogen-gestagen treatment in pharmacological doses together with detailed and objective counseling.
References
[1] De Moraes-Ruehsen M., Jones G.S.: Premature ovarian failure.
Fertil. Steril., 1967, 18, 440.
[2] Friedman C.I., Barrows H., Kim M.H.: Hypergonadotropic
hypogonadism. Am. J. Obstet. Gynecol., 1983, 145, 360.
[3] Varma T.R., Patel R.H.: Estrogen treatment and subsequent pregnancy in two patients with severe hypergonadotropic ovarian failure. Int. J. Gynaecol. Obstet., 1988, 26, 291.
[4] Starup J., Philip J., Sele V.: Oestrogen treatment and subsequent
pregnancy in two patients with severe hypergonadotrophic ovarian
failure. Acta Endocrinol., 1978, 89, 149.
[5] Gersak K., Meden-Vrtovec H., Peterlin B.: Fragile X premutation
in women with sporadic premature ovarian failure in Slovenia.
Hum. Reprod., 2003, 18, 1637.
[6] Powell C.M., Taggart R.T., Drumheller T.C., Wangsa D., Qian C.,
Nelson L.M. et al.: Molecular and cytogenetic studies of an X;
autosome translocation in a patient with premature ovarian failure
and review of the literature. Am. J. Med. Genet., 1994, 52, 19-26.
[7] Hreinsson J., Zhang P., Swahn M.L., Hultenby K., Hovatta O.:
Cryopreservation of follicles in human ovarian cortical tissue.
Comparison of serum and human serum albumin in the cryoprotectant solutions. Hum. Reprod., 2003, 18, 2420.
[8] Conway G.S., Hettiarachchi S., Murray A., Jacobs P.A.: Fragile X
premutations in familial premature ovarian failure. Lancet, 1995,
346, 309.
[9] Sherman S.L., Premature ovarian failure in the fragile X syndrome. Am. J. Med. Genet., 2000, 97, 189.
[10] Murray A., Webb J., Grimley S., Conway G., Jacobs P.: Studies of
FRAXA and FRAXE in women with premature ovarian failure. J.
Med. Genet., 1998, 35, 637.
[11] Ash P.: The influence of radiation on fertility in man. Br. J.
Radiol., 1980, 53, 271.
[12] Baker J.W., Morgan R.L., Peckham M.J., Smithers D.W.:

Preservation of ovarian function in patients requiring radiotherapy for para-aortic and pelvic Hodgkins disease. Lancet, 1972, 1,
1307.
[13] Menashe Y., Pearlstone A.C., Surrey E.S.: Spontaneous pregnancies despite failed attempts at ovulation induction in a woman with
iatrogenic premature ovarian failure. J. Reprod. Med., 1996, 41,
207.
[14] Mettler L., Garzon A., Khling-von Kaisenberg H., von
Kaisenberg C.S.: Ovarian surgery and follicular reserve. Expert.
Rev. Endocrinol. Metab., 2006, 1, 743.
[15] Chatterjee R., Banerjee S., Ghosh K.K., Chaudhuri N.: A study of
postpill amenorrhea. Int. J. Gynecol. Obstet., 1980, 18, 113.
[16] Betterle C., Volpato M.: Adrenal and ovarian autoimmunity.
Eur. J. Endocrinol., 1998, 138, 16.
[17] Kocijancic A., Meden-Vrtovec H.: Pregnancy in three patients
with hypergonadotropic ovarian failure. Acta Eur. Fertil., 1987,
18, 263.
[18] Verp M.S.: Environmental causes of ovarian failure. Semin.
Reprod. Endocrinol., 1983, 1, 101.
[19] van Kasteren Y.M., Schoemaker J.: Premature ovarian failure: a
systematic review on therapeutic interventions to restore ovarian
function and achieve pregnancy. Hum. Reprod. Update, 1999, 5,
483.
[20] Petsos P., Buckler H., Mamtora H., Anderson D.C.: Ovulation
after treatment with ethinyl-oestradiol and medroxyprogesterone
acetate in a woman approaching premature menopause. Case
report. Br. J. Obstet. Gynaecol., 1986, 93, 1155.
[21] Chen F.P., Chang S.Y.: Spontaneous pregnancy in patients with
premature ovarian failure. Acta Obstet. Gynecol. Scand., 1997,
76, 81.
[22] Boulieu D., Bully C.: The unexpected occurrence of spontaneous
pregnancy during hormone replacement therapy for premature
menopause. J. Gynecol. Obstet. Biol. Reprod., 1993, 22, 357.
[23] Tartagni M., Cicinelli E., De Pergola G., De Salvia M.A., Lavopa
C., Loverro G.: Effects of pretreatment with estrogens on ovarian
stimulation with gonadotropins in women with premature ovarian
failure: a randomized, placebo-controlled trial. Fertil. Steril.,
2007, 87, 858.
[24] Lin J., Yu C.: Hypergonadotropic secondary amenorrhea: clinical
analysis of 126 cases. Zhonghua. Fu. Chan. Ke. Za. Zhi., 1996,
31, 278.

H. MEDEN-VRTOVEC, M.D., Ph.D.
University Medical Centre Ljubljana
Slajmerjeva 3
SI-1000 Ljubljana (Slovenia)
e-mail: helena.meden@kclj.si
21 1196-30 - Validation of ultrasound:1648_29 Incidence of multiple 15/11/11 14:41 Pagina 373
[1196/30]
373
Validation of ultrasound scan in the diagnosis of female

stress urinary incontinence
A. Lukanovi1, T.S. Patrelli1, 2
1
Department of Obstetrics and Gynaecology, University Medical Center Ljubljana (Slovenia)

2
Department of Obstetrics and Gynaecology, University Medical Center Parma (Italy)
Summary
Objective: To validate transperineal ultrasound (US) in the assessment of urethrovesical junction hypermobility. Methods: In this
prospective study carried out between 1999 and 2003 at a university medical centre we enrolled 100 women with genuine stress urinary
incontinence (study group) and 50 continent women (control group). All women underwent the diagnostic protocol including urodynamic measurement and transperineal US scan using an abdominal semicircular 3.5 MHz linear array transducer. The position of the
urethrovesical junction was described in relation to the inferior edge of the symphysis pubis by two parameters: the cephalocaudal and
the ventrodorsal distance. The position and degree of urethrovesical junction descent during stress (3 consecutive coughs) were measured and the results compared between the groups. Classification performance was evaluated by sensitivity and specificity. Results:
There was no significant difference in the horizontal plane of the urethrovesical junction at rest and in the backward displacement during
stress between the groups. The downward displacement of the urethrovesical junction showed an average descent of 16.10 4.01 mm
in the study group vs 7.92 2.85 mm in the control group; the difference between the groups was statistically significant (p = 0.001).
Considering the 12 mm cut-off value of the descent, US evaluation had an 88% specificity, and a 92% sensitivity; the PPV and NPV
were 96 % and 79 %, respectively. Conclusions: We found a significantly greater downward displacement of the urethrovesical junction during stress in women with stress urinary incontinence compared to healthy controls. We may conclude that transperineal US can
accurately visualise a hypermobile urethrovesical junction.
Key words: Female stress urinary incontinence; Bladder neck hypermobility; Ultrasound evaluation.
Introduction
Urinary incontinence is one of the most frequent diseases in the female population. Among various types of
female urinary incontinence, the incidence of stress urinary incontinence is the highest by far [1, 2].
Due to the rational diagnostic approach, diagnostic
ultrasonography [3-5] has become more frequently used
in the morphologic diagnosis of anatomic changes of the
pelvic floor.
Ultrasound (US) examination is inexpensive, harmless
and well tolerated by patients, and reduces the need for
conventional radiography [6].
One of the most frequent causes of female stress urinary incontinence is hypermobility of the bladder neck
and proximal urethra. Hypermobility is the result of a
defect of the anatomic supporting structures of the proximal urethra [7].
Although tape procedures are currently used all over
the world as primary operations, the suprapubic approach
is the gold standard for surgical treatment of female stress
urinary incontinence. Surgical suspension of the bladder
neck and the proximal urethra represents the indirect fixation of the weakened endopelvic fascia [8].
Numerous modes of diagnostic US examinations have
been used in urogynecology: abdominal, rectal, vaginal,
introital and perinea [l9-13]. Since 1986, when the first
reports on the use and advantages of perineal US were
Revised manuscript accepted for publication May 31, 2011
XXXVIII, n. 4, 2011
published, this mode of diagnostic US examination has

become the method of choice in clinical practice [14, 15].
The advantages of perineal US are the following:
the US probe does not interfere with the mobility of
the anterior vaginal wall and the bladder neck during the
measurement at stress;
the US probe does not change its position during
cough or the Valsalva manoeuvre;
the examination provides a good topographic anatomic picture of the bladder base and bladder neck, the urethra and symphysis.
The aim of this study was to evaluate the use of perineal
US in preoperative diagnosis of female stress urinary
incontinence, and to find whether the evaluation of the
changed position of the bladder neck during cough is a
useful and reliable diagnostic method for deciding on the
surgical treatment of female stress urinary incontinence.
Methods
Study Population
The study was performed at the Department of Obstetrics and
Gynecology in Ljubljana between 1999 and 2003, after
approval by the national medical ethics committee. We enrolled
150 patients who had agreed to participate in the study by
signing the informed consent form. The study group consisted
of 100 women with clinically and urodynamically proven stress
urinary incontinence and the control group of 50 continent
women.
374
A. Lukanovi, T.S. Patrelli
Method
The women in both groups underwent standard urodynamic
measurements used in the diagnosis of stress urinary incontinence and perineal US scan.
To evaluate urethrovesical junction mobility and position
transperineal US was performed using a Toshiba Diagnostic
Ultrasound System SSA 250 and a semi-circular linear 3.75
MHz abdominal probe. The probe was placed on the sagittal
axis of the perineum after the woman was placed in the supine
position with the urinary bladder filled with 300 ml of physiological saline warmed to body temperature. The scan of the
symphysis pubis, bladder, urethrovesical junction and urethra at
rest was followed by the scan during cough. The images were
frozen for evaluation of the bladder neck and bladder base
descent.
The distance from the bladder neck in the horizontal and vertical planes to the reference point, set at the lower edge of the
symphysis, was measured and expressed in mm. The distance
was assessed at rest and during cough, and mean values were
calculated.
Data were analysed with SPSS software version 16.0 (SPSS,
Chicago, IL, USA). Numeric variables are presented as the
mean standard deviation (SD). To assess differences between
continuous variables the Students t-test and Mann-Whitney-U
test were used according to the normality of the variable in
question. Chi-square tests were used to compare categorical
data; p < 0.05 was considered statistically significant.
Specificity and sensitivity of the US method were determined. For the calculation of positive and negative predictive
values the prevalence of stress urinary incontinence in the population was assumed to be 25%. Classification performance was
evaluated by the area under ROC curve.
Results
Data on age, parity, menopausal status and type of work
were obtained from all the women enrolled in the study.
The mean age of women was 46.2 8.5 years in the
study group, and 53.8 10.9 years in the control group;
the difference was statistically significant (p < 0.001, ttest).
The mean number of deliveries was 1.98 in the study
group, and 1.64 in the control group; the difference was
not statistically significant (p = 0.053, Mann-Whitney
test).
As for menopausal status, 74 (74%) women in the study
group and 16 (32%) women in the control group were
menopausal; the difference was statistically significant (p
< 0.001, 2 test).
Heavy work was performed by 66 (66%) women in the
study group and 24 (48%) women in the control group;
the difference was statistically significant (p = 0.034, 2
test).
In the present study the position of the urethrovesical
junction was analysed using transperineal US in 100
women with confirmed stress urinary incontinence compared to 50 healthy controls. We measured the distance
between the urethrovesical junction and the inferior edge
of the symphysis pubis (X distance) and the distance
Table 1. Mean values of X and Y distances at rest and

during coughing in both groups.
Distance
Study group
X distance (mm)
Y distance (mm)
Control group
X distance (mm)
Y distance (mm)
Rest
Mean SD
Coughing
Mean SD
Displacement
Mean SD
22.24 6.57
20.55 5.68
28.56 6.33
36.39 6.75
6.32 2.4
16.10 4.01
23.60 4.98
25.98 5.14
30.36 5.74
33.70 5.31
6.76 3.07
7.92 2.85
Table 2. Mean displacement of X and Y distances comparison between the study and the control group.
Distance
Study group
Mean SD
Control group
Mean SD
X distance difference
(mm)
6.32 2.4 6.76 3.07
Y distance difference
(mm)
16.10 4.01 7.92 2.85
Stat. significance
p
0.37
< 0.001
between the urethrovesical junction and the vertical plane

of the front edge of symphysis pubis (Y distance). Mean
values of the distances X and Y are presented in Tables 1
and 2.
Mean distances of the bladder neck at rest in the horizontal plane with regard to the reference point, i.e., the
lower edge of the symphysis, did not differ significantly
between the groups. However, in the vertical plane the
difference of mean distances at rest was statistically significant, being 16.10 4.01 mm in the study group and
7.92 2.85 mm in the control group (p < 0.01). The comparison of mean values of the displacement of the bladder
neck at increased intraabdominal pressure during cough
in the horizontal plane did not reveal significant differences between the groups.
Sensitivity and specificity
Statistical analysis of the US measurements of bladder
neck mobility during cough in the study group showed
the method to have a sensitivity of 64% and a specificity
of 96%, considering the descent of the bladder neck for
15 mm as physiologic. If this cut-off value was reduced to
12 mm, the sensitivity of the method increased to 88%,
and specificity decreased to 92%.
Sensitivity and specificity according to the cut-off value
are presented in Figure 3.
Figure 4 presents the performance of US measurement
in the diagnosis of stress urinary incontinence by means
of ROC curves. The area under the curve is 0.952 (95%
confidence interval 0.904-0.980).
Predictive values
Predictive value of the method is influenced by the cutoff value considering the change of the bladder neck position during cough as physiologic. Positive and negative
predictive values were calculated at the cut-off value 12
cough
375
cough
Fig. 1
Fig. 2
rest
rest
Fig. 3
Fig. 4
Cut-off value
Figure 1. X distance measurements at rest and during coughing in both groups.

Figure 2. Y distance measurements at rest and during coughing in both groups.
Figure 3. Sensitivity and specificity according to the cut-off value.
Figure 4. Performance of ultrasound measurement in the diagnosis of stress urinary incontinence by means of ROC curves. The area
under the curve is 0.952 (95% confidence interval 0.904-0.980).
mm. A prevalence of stress urinary incontinence in the

screened population was assumed to be 25%.
The calculated positive predictive value (PPV) was
57% and the calculated negative predictive value (NPV)
was 98%. If the cut-off value was decreased to 10 mm, the
PPV increased to 76%, whereas the NPV was 95%.
Discussion
The suprapubic suspension of the bladder neck has
been increasingly used in the surgical treatment of female
stress urinary incontinence. Therefore, it is evident that
the prevailing theory in clinical practice is that hypermobility of the bladder neck is the main cause for the occurrence of stress urinary incontinence. In spite of favourable
outcomes of retropubic surgeries, 10-15% of women still

experience problems with urinary leakage after surgery
[16]. It is not quite evident whether this is the consequence of a failed surgical suspension of the bladder neck
or of an inappropriately chosen mode of treatment, i.e., of
undiagnosed unstable detrusor, or due to newly made
noninhibited detrusor contractions following surgery. In
the diagnosis of stress urinary incontinence, and especially before deciding on a surgical treatment, it is indispensable to find and prove the changes in the supporting
structures of the bladder neck and of the proximal urethra.
Numerous morphologic examinations and tests aim at
assessing pathoanatomical changes of the pelvic floor.
However, clinical practice requires a simple, reproducible, quick and inexpensive test that would provide a
376
more reliable diagnosis, and serve as the basis for the

decision on a proper surgical technique with an efficient
outcome. For their invasiveness, radiological methods
have been losing their impact in the diagnosis of stress
urinary incontinence [17, 18]. Using real-time imaging,
diagnostic US has changed the approaches from abdominal, rectal and vaginal to finally find the most advantageous approach, the perineal approach, which has been
proven to provide the best morphological assessment of
hypermobility of the bladder neck and of the proximal
urethra [19-22].
In this study we analyzed clinical applicability of diagnostic perineal US, and determined the specificity and
sensitivity of the method. The assessment involved mean
distances of the bladder neck with regard to the reference
point, i.e., the lower edge of the symphysis at rest women
with clinically and urodynamically proven stress urinary
incontinence in comparison to the distances obtained
from continent women. Then, the displacement of the
bladder neck with regard to the reference point was measured during cough and again the results were compared
between the two groups. We found that mean distances X
(ventro-dorsal plane) did not differ significantly between
the groups. However, the difference of the distance from
the bladder neck to the lower edge of the symphysis at
rest was statistically significant. We found significantly
lower positions of the bladder neck in control group
women. Demirci and Fine [23] provided a precise determination of the position of the bladder neck by measuring
the displacement during cough in craniocaudal and ventrodorsal directions. The results obtained in this study are
comparable to those by Johnson et al. [24]. They found
the mean value of displacement of the bladder neck in the
craniocaudal direction during cough to be 1.65 cm in
women with stress urinary incontinence, and 0.32 cm in
continent women. Shaer et al. [25] found the same values
of the displacement of the bladder neck during cough, and
considered the measurement in the craniocaudal direction
to be sufficient for a preoperative diagnosis of stress urinary incontinence.
Due to increased intraabdominal pressure during
cough, the descent of the bladder neck scanned in the
craniocaudal direction is greater in incontinent than in
continent women. In our study the descent was significantly greater in the study group than in the control group
women in whom the position of the bladder neck was significantly lower at rest as well.
To provide the possibility of using perineal diagnostic
sonography in clinical urogynecology, the method
requires standardisation. We should define the maximal
range of displacement of the urinary bladder during
cough, still to be considered physiological. The first to
suggest the critical limit of 10 mm was Bergman and colleagues [26], who then calculated the specificity of the
method (89%) and its sensitivity. Caputo and Benson [27]
chose the same limit (10 mm) as Bergmans group [26].
In our study we decided on the threshold value of 15 mm
when assessing displacement of the bladder neck during
cough. Using this threshold value the calculated sensitiv-
ity of the method reached only 64%. If this value was

decreased to 12 mm, the sensitivity of the method
increased to 88%. At a 15-mm displacement of the bladder neck, the specificity was 96%; if the threshold value
was decreased to 12 mm, the specificity of the method
was still 92%.
When we considered the measured values of the displacement of 15 mm and more as pathological, the statistical analysis provided a 100% NPV of this method.
Predictive values show the agreement of the sonographic
measurement with the diagnosis of stress urinary incontinence. The PPV at the threshold value of 15 mm was only
44%. If we considered the 12-mm value, the PPV reached
57%, whereas the NPV of the test remained almost
unchanged, i.e., 98%. Furthermore, lowering the cut-off
to 10 mm, we found the PPV to be 76% and the NPV
95%.
The mean age of women was significantly lower in the
study group than that in the control group (46.1 8.5
years vs 53.8 10.8 years; p < 0.01)). In the study group
only 26% of women were postmenopausal, and in the
control group 68%. The difference between the groups
was statistically significant. With regard to parity, we
found no statistically significant difference between the
study and control group women. The results of our study
do not prove the influence of delivery on the occurrence
of stress urinary incontinence. In the analysis of the incidence of stress urinary incontinence in nulliparas, Scott
[28] found that 40% of women who have never delivered,
experienced problems with urinary leakage.
However, we found a statistically significant difference
in the type of work in both groups: 66% of women in the
study group, and only 48% in the control group did hard
physical work. A lower position of the bladder neck at
rest in the control group women could be explained by the
variables such as older age and age-related estrogen status. These features affect the function of the muscle connective structures of the supporting mechanism.
Hypoestrogenemia results in reduced type III collagen
production [29, 30]. Increased intraurethral pressure has
been proven in women who had undergone estrogen treatment [31-33].
Although it is known that the weakness of the supportive structures of the urinary bladder and proximal urethra
are the most evident reasons for the occurrence of stress
urinary incontinence, the actual relationship between
morphological and pathophysiological events remain
unknown.
Enhorning [34] claimed that the proximal urethra is
positioned intraabdominally and that the transmission of
the increased intraabdominal pressure on the urethra is
inappropriate when the urethra is displaced below the
pelvic floor [35, 36]. As the intraurethral pressure is not
increased stress urinary incontinence occurs. According
to this theory, the position of the bladder neck determines
continence. The studies made by Richardson et al. [37]
have elucidated the reasons for continence in women with
urethrocystocele, in whom the bladder neck is positioned
low. Their studies have confirmed the importance of par-
avaginal fascia for urinary continence [38-40]. The proximal urethra lies on the support consisting of pubocervical fascia, anterior vaginal wall, arcus tendineus fascie
pelvis and levator ani muscle. The effect of bilateral compression on the urethra depends on the stability of suburethral support and not on the position of the bladder neck
[41]. If the support is firm, the proximal urethra presses
against the support in case of increased intraabdominal
pressure. In case of a weak support, the bilateral compression of the urethra is not sufficient and the transmission of
intraabdominal pressure on the urethra is weaker; as the
lumen of the urethra remains open, urinary leakage
occurs. The extent of transmission of increased intraabdominal pressure does not depend on the high position of
the bladder neck, because the firm support, which is
responsible for continence, may also have a lower position [42-44].
Contractions of the detrusor can be quite efficiently
assessed on real-time US scan using a probe that provides
good resolution; the time lapse of the opening of the bladder neck and urinary leakage during cough is a warning
for the physician that the diagnosis of stress urinary
incontinence is unreliable. In this case, cystometry is
required, because this is the only procedure to exclude the
increase in the intravesical pressure for more than 15 cm
of water during spontaneous contractions of the detrusor,
which is necessary for the diagnosis of unstable detrusor
and appropriate treatment of urinary incontinence.
Diagnostic US of the lower urinary tract has numerous
advantages over radiological and morphological methods
for the patient and the examiner. The diagnostic perineal
approach combined with modern US equipment with
good imaging resolution provides optimal scans of
pathoanatomical changes of the pelvic floor.
Diagnostic perineal US scan is a simple, non-invasive,
cost-effective, safe and reproducible method providing
morphological assessment of hypermobility of the bladder neck and the proximal urethra. The method is well tolerated by the patients.
We found the perineal US examination to have the
highest performance when the threshold value, still considered physiological, of the displacement of the bladder
neck during cough was 12 mm. Taking this cut-off value
into consideration, the method has an 88% sensitivity and
a 92% specificity; the calculated PPV is then 96%, and
the NPV 79%.
References
[1] Kralj B., Lazarevski M.: Ginekoloka urologija. In: Ginekologija
i perinatologija, Kurjak A (ed.). Golden Times: Varadinske
Toplice, 1995, 439.
[2] Kralj B.: Epidemiology of female urinary incontinence, classification of urinary incontinence, urinary incontinence in elderly
women. Eur. J. Obstet. Gynecol. Reprod. Biol., 1994, 55, 39.
[3] Fischer W.: Epidemiologie der Harninkontinenz. In: Fischer W.,
Kolbl H. (eds.). Urogynaekologie in Praxis und Klinik, Berlin,
Walter de Gruyter, 1995, 192.
[4] Ghoniem G.M., Shoukry M.S., Yang A., Mostwin J.L.: Imaging
for urogynecology, including new modalities. Int. Urogynecol. J.,
1992, 3, 212.
377
[5] Reddy A.P., DeLancey J.O., Zwica L.M., Ashton-Miller J.A.: Onscreen vector-based ultrasound assessment of vesical neck movement. Am. J. Obstet. Gynecol., 2001, 185, 165.
[6] Kurjak A.: Atlas of ultrasonography in Obstetrics and Gynecology. Zagreb, Mladost, 1986.
[7] Summitt R.L. Jr., Bent A.E.: Genuine stress incontinence: an
overview. In: Ostergard D.R., Bent A.E. (eds.). Urogynaecology
and Urodynamics. Theory and Practice, 4th edition. Williams &
Wilkins, Baltimore, London, Los Angeles, 1996, 493.
[8] Bernaschek G., Deutinger J., Kratochwil A.: Diagnostic evaluation of urinary incontinence. In: Bernaschek G., Deutinger J.,
Kratochwill A. (eds.). Endosonography in Obstetrics and Gynecology, Springer-Verlag: Berlin, Heidelberg, New York, 1990, 123.
[9] Richmond D.H., Sutherst J.: Transrectal ultrasound scanning in
urinary incontinence: the effect of the probe on urodynamic
parameters. Br. J. Urol., 1989, 64, 582.
[10] Weil E.H., van Waalwijk van Doorn E.S., Heesakkers J.P., Meguid
T., Janknegt R.A.: Transvaginal ultrasonography: a study with
healthy volunteers and women with genuine stress incontinence.
Eur. Urol., 1993, 24, 226.
[11] Quinn M.J.: Vaginal ultrasound and urinary stress incontinence.
Contemp. Rev. Obstet. Gynaecol., 1990, 2, 104.
[12] Hol M., van Bolhuis C., Vierhout M.E.: Vaginal ultrasound
studies of bladder neck mobility. Br. J. Obstet. Gynaecol., 1995,
102, 47.
[13] Beco J., Sulu M., Schaaps J.P., Lambotte R.: A new approach to
urinary continence disorders in women: urodynamic ultrasonic
examination by the vaginal route. J. Gynecol. Obstet. Biol.
Reprod., 1987, 16, 987.
[14] Wise B., Cutner A., Cardozo L., Abbott D., Burton G.: The
assessment of bladder neck movement in postpartum women using
perineal ultrasonography. Ultrasound Obstet. Gynecol., 1992, 2,
116.
[15] Dietz H.P.: Ultrasound imaging of the pelvic floor. Part II: threedimensional or volume imaging. Ultrasound Obstet. Gynecol.,
2004, 23, 615.
[16] DeLancey J.O., Cullen Richardson A.: Anatomy of genital
support. In: Hurt G.W. (ed.). Urogynecologic Surgery, Raven
Press, New York, 1992, 19.
[17] Koelbl H.: Ultrasound in urogynecology. In: Ostergard D.R.,
Bent A.E. (eds.). 4th edition. Urogynecology and Urodynamics.
Theory and practice, Williams & Wilkins: Baltimore, London, Los
Angeles, 1996, 213.
[18] Enzelsberger H., Schatten C., Kurz C., Fitzal P.: Urodynamic and
radiologic parameters before and after loop surgery for recurrent
urinary stress incontinence. Acta Obstet. Gynecol. Scand., 1990,
9, 51.
[19] Richmond D.H., Sutherst J.R.: Clinical application of transrectal
ultrasound for the investigation of the incontinent patient. Br. J.
Urol., 1989, 63, 605.
[20] Mouritsen L., Rasmussen A.: Bladder neck mobility evaluated by
vaginal ultrasonography. Br. J. Urol., 1993, 71, 166.
[21] Kohorn E.I., Scioscia A.L., Jeanty P., Hobbins J.C.: Ultrasound
cystourethrography by perineal scanning for the assessment of
female stress urinary incontinence. Obstet. Gynecol., 1986, 68,
269.
[22] Meyer S., De Grandi P., Schreyer A., Caccia G.: The assessment
of bladder neck position and mobility in continent nullipara, mulitpara, forceps-delivered and incontinent women using perineal
ultrasound: a future office procedure?. Int. Urogynecol. J. Pelvic
Floor Dysfunct., 1996, 7, 138.
[23] Demirci F., Fine P.M.: Ultrasonography in stress urinary incontinence. Int. Urogynecol. J. Pelvic Floor Dysfunct., 1996, 7, 125.
[24] Johnson J.D., Lamensdorf H., Hollander I.N., Thurman A.E.: Use
of transvaginal endosonography in the evaluation of women with
stress urinary incontinence. J. Urol., 1992, 147, 421.
[25] Schaer G.N., Koechli O.R., Schuessler B., Haller U.: Perineal
ultrasound for evaluating the bladder neck in urinary stress incontinence. Obstet. Gynecol., 1995, 85, 220.
[26] Bergman A., Vermesh M., Ballard C.A., Platt L.D.: Role of ultrasound in urinary incontinence evaluation. Urology, 1989, 33,
443.
[27] Caputo R.M., Benson J.T.: The Q-tip test and urethrovesical junction mobility. Obstet. Gynecol., 1993, 82, 892.
378
[28] Scott J.C.: Stress incontinence in nulliparous women. J. Reprod.

Med., 1969, 2, 96.
[29] Walters M.D., Jackson G.M.: Urethral mobility and its relationship to stress incontinence in women. J. Reprod. Med., 1990, 35,
777.
[30] Falconer C., Ekman G., Malmstrm A., Ulmsten U.: Decreased
collagen synthesis in stress-incontinent women. Obstet. Gynecol.,
1994, 84, 583.
[31] Elia G., Bergman A.: Estrogen effects on the urethra: beneficial
effects in women with genuine stress incontinence. Obstet.
Gynecol. Surv., 1993, 48, 509.
[32] Fantl J.A., Cardozo L., McClish D.K.: Estrogen therapy in the
management of urinary incontinence in postmenopausal women: a
meta-analysis. First report of the Hormones and Urogenital
Therapy Committee. Obstet. Gynecol., 1994, 83, 12.
[33] Ulmsten U., Stormby N.: Evaluation of the urethral mucosa
before and after oestrogen treatment in postmenopausal women
with a new sampling technique. Gynecol. Obstet. Invest., 1987,
24, 208.
[34] Enhorning G.: Simultaneous recording of intravesical and intraurethral pressure. A study on urethral closure in normal and stress
incontinent women. Acta Chir. Scand. Suppl., 1961, 276, 1.
[35] McGuire E.J.: Active and passive factors in urethral incontinence
function. Int. Urogynecol. J., 1992, 3, 54.
[36] DeLancey J.O.: Structural aspects of the extrinsic continence
mechanism. Obstet. Gynecol., 1988, 72, 296.
[37] Richardson D.A., Bent A.E., Ostergard D.R.: The effect of
uterovaginal prolapse on urethrovesical pressure dynamics. Am.
J. Obstet. Gynecol., 1983, 146, 901.
[38] DeLancey J.O.L.: Pubovesical ligament: A separate structure
from the urethral supports (pubo-urethral ligaments). Neurourol.
Urodynam., 1989, 8, 53.
[39] DeLancey J.O.: Structural support of the urethra as it relates to

stress urinary incontinence: the hammock hypothesis. Am. J.
Obstet. Gynecol., 1994, 170, 1713.
[40] DeLancey J.O.L.: Anatomy of the female bladder and urethra.
In: Ostergard D.R., Bent A.E. (eds.) Urogynecology and
Urodynamics, 3rd edition. William & Wilkins, New York, London,
1991, 3.
[41] Boutteville C., Anidjar M., Crequat J., Boccon-Gibod L.,
Madelenat P.: Urodynamic ultrasonography in the management of
urinary disorders in women. Contracept. Fertil. Sex, 1993, 21,
317.
[42] Gosling J.A., Dixon J.S., Critchley H.O., Thompson S.A.: A comparative study of the human external sphincter and periurethral levator ani muscles. Br. J. Urol., 1981, 53, 35.
[43] DeLancey J.O.: Anatomy and physiology of urinary continence.
Clin. Obstet. Gynecol., 1990, 33, 298.
[44] DeLancey J.O., Starr R.A.: Histology of the connection between
the vagina and levator ani muscles. Implications for urinary tract
function. J. Reprod. Med., 1990, 35, 765.

T.S. PATRELLI, M.D.
Department of Obstetrics, Gynecology
and Neonatology
University Hospital of Parma
Antonio Gramsci, 14
43126 Parma (Italy)
e-mail: titosilvio.patrelli@gmail.com
22 1193-30 - A new classification:1648_29 Incidence of multiple 15/11/11 14:44 Pagina 379
[1193/30]
379

A. Aflatoonian1, B. Baghianimoghadam1, P. Partovi1, A. Abdoli1, P. Hemmati2,
N. Tabibnejad1, M. Dehghani3
1
Research and Clinical Center for Infertility, Shaheed Sadoughi University of Medical Sciences, Yazd
Center for Disease Control, Deputy Ministry for Health Affairs, Ministry of Health and Medical Education, Tehran
3
Human Genetics Department, Shaheed Sadoughi University of Medical Sciences, Yazd (Iran)
Summary
Infertility is defined as the inability of a couple to conceive after 12 months of regular, unprotected intercourse. However infertility
is a clinical presentation and not a disease. Thus to be able to offer a new classification, it is necessary to apply a clinical presentation
(philosophy) suggested by the University of Calgary in 1991. In recent years several classification algorithms have been proposed which
apply key predictors of clinical, imaging, or morphological types to determine the diseases that can cause infertility. On the other hand,
an algorithm is a product of an experts mind after many years of practice and experience, which is too difficult to understand by a
medical student. However there has not been any simple schematic classification based on a logical justification applying integration
of etiologies with basic science to break down etiologies into categories, subcategories and disease classes of this clinical presentation.
Because etiology has also become an important criterion for the characterization of causes of infertility, a classification proposal is presented here that attempts to include all relevant (basic science) features of the causative diseases of this clinical presentation.
Key words: Infertility; Clinical presentation; Etiology; Classification.
Introduction
Infertility is defined as the inability of a couple to conceive after 12 months of regular, unprotected intercourse.
So infertility is not a disease with a particular etiology. In
recent years several classification schemes have been proposed which focus on the clinical, imaging, or morphological features of the diseases that can cause infertility but all
the classifications were based on a diagnostic approach to
female infertility. Today based on our research there is one
accepted etiologic classification of infertility that is used in
almost all textbooks with minor changes and also one other
accepted approach that could be an approved classification
if simplified. We will discuss them and discuss our proposed etiologic scheme, justified by completely using
basic scientific concepts.
Causes of female infertility are a combination of
several factors that reflect the complications of different
aspects of the diagnosis.
According to an accepted classification by many reputable clinical textbooks [1-4], it divides female infertility into amenorrhea/ovulatory dysfunction (46%), tubal
defects (38%), endometriosis (9%) and others (7%) and
then divides amenorrhea/ovulatory dysfunction into four
subcategories including hypothalamic pituitary causes
(51%), polycystic ovarian syndrome (30%), premature
ovarian failure (12%) and uterine or outflow tract disorders (7%). As can be noted in this classification the
authors emphasis is on epidemiology and prevalence of
predisposing factors of female infertility, and mechanism
of disease is inconspicuous.
Revised manuscript accepted for publication January 11, 2011

XXXVIII, n. 4, 2011
Another classification approach is presented in

Novaks textbook of gynecology [4]. Although at first
view this is not a classification but an approach, if we
simplify it and omit suggested diagnostic ways, we can
find a classification. In first line it divides female infertility into anovulation, tubal factor, unexplained infertility endometriosis, and uterine factor. After that it
divides anovulation into hypothalamic disorders,
thyroid diseases, hyperprolactinemia, and panhypopituitarism. Ovarian disorders in this approach are studied
separately. There are no further subclasses for tubal
factors.
Methods
In 2007 in the Research and Clinical Center for Infertility
(Yazd University of Medical Sciences, Iran) we decided to
make a simple etiologic classification for female infertility. We
recruited a research team combined of four medical students, a
professor in infertility, and medical educator. During the study
phase we also benefitted by consultations with other members
of the Gynecology and Infertility Department, Faculty of Medicine at Yazd University of Medical Sciences. We started with a
watchful study on basic physiology and anatomy of the female
reproductive tract. After that we made a primary classification
based on all possible disorders in this physiologic and anatomic
system. Then we tried to match all known diseases that might
alter this system and cause infertility.
Making the scheme was based on the clinical presentation
curriculum (CPC) which was the latest medical education curriculum generated by the University of Calgary in Canada [5].
We consulted with an authority from the University of Calgary,
which is the pioneer in designing the schemes, and our medical
educator.
380
A. Aflatoonian, B. Baghianimoghadam, P. Partovi, A. Abdoli, P. Hemmati, N. Tabibnejad, M. Dehghani
Thyroid
dysfunction
Female
genitalia
movement/
mucosal
secretion
defect
Table 1. Finalized schematic classification of female infertility.
Results
We divided female infertility into three main causes
(category): ovulation dysfunction, fecundation pathway
and implantation disorders (uterine). The fecundation
pathway is a new term that we devised to make the first
line of our scheme on the same level with the other two
main categories. The fecundation pathway means the way
that sperm must transfer from external genitalia to ovum
and fecundate.
Ovulation dysfunction was divided in four subcategories: hypothalamic-pituitary axis disorders, thyroid disorders, hyperprolactinemia and ovarian disorders.
Ovarian disorders were divided into polycystic ovarian
syndrome, premature ovarian failure and decreased
ovarian reserve.
The fecundation pathway was divided into anatomical
pathway defects, female genitalia/mucosal secretion
defects, cellular fecundation and peritoneal factors.
Implantation disorders did not have a subcategory.
In this scheme we started with the main causes (categories) of female infertility and then put each category
into subcategories. We tried to put the main etiology into
detailed categories with each of them including a group
of categories. It is note-worthy that after the last sub or
sub-sub category we had some diseases whose mechanisms in infertility are the same.
In other classifications endometriosis has a separate
category but endometriosis is a disease that we considered as a disease in the category of peritoneal factors.
There is no limitation in placing a disease under more

than one subcategory because the same diseases have
several mechanisms that cause infertility. For example
TB can cause infertility by causing tubal defects or
implantation disorders (Table 1).
It is encouraging when we know that based on this classification we can make a simpler diagnosis because we
have a main key predictor for each category. To diagnose
ovulation dysfunction from the fecundation pathway and
implantation disorders our key predictor was the menstrual pattern. Menstrual irregularity gave us a diagnosis
of ovulation dysfunction with high sensitivity and specificity. For differentiation of ovarian disorders from the
hypothalamic-pituitary axis, thyroid dysfunction and
hyperprolactinemia we found some key paraclinical
signs. For example, in ovarian disorders in our prototype
for diseases we found a normal FSH and LH/FSH ratio
of more than 2. However in thyroid dysfunction we found
specific lab data for hypo or hyperthyroidism. Also we
could differentiate anatomical pathway defects from
other disease classes in the same level by detecting
obstruction in hysterosalpingography (HSG), hysteroscopy or laparoscopy. Every disease class has specific
key predictors. For example, IVF failure is the key predictor of the cellular fecundation category (if other diseases are ruled out).
We tried to make this classification (Table 1) as a broad
picture for all causative diseases of infertility and justify
every part of it with anatomy and physiology of female
the reproduction system. This may help medical students
381
to memorize and also categorize etiologies of female

infertility better than previous classifications and even
approaches.
consultations. We also must thank the Ministry of Health and

Medical Education of I.R. Iran and WHO for their financial
support.
Conclusions
References
In comparison with our new classification and previous

ones, it is notable that ours is more detailed. In all other
classifications we can see an unknown word unexplained
infertility. In fact when authors could not justify the cause
of infertility they used this word. Nonetheless it is obvious
that anything is not without cause. Thus we decided to
approach this problem via physiology and anatomy of
reproduction. Based on this approach we can claim that we
included all causes (explained or unexplained causes). In
Novaks classification ovarian disorders are separated,
whereas the mechanism is by anovulation.
We believe that the new classification of female infertility can provide better concepts about all causative etiologies of female infertility. However the authors are not
free of competing ideas and revisory suggestions that
could improve it.
[1] Fauci A.S., Braunwald E., Kasper D.L., Hauser S., Longo D.,
Jameson J.L., Loscalzo J. (eds.). Harrisons Principles of Internal
Medicine, 17th edition, New York, McGraw-Hill Medical. 2008.
[2] Gibbs R.S., Karlan B.Y., Haney A.F., Nygaard I.E.: Danforth's
Obstetrics and Gynecology. 10th edition, Philadelphia, Lippincott
Williams & Wilkins, 2008,
[3] Speroff L., Fritz M.A.: Clinical Gynecologic Endocrinology and
Infertility, 7th edition, Philadelphia, Lippincott, Williams & Wilkins,
2004.
[4] Berek J.S. Berek & Novak's Gynecology, 14th edition, Philadelphia,
Lippincott, 2006.
[5] Mandin H., Harasym P., Eagle C., Watanabe M.: Developing a
"clinical presentation" curriculum at the University of Calgary.
Acad. Med., 1995, 70, 186.
Acknowledgment
Special thanks to Prof. Peter Harasym for his guidance, and
to all scientific members of the Research and Clinical Center for
Infertility (Yazd University of Medical Sciences, Iran) for their

B. BAGHIANIMOGHADAM, M.D.
Falahi BLVD
Bu ali street
Research and Clinical Center for Infertility
Yazd (Iran)
e-mail: behnam.baghian@gmail.com
23 1208-31 - Correlatio between:1648_29 Incidence of multiple 15/11/11 14:45 Pagina 382
[789/27]
[1208/31]
382
Correlation between fetal movement revealed in actography

and fetal-neonatal well-being: observational study
on 3,805 pregnancies followed in a Northern Italy tertiary
care hospital
T.S. Patrelli1,2,3, F. DAddetta1, S. Gizzo3, L. Franchi1, S. Di Gangi3, N. Sianesi1, F. Peri1,
G. Pedrazzi4, R. Berretta1, G. Piantelli1, A. Lukanovic2, G.B. Nardelli3, A. Bacchi Modena1
1
Department of Obstetrics and Gynecology, University Medical Center Parma (Italy)
Department of Obstetrics and Gynecology, University Medical Center Ljubljana (Slovenia)
3
Department of Obstetrics and Gynecology, University Medical Center Padova (Italy)
4
Department of Public Health, University of Parma (Italy)
Summary
Purpose of investigation: To evaluate the correlation between fetal movement revealed in cardiotocography and fetal-neonatal
well-being as well as to assess the value of cardiotocography in our clinical practice. Methods: Retrospective analysis of 3,805 pregnancies followed at Parma General Hospital. Exclusion criteria were cesarean section, preterm delivery, and stillbirth. We analyzed
the predictive power of actography during the dilating and expulsive phases of labor by establishing a correlation between number
of fetal movements and our neonatal indexes of well being, i.e., cardiotocographic score, Apgar index and neonatal pH value. Statistical tests used were Fishers test, chi-square test (X2), Pearson correlation and Spearman Rho; p value was considered significant
if it was less than 0.05. Results: We considered 2,389 vaginal deliveries. Analyzing the correlation between fetal movement and cardiotocographic score in the two different phases of labor, the comparison among subpopulations identified by different cardiotocograph scores revealed no statistical difference. Conclusion: Cardiotocography is reconfirmed as a good instrument to evaluate neonatal outcome, while actigraphy cannot be used alone to define fetal well-being, mainly due to the inability to standardize assessment
of the actographic study.
Key words: Actigraphy; Cardiotocography; Fetal well-being; Neonatal well-being; Mode of delivery; Medico-legal implications.
Introduction
To reduce perinatal morbidity and mortality rates it is
necessary to have an adequate control system of fetal
well-being. In the 70s this attempt was discharged by the
introduction of cardiotocography, a technique of monitoring fetal well-being able to identify impromptu conditions of fetal distress. Since its introduction in obstetric
clinical practice cardiotocography has achieved a fundamental role in obstetric decision making in the delivery
room, thus it has a crucial role in defining timing and
mode of delivery. Up to date cardiotocography is the gold
standard technique for fetal well-being surveillance in the
third trimester of pregnancy, in particular by the 28th gestational week, and more during labor [1]. As a screening
test its aim is to identify early acute intrapartum hypoxia
in order to prevent fetal consequences with an early intervention by obstetricians [2]. Since its routine introduction
in the clinical evaluation of fetal well-being, cardiotocography has been an important instrument even under legal
and medico-legal aspects. There is a direct correlation
between a low reassuring cardiotocogram and the modality of delivery, vaginal or abdominal mode [3]. Thus an

XXXVIII, n. 4, 2011
accurate analysis of the cardiotocogram makes it possible

to evaluate the clinical evolution of labor in the medicolegal area, even post partum [4]. Indeed in the literature
it is well known that there is a close correlation between
pathologic cardiotocogram and unfavorable fetal
outcome, and also the correlation between a non reactive
cardiotocography (CTG) and increased fetal morbidity
and mortality, especially in high-risk pregnancies [5].
The primary endpoint of our study was to evaluate the
correlation between fetal movement revealed in the CTG
(echocardiography) and fetal-neonatal well-being. The
secondary endpoint was to assess the value of CTG in our
clinical practice.
Our study was a retrospective analysis of 3,805 pregnancies
followed in the Obstetric and Gynecological Clinic of the University of Parma from 1 January 2008 to 30 June 2009. The
selection of patients was done based on mode of delivery, gestational age and fetal condition. Exclusion criteria were:
Delivery by cesarean section (urgent or elective)
Preterm delivery (before 38 gw)
Fetal endouterine death before labor
For each pregnancy we considered gestational and maternal
age, but our attention was focused on the CTG during dilation
and expulsive phases of labor. We used a scoring system for the
Correlation between fetal movement revealed in actography and fetal-neonatal well-being: observational study on 3,805 etc.
CTG to systematize the analysis; in particular we used the

Arduini et al. scoring system [6], still used in practical obstetric management in our institute. The score was called Score D
for the dilation period and Score E for the expulsive phase. The
cardiotocographic track was compared with the value of zero in
absence of fetal movement, 1 point if one-two movements were
revealed in 30 minutes, and 2 points if more than two fetal
movements were seen in 30 minutes. For neonatal well-being
we considered the physiologic pH value more or equal to 7.25
and the pathologic pH value less than 7.25 [7, 8]. Neonatal
weight was considered normal in a range from 2,500 to 3,200
kg [9], as we took into account term pregnancies. We analyzed
the predictive power of actigraphy during the dilation and
expulsive phases of labor by establishing a correlation between
number of fetal movements and our neonatal indexes of wellbeing, i.e., CTG score, Apgar index and neonatal pH value. The
other part of our study was the evaluation of the cardiotocographic track during the two different phases of labor, dilation
and expulsive periods, considering correlations of the cardiotocographic score [6] and Apgar index and neonatal pH
value, and weight in each of the two considered periods.
Statistical analysis was done by SPSS software for Windows
18. Statistical tests used were Fishers exact test, chi-square test,
Pearsons correlation and Spearman rho.
A p value was considered significant if it was less than 0.05
and highly significant if less than 0.01.
Results
We considered 2,389 vaginal deliveries of which 2,166
(94.9%) were spontaneous vaginal deliveries and 223
(5.1%) operative vaginal deliveries (using a disposable
vacuum extractor and/or forceps). Median maternal age
was 32 years (interquantile range 28-35 years). Median
gestational age was 278 days (interquartile range 272.25283). From the analysis of the CTG during the dilation
phase a median value of Score D was 8 (interquartile distance equal to one), while median value of Score E was
7 (interquartile distance equal to one).
From the analysis of correlations between fetal movement and cardiotocographic score in the two different
phases of labor, in the dilation period among cases with
a high rate of fetal movement (1,503), 86 cases (5.7%)
had a Score D less or equal to 6, 808 cases (53.8%) had
a Score D equal to 7, and 609 cases (40.5%) had a Score
D equal to 8. Among cases with a low rate of fetal movements (886), 151 case (17.04%) had a Score D less or
equal to 6, 135 cases (15.2%) had a Score D equal to 7,
and 600 cases (67.7%) had a Score D equal to 8. Comparison among subpopulations identified by different
CTG scores revealed no statistical difference. Analyzing
the correlation between fetal movements and Score E,
among cases with a high movement rate (2,365), 347
cases (14.7%) had a Score E less or equal to 6,903 cases
(38.2%) had a Score E equal to 7, and 1,115 cases
(47.1%) had a Score E equal to 8. All fetuses with a low
movement rate (22) or absence of movement (2) had a
Score D less or equal to 6. Comparison among subpopulations identified by different CTG scores revealed no
statistical difference.
We also considered the correlation between fetal move-
383
ment from the CTG during the two phases of labor and
neonatal outcome by evaluation of the Apgar index.
During the dilation period among cases with a high fetal
movement rate (1,434), 60 cases (4.2%) had an Apgar
index equal to 8, 1,302 cases (90.8%) had an Apgar index
equal to 9 and 72 cases (5.2%) had an Apgar index equal
to 10, whereas among cases with an ante-partum low
fetal movement rate (825), 39 cases (4.7%) had an Apgar
index equal to 8, 783 cases (94.9%) had an Apgar index
equal to 9 and three cases (0.3%) had an Apgar index
equal to 10. Comparison among subpopulations identified by Apgar index values revealed no statistical differences.
From our analyses during the expulsive phase of labor
in cases with a high fetal movement rate (2,245), 96 cases
(4.3%) had an Apgar index equal to 8, 2,075 cases
(92.4%) had an Apgar index equal to 9 and 74 cases
(3.3%) had an Apgar index equal to 10, while in cases
with an ante-partum low fetal movement rate (12), three
cases (25%) had an Apgar index equal to 8, eight cases
(66.7%) had an Apgar index equal to 9 and one case
(8.3%) had an Apgar index equal to 10. All cases with no
fetal movement (2 fetuses), had an Apgar index equal to
9 at birth. Comparison among subpopulations identified
by the Apgar index value revealed no statistical differences.
We then considered the correlation between fetal
movement from the cardiotocographic track during the
two phases of labor and neonatal outcome by evaluation
of the neonatal pH value by blood gases on cord blood
immediately after the delivery. During the dilation period
in cases with a low fetal movement rate (886), 54 cases
(6.1%) had a pH value less than 7.25 and 832 cases
(93.9%) had a pH value more or equal to 7.25, whereas
in cases with a high fetal movement rate (1,503), 82 cases
(5.5%) had a pH value less than 7.25 and 1,421 cases
(94.5%) had a pH value more or equal to 7.25. Comparison among subpopulations identified by neonatal pH
value revealed no statistical differences.
From our analyses during the expulsive period, considering the correlation between fetal movement from the
cardiotocographic track and neonatal outcome by evaluation of neonatal pH value, among cases with no antepartum fetal movements (2 fetuses), all had a pH value
less than 7.25 and none had a pH value more or equal to
7.25. Among cases with a low fetal movement rate (22),
six cases (27.3%) had a pH value less than 7.25 and 16
cases (72.7%) had a pH value more or equal to 7.25,
whereas among cases with a high fetal movement rate
(2,365), 130 cases (5.5%) had a pH value less than 7.25
and 2,235 cases (94.5%) had a pH value more or equal to
7.25. Comparison among subpopulations identified by
neonatal pH value revealed no statistical differences.
Considering the correlation between Score D and Score
E, among 237 fetuses with Score D less or equal to 6
(93.2%), 221 cases had the same score even in the expulsive period, while 16 cases had a SCORE E equal to 7,
and none had a Score E equal to 8. Of 943 fetuses with
Score D equal to 7, 150 cases (15.9%) had a Score E less
384 T.S. Patrelli, F. DAddetta, S. Gizzo, L. Franchi, S. Di Gangi, N. Sianesi, F. Peri, G. Pedrazzi, R. Berretta, G. Piantelli et al.
or equal to 6, 789 cases (83.6%) had a Score E equal to

7 and four cases (0.4%) had a Score E equal to 8. Among
1209 fetuses with Score D equal to 8, none had a Score
E less or equal to 6, 98 cases (8.1%) had a Score E equal
to 7 and 1111 cases (91.9%) had a Score E equal to 8.
On completion of the analysis on actography, a possible correlation was considered between cardiotocographic score and neonatal outcome defined by neonatal
weight, Apgar index and neonatal pH value. A proportional correlation was noticed between cardiotocographic
score values and neonatal Apgar index in the dilation
period and the expulsive period of labor, respectively
with p < 0.0001 (Spearman p = 0.175) and p < 0.0001
(Spearman p = 0.126).
There was also a proportional correlation between
values of the cardiotocographic score and neonatal pH
values in both the dilation and expulsive phases of labor,
respectively with p < 0.0001 (Spearman p = 0.112) in the
dilating period and p < 0.0001 (Spearman p = 0.115) in
the expulsive period.
A statistically significant correlation was noted
between Score E and neonatal weight with p < 0.0001
(Spearman p = 0.74). Finally a proportional correlation
between neonatal pH values and Apgar index was seen
with p < 0.0001 (Pearson p = 0.140).
Discussion
Since CTG can evaluate fetal heart rate and its relation
with uterine tone, it plays an important role in the evaluation of fetal well-being during labor and in identifying
fetal suffering due to hypoxia. Thus it is a fundamental
step in obstetric decision making to define a quick delivery in cases at risk of fetal suffering. In the literature the
role of actigraphy is still described as an instrument to
better evaluate fetal well-being together with cardiotocography. Actography is able to reduce false-positive non reassuring the CTG, increasing predictive value
and specificity of the latter in determining neonatal
outcome in the ante-partum period [10-13]. A close correlation between fetal heart rate and fetal movement has
been described as a highly significant index of fetal wellbeing. Accelerations often precede or coincide with fetal
movement from the 26th-28th gestational weeks [14]. This
finding supports the hypothesis of a coordinated control
of acceleration and fetal movement by the autonomous
nervous system and negates the idea that acceleration
happens as consequence of fetal movement [14]. In a non
reassuring CTG, with absence of acceleration and low
variability, low or absent fetal movements suggest fetal
hypoxia thus establishing fetal distress [12, 13]. Finally
actigraphy and CTG can be used together in a diagnostic
algorithm to predict a sudden and imminent fetal distress
[12, 13]. In the literature fetal movements have been
described in the presence of big accelerations in the CTG
since there is a close association between fetal movements and big accelerations in 99.6% of cases [15].
The endpoint of our study was to evaluate if actography alone could be a useful parameter of good neonatal
outcome in the prenatal period. We considered a correlation between fetal movement revealed in actography and
cardiotocographic score also during labor. The aim was
to define if actigraphy could help cardiotocography in
defining modus operandi in the delivery room, since
today obstetric management in the delivery room is based
on evaluation of the cardiotocographic track. We analyzed the prognostic power of actography, establishing a
relation between fetal movement and common fetal wellbeing indexes, such as neonatal pH, Apgar index, and
neonatal weight. As a control we also compared CTG
scores with the same indexes of neonatal outcome in both
periods of labor, dilation and expulsion. The results
demonstrated that there is no correlation between absence
of fetal movements and low Apgar score, or low neonatal pH value or neonatal weight out of physiologic range,
in either the dilating or expulsive phase of labor. These
findings support the idea that actography is not useful in
monitoring fetal well-being during labor, while it has an
important role in monitoring fetuses during the last weeks
of gestation. This is in accord with results of studies conducted by Mangesi and Hofmeyr [16], but not by the
results of Maeda and Zhao [13, 14]. As widely described
in the literature [3, 4, 11, 17, 18], it has been the correspondence between progressively higher CTG scores and
better fetal well-being indexes during labor has been
reconfirmed. Particularly, in our study during dilation the
cardiotocographic score correlated with a good Apgar
index and neonatal pH value, whereas in the expulsive
period the cardiotocographic score was also correlated
with neonatal weight in the optimal range with a good
Apgar index and a good neonatal pH value.
Thus CTG is reconfirmed as a good instrument to evaluate neonatal outcome, while actigraphy alone cannot be
used to define fetal well-being, mainly due to the inability to standardize assessment of the actographic study.
References
[1] Grivell R.M., Alfirevic Z., Gyte G.M., Devane D.: Antenatal cardiotocography for fetal assessment. Cochrane Database Syst.
Rev., 2010, 20, CD007863.
[2] Pattison N., McCowan L.: Cardiotocography for antepartum fetal
assessment. Cochrane Database Syst. Rev., 2000, CD001068.
Review. Update in: Cochrane Database Syst Rev. 2010, CD001068.
[3] Hardwick J.C., Duthie S.J.: Can cardiotocography prior to induction of labour predict obstetric intervention? A pilot study. J.
Obstet. Gynaecol., 2001, 21, 258.
[4] Bailey R.E.: Intrapartum fetal monitoring. Am. Fam. Physician.,
2009, 80, 1388.
[5] Freeman R.K.: Problems with intrapartum fetal heart rate monitoring interpretation and patient management. Obstet. Gynecol.,
2002, 100, 813.
[6] Arduini D., Valensise H.: Cardiotocografia Clinica. Roma, CIC
Edizioni Internazionali, 2007.
[7] MacLennan A.: A template for defining a causal relation between
acute intrapartum events and cerebral palsy: international consensus statement. BMJ, 1999, 319, 1054.
[8] Ross M.G., Gala R.: Use of umbilical artery base excess: algorithm for the timing of hypoxic injury. Am. J. Obstet. Gynecol.,
2002, 187, 1.
[9] Ingemarsson I.: Fetal monitoring during labor. Neonatology,
2009, 95, 342.
Correlation between fetal movement revealed in actography and fetal-neonatal well-being: observational study on 3,805 etc.
[10] Devoe L., Boehm F., Paul R., Frigoletto F., Penso C., Goldenberg
R. et al.: Clinical experience with the Hewlett-Packard M-1350A
fetal monitor: correlation of Doppler-detected fetal body movements with fetal heart rate parameters and perinatal outcome. Am.
J. Obstet. Gynecol., 1994, 170, 650.
[11] Maeda K., Iwabe T., Yoshida S., Ito T., Minagawa Y., Morokuma
S. et al.: Detailed multigrade evaluation of fetal disorders with
the quantified actocardiogram. J. Perinat. Med., 2009, 37, 392.
[12] Maeda K., Tatsumura M., Nakajima K.: Objective and quantitative evaluation of fetal movement with ultrasonic Doppler actocardiogram. Biol. Neonate, 1991, 60 (suppl. 1), 41.
[13] Maeda K.: Quantitative studies on fetal actocardiogram. Croat.
Med. J., 2005, 46, 792.
[14] Zhao H., Wakai R.T.: Simultaneity of foetal heart rate acceleration and foetal trunk movement determined by foetal magnetocardiogram actocardiography. Phys. Med. Biol., 2002, 47, 839.
[15] Rabinowitz R., Persitz E., Sadovsky E.: The relation between
fetal heart rate accelerations and fetal movements. Obstet.
Gynecol., 1983, 61, 16.
[16] Mangesi L., Hofmeyr G.J.: Fetal movement counting for assessment of fetal well-being. Cochrane Database Syst. Rev., 2007,
(1): CD004909.
385
[17] Schiermeier S., Pildner von Steinburg S., Thieme A., Reinhard J.,
Daumer M., Scholz M. et al.: Sensitivity and specificity of intrapartum computerised FIGO criteria for cardiotocography and fetal
scalp pH during labour: multicentre, observational study. BJOG,
2008, 115, 1557.
[18] Zimmer E.Z., Divon M.Y., Vadasz A.: The relationship between
uterine contractions, fetal movements and fetal heart rate patterns
in the active phase of labor. Eur. J. Obstet. Gynecol. Reprod.
Biol., 1987, 25, 89.

T.S. PATRELLI, M.D.
Via P.P. Vergerio, 33
35126 Padua (Italy)
e-mail: titosilvio.patrelli@gmail.com
24 1229-31 - Factors associated:1648_29 Incidence of multiple 15/11/11 14:47 Pagina 386
[789/27]
[1229/31]
386
Factors associated with the success of external cephalic

version (ECV) of breech presentation at term
N. Obeidat1, I. Lataifeh1, M. Al-Khateeb2, F. Zayed1, W. Khriesat3, Z. Amarin1
1
Department of Obstetrics and Gynaecology, King Abdullah University Hospital, Jordan University of Science and Technology (JUST), Irbid
2
Prince Rashid Ben Al-Hassan Military Hospital
3
Department of Pediatrics, King Abdullah University Hospital, Jordan University of Science and Technology (JUST), Irbid (Jordan)
Summary
Objective: To evaluate the predictors of success of ECV for breech presentation at term. Methods: A retrospective study was conducted over a 3-year period from 2005-2007, where 101 patients who had singleton breech presentation at term were undergoing
external cephalic version (ECV) after 37 weeks of gestation at two major teaching hospitals in the North of Jordan. Comparative
analysis was made between the successful ECV and unsuccessful ECV groups. The collected data were analysed by using statistical analysis Sudents t-test and Mann-Whitney test as appropriate and on discrete results chi square or Fishers exact test when appropriate. The differences were considered significant at a p value of < 0.05. Results: The ECV success rate was 72.3%. Favourable
factors for success were multiparity (95.5% vs 4.1%, p = 0.0001), flexed breeches (74% vs 26%, p = 0.002), posterior placenta
(38.6% vs 16.4%, p = 0.0001) and anterior fetal back (53.4% vs 34.8%, p = 0.03). Once turned the babies remained cephalic until
delivery. All the 28 cases who had failed ECV had caesarean section. Among those who had a successful external cephalic version,
the incidence of intrapartum caesarean section was only 8.2% which was lower than that of the average of both units caesarean rate
(28%). There were no complications related to the ECV procedure in the study. Conclusion: Multiparity, flexed breech, posterior
placenta, and anterior foetal back were the most favourable factors for successful ECV in our study. Moreover, with careful evaluation of individual predictors patient selection and success rates can be optimised.
Key words: ECV; Breech presentation.
Introduction
Breech presentation occurs in 3-4% of all pregnancies
at term [1]. In many countries, caesarean section (CS) is
now considered the preferred mode of delivery for pregnant women with breech presentation at term. This trend
was adopted following the Term Breech Trial which
demonstrated lower neonatal risks with CS compared to
vaginal breech delivery [2, 3]. Caesarean delivery for
breech presentation accounts for approximately 15% of
all abdominal deliveries [4]. Recent studies have
described the predictors of success of external cephalic
version (ECV), such as multiparity, amniotic fluid
volume, foetal weight, and the type of breech [5, 6].
ECV is now routinely offered in many obstetric units
with significant reduction in the breech presentations and
number of CS performed for this malpresention. Therefore, ECV has become an attractive alternative to CS of
breech presentation at term [7-9]. In spite of the fact that
ECV is a safe and effective procedure when performed at
term, the mothers and obstetricians acceptance to have
a trial varies [10]. Leung et al. reported mothers refusal
of an ECV attempt from 18% to 76% [11]. The success
rate of ECV has been reported to vary from 41% to 77%
[12-14].
In Jordan, as in many other developing countries,
where ECV is not a popular procedure, CS is usually the
mode of choice for the delivery of a woman with breech
presentation at term.
Revised manuscript accepted for publication March 16, 2011
XXXVIII, n. 4, 2011
This retrospective study evaluates the factors associated with the success of ECV for breech presentation at
term in two obstetric units in the North of Jordan.
A retrospective study and chart review was performed to
evaluate ECV for breech presentation at term in two obstetric
units: King Abdullah University Hospital (KAUH) and Prince
Rashid Ben Al-Hassan Military Hospital (PRBAMH) in Irbid,
northern Jordan. The study was conducted over a 3-year period
from January 2005 to December 2007.
Data was retrieved from the medical records at the two hospitals by using Excel spread sheets. The hospital charts of all
pregnant women with breech presentation at term were
reviewed to collect the following data: age, weight, parity, gestational age, type of breech, position of foetal back, placental
location, amniotic fluid index, mode of delivery, foetal weight,
Apgar score, and foetal gender.
The exclusion criteria for ECV included patients who had any
contraindication to vaginal delivery (e.g., placenta previa), multiple pregnancies, previous uterine scar, major foetal abnormality, intrauterine growth restriction (IUGR), abnormal cardiotocogram in established labor, premature rupture of
membranes (PROM), preeclampsia, oligohydramnios (amniotic
fluid index < 5 cm), and polyhydramnios (amniotic fluid index
> 25 cm), as well as taking into consideration the obstetricians
and patients involvement in the study.
Women were admitted to the delivery room and consented to
the procedure and possible emergency CS if needed. A reactive
cardiotocogram (CTG) and known rhesus blood group were
prerequisites for the procedure. Obstetric history was reviewed
and an ultrasonographic (US) scan was performed before the
procedure to exclude any contraindications.
ECV was only performed by physicians who were experienced in performing the procedure. US examination was performed immediately after the procedure to confirm successful
version and to exclude foetal bradycardia. The CTG was then
repeated at the conclusion of the version. Women who had successful version and reactive CTG were discharged home and
followed in an antenatal clinic waiting for spontaneous labour.
The option of immediate induction of labour after successful
version was allowed. Women who had an unsuccessful ECV
were advised to have an elective CS. No anaesthesia, analgesia,
or sedation were used during ECV.
Statistical analysis was performed as comparative analysis
between the successful and failed ECV groups using the
Students t-test and Mann-Whitney test as appropriate and on
discrete results chi square or Fishers exact test when appropriate. The differences were considered significant at p < 0.05.
Results
During the 3-year study period, there were a total of
20,000 deliveries of which 5,600 caesarean sections were
performed giving a caesarean section rate of 28%. There
were 620 singleton breech presentations at term. Of the
620, only 101 charts were reviewed in this study. Those
cases that were included in our study were mainly those
who accepted the ECV attempt (obstetrician or patient).
The two groups were similar in baseline characteristics
(Table 1). Only eight patients were rhesus negative, and
they received anti-D prophylaxis at the conclusion of the
procedure.
Table 2 shows a comparison of the clinical features of
the participants.
Table 3 shows the clinical outcomes in both groups.
Discussion
The rising caesarean section rate with its associated
maternal morbidity and cost encouraged obstetricians to
seek an alternative other than vaginal delivery for the
management of breech at term and that is ECV. This technique has been known for 50 years [15].
There has been a resurgence in the use of external
cephalic version in recent years possibly due to a few
factors. First, due to the medicolegal aspect in considering the morbidity of vaginal breech delivery a liability,
and residents are less and less experienced in delivering
breeches vaginally. Finally, healthcare providers have
been pressured to consider the economic impact of caesarean birth [16].
Previous studies have examined maternal and foetal
factors related to successful ECV [5, 17-19]. The factors
have varied from study to study and conclusions have
been inconsistent. Kok and colleagues studied in a metaanalysis 53 primary articles reporting on 10,149 women
and found that multiparity, nonengagement of the breech,
a relaxed uterus, a palpable foetal head, and maternal
weight less than 65 kg were good factors for successful
ECV [20].
Our success rate of ECV at term of 72% compares
favourably with that of previous reports. Although a
387
Table 1. Baseline characteristics of women with successful

and unsuccessful ECV at term in the north of Jordan Hospital
population (2005-2007).
Mean maternal age + SD

Gest. age at ECV (mo.)
Maternal weight + SD (kg)
ECV successful
n = 73 (72.3%)
ECV unsuccessful
n = 28 (27.3%)
31y + 4.9
39.7 + 1.9
73 + 5.7
28.6 + 5.6
39.2 + 1.5
70 + 7.2
Table 2. Comparison of clinical features of women with

successful and unsuccessful ECV at term in the north of Jordan
Hospital population (2005-2007).
ECV successful ECV unsuccessful Significant
n = 73 (72.3%) n = 28 (27.7%)
p < 0.05
Parity
nulliparous
multiparous
Types of breech flexed
extended
Foetal position back posterior
back anterior
back lateral
Placental localisation
anterior
posterior
Amniotic fluid
index
3 (4.1%)
70 (95.9%)
54 (74%)
19 (26%)
32 (34.8%)
39 (53.4%)
2 (2.8%)
15 (53.6%)
13 (46.4%)
11 (39.3%)
17 (67.9%)
19 (54.5%)
6 (21.4%)
3 (10.7%)
12 (16.4%)
61 (83.6%)
21 (75%)
7 (25%)
0.0001
11.9 + 2.2
10.9 + 2.5
ns
0.0001
0.002
0.03
ns = not significant.
Table 3. Clinical outcomes of successful and unsuccessful

ECV groups in the north of Jordan Hospital population (20052007).
ECV successful ECV unsuccessful Significant
n = 73 (72.3%) n = 28 (27.7%)
p < 0.05
IOL
Mode of delivery Vag. delivery
CS
Foetal weight
Apgar score
Foetal gender
male
female
18 (24.7%)
67 (91.8%)
6 (8.2%)
3.26 + 0.23
9 + 0.68
39 (53.4%)
34 (46.6%)
0 (0%)
0 (0%)
28 (100%)
3.2 + 0.28
8.7 + 0.57
13 (46.4%)
15 (53.6%)
ns
ns = not significant.
IOL = induction of labor.
higher success rate of 77% has been reported for ECV at

term [13], the majority of the larger series had lower
figures ranging from 51% to 58% [12, 14]. In other
studies the success rate was reported to range from 41%
to 97%; the lower figures were from Europe and the
highest were African [21].
Unfortunately, not all women present with equal
chances of a successful procedure, and improved subject
selection would increase success rates. We found in our
study that the chance of success was increased when the
woman was multiparous, the baby presented as a flexed
breech, the placenta was posterior in location, the foetal
back was anterior and liquid volume was normal, and this
concurs with the findings of other researchers [22-24].
Such positive factors for successful ECV would potentially be beneficial in counseling pregnant women about
an ECV attempt. Fortunato et al. demonstrated that posterior foetal back position significantly decreased the
388
N. Obeidat, I. Lataifeh, M. Al-Khateeb, F. Zayed, W. Khriesat, Z. Amarin
success of ECV at term [17] which was also demonstrated in our study with significant increase in the
success rate compared with posterior foetal back.
The effect of placental location on the success of ECV
has been contradictory. Although, some studies found no
association between placental location and ECV success
[17, 25], Ferguson et al. and Newman et al. reported
higher failure rates with anterior location [6, 20], while,
Brocks et al. reported an increased success rate with an
anterior placenta [26]. Our study determined a posterior
placenta to be a significant predictor of success.
Interestingly, in our study the caesarean section rate in
the successful ECV group was significantly lower than
the background unit caesarean section rate (8.2% vs
28%) and it was slightly higher in multiparous than nulliparous women (7.1% vs 3.0%), whereas previous
studies demonstrated an increase in the rate of caesarean
sections in women who had undergone successful version
[12, 27]. Vezina et al. found that the odds of a caesarean
delivery after successful ECV was increased four-fold
and two-fold in nulliparous and multiprous women,
respectively, when compared with women with spontaneous vertex presentation [28]. Laros et al. reported a
caesarean section rate of 30% in patients after successful
ECV compared with 15% in all term singleton pregnancies with cephalic presentation; this large number of
abdominal deliveries was due to a significantly higher
incidence of foetal distress and dystocic labour [12]
Although it has been recognised that there is higher
perinatal mortality and morbidity associated with breech
presentation which may be related to foetal congenital
malformations, birth asphyxia or trauma [3], breech presentation, regardless the mode of delivery, is a signal for
potential foetal handicap [29]. Hannah et al. also showed
that compared with caesarean delivery, vaginal breech
delivery was associated with a poor foetal outcome [2].
Collaris and Oei reported the possible complications
associated with ECV such as abnormal CTG either transient (5.7%) or pathological (0.37%), vaginal bleeding
(0.47%), placental abruption (0.12%) and emergency
caesarean section (0.43%) [30]. In our study there were
however no foetal or maternal complications reported in
relation to either ECV or caesarean delivery.
In conclusion, multiparity, flexed breech, posterior placenta, and anterior foetal back were the most favourable
factors for successful ECV in our study. Moreover, with
careful evaluation of individual predictors patient selection can be optimised and success rates and ECV may
offer a safe and effective alternative to caesarean section
resulting in vaginal delivery with rapid maternal recovery
and normal infant bonding.
References
[1] Hickok D.E., Gordon D.C., Milberg J.A., Williams M.A., Daling
J.R.: The frequency of breech presentation by gestational age at
birth: a large population-based study. Am. J. Obstet. Gynecol.,
1992, 166, 851.
[2] Hannah M.E., Hannah W.J., Hewson S.A., Hodnett E.D., Saigal
S., Willan A.R.: Planned caesarean section versus planned
vaginal birth for breech presentation at term: a randomized multicentre trial. Lancet, 2000, 356, 1375.
[3] Cheng M., Hannah M.: Breech delivery at term. A critical review
of the literature. Obstet. Gynacol., 1993, 82, 605.
[4] Eller D.P., VanDorsten J.P.: Breech presentation. Curr. Opin.
[5] Hofmeyr G.J.: Interventions to help external cephalic version for
breech presentation at term (Cochrane Review). In: The
Cochrane Library. Issue 1. Chichester, UK: John Wiley & Sons,
2003.
[6] Ferguson J.E. 2nd, Armstrong M.A., Dyson D.C.: Maternal and
foetal factors affecting success of antepartum external cephalic
version. Obstet. Gynecol., 1987, 70, 722.
[7] Hofmeyr G.J.. External cephalic version facilitation for breech
presentation at term (Cochrane Review). In: The Cochrane
Library, Issue 2. Oxford, 2002.
[8] Bewley S., Robson S.C., Smith M., Glover A., Spencer J.A.: The
introduction of external cephalic version at term into routine clinical practice. Eur. J. Obstet., Gynaecol. Reprod. Biol., 1993, 52,
89.
[9] Hofmeyr G.J., Kulier R.: External cephalic version for breech
presentation at term (Cochrane Review). In: The Cochrane
Library. Issue 3. Chichester, UK: John Wiley & Sons, 2003.
[10] American College of Obstetricians and Gynecologists (ACOG)
Committee Opinion No. 340 Mode of term singleton breech delivery. Obstet. Gynecol., 2006, 108, 235.
[11] Leung T.Y., Lau T.K., Lo K.W., Rogers M.S.: A survey of pregnant womens attitude towards breech delivery and external
cephalic version. Aust. N.Z.J. Obstet. Gynaecol., 2000, 40, 253.
[12] Laros R.K. Jr., Flanagan T.A., Kilpatrick S.J.: Management of term
breech presentation: a protocol of external cephalic version and
selective trial of labor. Am. J. Obstet. Gynecol., 1995, 172, 1916.
[13] Dyson D.C., Ferguson J.E. II, Hensleigh P.: Antepartum external
cephalic version under tocolysis. Obstet. Gynecol., 1986, 67, 63.
[14] Hellstrom A.C., Nilsson B., Stange L., Nylund L.: When does
external cephalic version succeed?. Acta Obstet. Gynecol. Scand.,
1990, 69, 281.
[15] Fell M.R.: External cephalic version. Lancet, 1953, 265, 264.
[16] Aisenbrey G.A., Catanzarite V.A., Nelson C.: External cephalic
version: predictors of success. Obstet. Gynecol., 1999, 94, 783.
[17] Fortunato S., Mercer L., Guzick D.: External cephalic version
with tocolysis: Factors associated with success. Obstet. Gynecol.,
1988, 72, 59.
[18] Newman R., Peacock B., Van Dorsten J., Hunt H.: Predicting
success of external cephalic version. Am. J. Obstet. Gynecol.,
1993, 169, 245.
[19] Lau T., Lo K., Wan D., Rogers M.: Predictors of successful
version at term: A prospective study. Br. J. Obstet. Gynaecol.,
1997, 104, 798.
[20] Kok M., Cnossen J., Gravendeel L., van der Post J., Opmeer B.,
Mol B.W.: Clinical factors to predict the outcome of external
cephalic version: a metaanalysis. Am. J. Obstet. Gynecol., 2008,
199, 630.
[21] Hofmeyr G.J., Sadan O., Myer I.G., Galal K.C., Simko G.: External cephalic version and spontaneous version rates: ethnic and
other determinants. Br. J. Obstet. Gynaecol., 1986, 93, 13.
[22] Feyi-Waboso P.A., Selo-Ojeme C.O., Selo-Ojeme D.O.: External
cephalic version (ECV): experience in a sub-Saharan African hospital. J. Obstet. Gynaecol., 2006, 26, 317.
[23] Guyer C.H., Heard M.J.: A prospective audit of external cephalic
version at term: are ultrasound parameters predictive of
outcome?. J. Obstet. Gynaecol., 2001, 21, 580.
[24] Boucher M., Bujold E., Marquette G.P., Vezina Y.: The relationship between amniotic fluid index and successful external cephalic
version: a 14-year experience. Am. J. Obstet. Gynaecol., 2003,
189, 751.
[25] Morrison J.C., Myatt R.E., Martin J.N., Meeks G.R., Martin R.W.,
Bucovaz E.T.. et al.: External cephalic version of the breech presentation under tocolysis. Am. J. Obstet. Gynecol., 1986, 154, 900.
[26] Brocks V., Philipsen T., Secher N.J.: A randomized trial of external cephalic version with tocolysis in late pregnancy. Br. J.
Obstet. Gynaecol., 1984, 91, 653.
[27] Lau T., Lo K., Rogers M.: Pregnancy outcome after successful
cephalic version for breech presentation at term. Am. J. Obstet.
Gynecol., 1997, 176, 218.
[28] Vezina Y., Bujold E., Varin J., Marquette G.P., Boucher M.: Caesarean delivery after successful external cephalic version of breech
presentation at term: a comparative study. Am. J. Obstet.
Gynecol., 2004, 190, 763.
[29] Danielian P.J., Wang J., Hall M.H.: Long-term outcome by
method of delivery of fetuses in breech presentation at term: Population-based follow-up. Br. Med. J., 1996, 312, 1451.
[30] Collaris R.J., Oei S.G.: External cephalic version: a safe procedure? A systematic review of version-related risks. Acta Obstet.
Gynaecol. Scand., 2004, 83, 511.
389

F. Zayed, MBBCH, FRCOG, M.D.
Department Obstetrics and Gynaecology
Jordan University of Science and Technology
P.O. Box 962106
Amman-11196 (Jordan)
e-mail: fhmzayed@just.edu.jo
25 1235-31 - New results regarding:1648_29 Incidence of multiple 15/11/11 14:50 Pagina 390
[789/27]
[1235/31]
390
New results regarding trends in Iranian womens health

and a comparison with WHO data
E. Barooti1, N. Sadeghi2, M. Karimi-Zarchi3, H.R. Soltani4
1
Functional Gynecology Department, Shahid Beheshti University MC, Tehran; 2Health Care Ministry, Tehran
3
Gynecology Oncology Department, Shahid Sadoughi University of Medical Science, Yazd
4
Ali ben Abiltaleb Medical School, Islamic Azad University Branch Yazd (Iran)
Summary
Half of the worlds population consists of women, who play important roles in cultural formation and education, maintain and
promote households and their health, and consequently affect the community. In a general sense, womens health may be an important cornerstone for the formation of a healthy community. In developing countries, 67% of women work in the agriculture sector
and produce 55% of the food products throughout the world. In East Asian countries, which have the highest level of cloth and furniture export, 74% of workers are women. Due to these considerations, we assessed womens health indicators in Iran. We reviewed
health information from national health reports, including two national health surveys conducted in 1991 and 2009 with a sample
size of 1/1,000 of the Iranian population, the 2000 Iran Demographic and Health Survey, and all published indices that were calculated in 2006 or later. The most important finding was that the maternal mortality rate decreased from 54 per 100,000 live births in
1991 to 37.4 per 100,000 live births in 1997. It decreased further to 24.7 per 100,000 live births in 2006. The Millennium Development Goal is 18-22 per 100,000 live births in 2015.
Key words: Uterine artery embolization; Fibroids; Adhesions; Hysterectomy.
Introduction
The health of half of the population is guaranteed as long
as we have healthy women. Healthy women provide a suitable foundation for educating and raising children, and
peace among men could guarantee the health of the other
half of the population. When women control the health of
their family members, two elements of the community,
namely men and children, who both constitute human and
social capital in their countries, are enabled to provide
services and improve themselves. Furthermore, womens
own effectiveness in social and economic arenas is considerable. On the basis of official statistics, two-thirds of the
worlds work is performed by women [1].
Sociologists, economists, and scientists from different
fields believe that if we pay attention to the talents of
women, who engage in all types of formal and informal
work, women can be viewed as among the most valuable
forms of social capital in their countries. Other groups of
specialists believe that women and families are the foundation of evolution and progress. Women not only allow
generations to survive but also play roles in progress and
strive alongside men to improve their communities [2].
Based on this perspective, we assessed womens health
indicators in Iran. We reviewed health information from
national health reports, including two national health
surveys conducted in 1991 and 2009 with a sample size
of 1/1,000 of the Iranian population, the 2000 Iran Demographic and Health Survey (DHS), and all published
indices that were calculated in 2006 or later [3].
Data from the National Health and Disease Surveys of
1991, 1999, and 2000 and the 2009 World Health StatisRevised manuscript accepted for publication April 11, 2011
XXXVIII, n. 4, 2011
tics from the World Health Organization (WHO) were

used. The population sample of the national health
surveys included 1/1,000 of the total Iranian population,
chosen by random cluster sampling. Each cluster consisted of eight families. The urban population sample
comprised 1,097 clusters (9,276 families), and the rural
population sample comprised 1,009 clusters (5,719 families). A total of 7,137 subjects were interviewed [4].
The principal objective of this study was to determine
population and health indicators using the 2009 World
Health Statistics from WHO, the DHS of 2000, and the
latest indices published in Iran [2]. The specific objectives were to determine baseline household welfare and
to assess fertility and contraceptive-use indicators. The
sample size for each province (28 provinces plus Tehran,
the capital city) was set at 2,000 urban and 2,000 rural
households. The actual number of households eventually
accessed was 128,957 including 707,108 persons. The
sampling method was single-stage cluster sampling (clusters of equal size). Each cluster consisted of ten ordinary
residential households. Variables included safe motherhood, reproductive health, family planning, education,
nutritional risk factors, menopausal indicators, and
socioeconomic statistics.
Health workforce, infrastructure, and essential
medicine
Today, 97% of births are attended by skilled health
personnel, meaning that these deliveries are performed by
physicians and trained midwives (WHO, 2009). Mothers
access to healthcare services during pregnancy, delivery,
and subsequent periods can prevent maternal and neonatal mortality [1, 4].
Improvement in healthcare services is necessary for all

communities wherever and whenever women need them.
Examples of these services include establishing delivery
care units and rural midwife training, increasing the literacy rate in women, and improving and increasing access
to healthcare. According to WHO documents, the number
of community health workers in Iran during 20002007
was 25,242, representing a density of 4/10,000 population. The number of other health service providers was
128,160, for a density of 18/10,000 population. During
2000-2007, the number of physicians was 61,870, for a
density of 9/10,000 population; the number of nursing
and midwifery personnel was 98,020, a density of
16/10,000 population; and the number of dentistry personnel was 13,210, a density of 2/10,000 population.
According to WHO documents, during 2000-2008, there
were 17 hospital beds per 10,000 population, which has
since nearly doubled [4].
The WHO statistics with respect to the healthcare
workforce, infrastructure, and essential medicine in the
Southeast Asia region during the same reference period
were 132,612 health workers, a density of 1/10,000 population, and 2,002,575 for a density of 12/10,000 population. Physicians numbered 849,324, for a density of
5/10,000 population, and 1,955,203, a density of
12/10,000. Dentistry personnel in our region. Numbered
92,759 for a density of one per 10,000; and the density of
hospital beds per 10,000 population was 12. During 1976
to 1986 we had 2,993 physicians, of whom 25.19% were
women and 74.81% were men. The number of women
general practitioners increased from 754 during 19761986 to 13,305 in 2006. The same dataset indicated that
women professors numbered 597 (12% of all professors),
and this population increased during 1996-2006 to 4,210
(40% of all professors). The median public availability of
selected generic medicines from 2000 to 2007 was
92.7%, and private availability was 92.8% [4, 5].
In 2000, 61% of deliveries were performed by physicians, and 35% (of all births or of physician-attended
births) resulted in childbirth by cesarean section. Other
than increasing the number of educated midwives,
women surgeons and gynecologists, and womens access
to all of these trained people and family physicians, the
most important factor in decreasing the rate of maternal
and neonatal mortality is increasing the growth of literacy in women. At the country level, antenatal care coverage in 2000 was 79%, and the index for at least four prenatal visits was 94% in 2008 [4].
The maternal mortality rate in Iran decreased from 54
per 100,000 live births in 1991 to 37.4 per 100,000 live
births in 1997. It further decreased to 24.7 in 2006.
According to the Millennium Development Goals, the
target is to reach 18-22 per 100,000 live births in 2015.
Meanwhile, according to WHO statistics, the maternal
mortality rate per 100,000 live births was 140 in Iran, 450
in Southeast Asia, and 400 globally; the median country
value was 130. The adult female mortality rate decreased
from 208/10,000 in 1990 to 100 in 2007 [4]. The female
infant mortality rate (probability of dying between birth
391
and age 1 year per 1,000 live births) decreased from 46

in 1990 to 25 in 2007. The mortality rate for females
under five years of age (probability of dying by age 5 per
1,000 live births) decreased from 69 in 1990 to 33 in
2007 [4, 5].
Health service coverage
We currently have 94% antenatal care coverage, and
97% of births are attended by skilled health care personnel (WHO, 2009). Maternal tetanus killed an estimated
150,000 to 300,000 women during the 1990s. Tetanus
toxin vaccines can prevent infections and save lives of
mothers and infants alike. The number of neonates protected against neonatal tetanus at birth increased from
71% in 1990 to 83% in 2007 (WHO, 2009). The contraceptive prevalence in 2000 to 2006 was 73.8% (WHO,
2009). According to the DHS, approximately 45.2% of
mothers in 2000 had unplanned pregnancies, and 22.5%
of all pregnancies were unwanted pregnancies. Approximately 7.5% of women have unmet needs in family planning. A 1% stillbirth and 5.6% abortion rate have been
reported. We had access to no official WHO documents
regarding these indices from 2000 to 2006. Of the total
population, the tuberculosis detection rate under the
directly observed treatment, short course (DOTS) in 1995
was 42%, increased to 58% in 2000, and further
increased to 68% in 2007. The tuberculosis treatment
success rate under DOTS in 2000 was 85%, and in 2006
it was 83% [4, 5]. We have no official WHO documents
regarding antiretroviral therapy coverage in pregnant
women, but the antiretroviral therapy coverage rate in
people with advanced HIV infection in 2007 was 5%. In
the southeast region in 2007, antiretroviral therapy coverage in pregnant women was 24% and in people with
advanced HIV infection it was 25% [4, 5].
Reproductive health indicators, marital status, and
prevalence of contraception usage are shown in Table 1.
Demographic and socioeconomic health factors
As fertility declines, income rises. Increasing population age and education, especially of women, also have
major impacts on the use of healthcare and on health
status. Literacy improves womens ability to reduce fertility risks, avoid sexually transmitted diseases, and
promote safe pregnancy and childbirth. Furthermore,
education is a key factor in improving the overall well
being of the family, facilitating the participation of
women in the labor market, and improving their preparation for leadership roles in community and national life.
The illiteracy rate in women in the 15-49-year age group
decreased from 30.8% in 1991 to 23.4% in 1999. The
annual growth rate decreased from 2.1% during 19871997 to 1.1% during 1997-2007. The median age in 2007
was 24 years. The total fertility rate (per woman) in 1990
was five; it decreased to 2.2 in 2000 and further
decreased to 2.0 in 2007. The adolescent fertility rate (per
1,000 women) during 2000-2007 was 25. The adult liter-
392
E. Barooti, N. Sadeghi, M. Karimi-Zarchi, H.R. Soltani
Table 1. Trends in reproductive health, marital status and

contraception prevalence rates in Iranian women: 1991-2000.
Some data in 2007 based on IMES.
Case
Reproductive health intentions

Age at first pregnancy (years)
Interval between marriage and the first
pregnancy (months)
Family spacing between 2 living
children (months)
Number of living children
Conception by age 18 or under (%)
Conception by age 40-49 years (%)
Pregnancy rates (%)
Population growth rate per year
Total fertility rate (%)
Cesarean section rate (%)
Antenatal injection of tetanus toxoids
Marital status of women 15-49 years
Mean age at first marriage (years)
Urban
Rural
Percent of married women
Percent of single women
1991
2000
2007
20
22
9.6
18
33.1
4.1
6
3
10.2
1.47
4.9
N/A
N/A
47.8
3.2
4.1
1.1
5.2
1.2
2
35 40/60
79.6
19.2
18.2
70.3
23.3
20.8
19.7
64.4
26.3
Table 2. Percentage of contraceptive methods used by Iranian

women.
Percent of divorced women
Percent of first marriage at age

of 18 or under
Use of contraceptive methods by married
women ages 15-49, currently using
Unwanted pregnancy(mother & father)
Unmet need
Traditional (withdrawal) methods
Oral contraceptive pills
IUD
Condom (husband of women 15-49 years)
Female sterilization
Injectables/implants
Vasectomy
0.8
0.8
1.3
25/1
17.87
26.9
6.9
7.8
6.35
3.17
<1
73/8
24/1
7/5
17.8
18.4
8.5
5.9
8.5
3
2.7
78/9
18/6
5/9
19/2
19/3
8/1
9/2
9/3
2/6
3
Table 3. Maternal health indicators for 2007. Percentage of

women receiving services in some countries WHO 2009.
Regions/country
Total
fertility
rates
Contraception use Unmet

Any
Modern need for
method method* family
planning
Maternal
mortality
ratio per
100,000
live births
Antenatal Skilled
care
attendants
coverage at birth
% at least
4 visits
Africa
Gabon
Turkey
South-East Asia
Egypt
Jordan
Asia
Bangladesh
India
Iran
Eastern
Mediterranean
Colombia
European region
Armenia
Ukraine
5.1
3.1
2.1
2.7
2.9
3.1
24.4
32.7
71
57.2
59.2
55.8
900
520
44
420
130
62
45
63
54
42
65
94
46
86
83
48
79
99
2.9
2.8
2.0
58.1 44
56.3 43
73.8 56
11.3 570
12.8 450
N/A 140
21
37
94
18
47
97
3.4
2.2
1.6
1.4
1.2
43
78.2 63
5.8
420
130
27
13.3 76
N/A 18
45
83
N/A
71
75
59
96
96
98
99
12
55
54
38
53.1 20
N/A 38
24.4
28
6.0
12.4
10.3
11
acy rate during 1990-1999 increased from 73.1% to

84.7%. The net percentage of females enrolled in primary
school increased from 81% in 1999 to 100% in 2007 [1,
3]. From 1976 to 2004, the employment growth rate was
44% in men and +0.31% in women. In recent years, the
number of employers in the government system increased
to 63.6% in 2005. Approximately 2.4% of women work
as governmental employees compared with 8.5% of men;
54% of women are housekeepers, but only 10% of
women who work outside the home earn their own
income [1, 3].
Risk factors
Access to improved drinking-water sources in the total
population (urban and rural) increased from 92% in 1990
to 94% in 2006. Furthermore, access to improved sanitation is now approximately 83% [4].
The number of infants who exclusively breastfed for
the first six months of life during 2000-2008 was 44.1%
(WHO, 2009). The number of female adults aged 15
years who were obese during 2000-2007 was 19.2%
(WHO, 2009). During 2000-2008, the mean height of
girls at the age of 18 years was 158.1 cm, and their mean
weight was 54.1 kg. Approximately 12% of 15-39-yearold women in urban and 6.9% in rural areas were obese;
in the 40-69-year-old age group, obesity reached 27.9%
in urban and 15.6% in rural areas. The prevalence of
current tobacco use in female adults 15 years of age in
2005 was 5.5%, and that in female adolescents (13-15
years of age) during 2000-2008 was 19.5% [4]. Approximately 98.3% of women reported smoking no cigarettes
in a survey in 1999 compared with 96.6% in a previous
survey. However, this total may have been underestimated. The age at first cigarette smoking in 2000 was
older than 25 years, and most women consumed fewer
than ten cigarettes a day. An official report of the prevalence of addiction is not available [4, 5].
The average age of menopause, according to reliable
statistics, is 50 years in Iran [2]. In 2000, in the 40-69year-old age group, hypertension was seen in 20.6% of
women, hypercholesterolemia of 240 mg/dl in 20.7%,
obesity as measured by bone marrow indexing > 30 in
27.9% of urban and 15.6% of rural women, arthralgia or
arthritis in 39.4%, low back pain in 49.2%, and kyphosis
in 3.5%. Approximately 2.6% of women 60 to 96 years
of age have had hip or spinal fractures in recent years.
With the exception of hypertension, which was seen in
14.7% of women, and was higher in the current data,
other indicators showed no significant differences
between these figures and a previous study. A total of
6.8% of women at the reproductive ages of 15-39 years
had intermediate to severe anemia (iron deficiency).
Approximately 25.4% of women suffered from anxiety,
and 24.6% were depressed; somatization, neurosis, and
psychosis were seen in 10.6%, 6.2%, and 0.3% of
women, respectively. One of the health-related Millennium Development Goals concerns HIV prevalence
among adults aged 15 years per 100,000 population; in
Iran, the level was 163, and the regional average was 202.
The cause-specific mortality rate in both sexes for
HIV/AIDS in 2007 was 6/100,000 [4, 5]. HIV and AIDS
are crucial factors affecting womens health. However,
HIV and AIDS are seen more in males than in females,
mostly due to intravenous drug use among addicts, but its
impact on women cannot be ignored; they should become
increasingly aware of HIV and AIDS and learn how to
avoid infection. We do not have a correct estimation of
the percent of females aged 15 to 24 years with a comprehensive, correct knowledge of HIV/AIDS. Four of
466,331 blood samples were reported to be positive for
HIV; 31 of 413 cases (7.5%) with AIDS were females,
and 178 of 3912 cases infected with HIV (4.55%) were
females. The route of infection was sexual intercourse in
61% of women, but intravenous drug abuse was the main
route of infection in 67% of males [2, 3].
According to the latest official data, the age at first marriage was 20.8 years in Iran [3]. Attending to the age at first
marriage helps to lower the birth rate and other maternal
problems. While the precise relationship of age at marriage
to fertility is difficult to measure, surveys reveal a strong
inverse relationship between the average age at marriage
and the total fertility in a country (Table 2).
Mortality and burden of disease
Life expectancy has increased not only in Iran but also
in most other countries [2]. The proportions of middleaged and elderly people are growing. For example, according to WHO documents, life expectancy at birth in females
was 65 years in 1990 and increased to 74 years in 2007.
Healthy life expectancy (HALE) in 2007 was 61 years,
whereas this index was 57 years and 61 years globally.
Lifestyle, good health programs, and exercise can contribute to the health of women during menopause [4, 5].
Women who do not use contraception, even though
they are sexually active and want to avoid pregnancy, are
at risk of unwanted pregnancy. Such women are considered to have unmet needs for family planning. In Iran, we
have no formal data for unsafe abortions. Abortion rates
can be reduced if couples switch to more effective family
planning methods. A comparison of two surveys, conducted in Iran in 1991-1999 and 2006, indicated that the
number of women using contraception increased from
69% during 1991-1999 to 73.6% in 2000 and has further
393
increased to more than 73.8% [4, 5]. In Iran, although

significant progress has been made in the field of
womens health, much more remains to be done, especially in the area of family health rights. This task could
not be accomplished without the sociopolitical participation of women. We have over 100,000 health volunteers
(urban, rural, tribes, and expert volunteers) who have
covered a population of 16 million, and they voluntarily
cooperate with the health system for the improvement
and development of community health [2, 3]. The expert
volunteers project was established in 2004 to improve
the knowledge and skills of these community networks as
well as to promote a healthy population. We currently
have more than 10,000 expert volunteers constituting the
Health Volunteers, a group that cooperates with the
public health system. Health volunteers are communicators who cooperate with donors and charitable organizations and can find resources and regional funding for creating and facilitating healthcare services to solve
community health problems [4, 5].
References
[1] Population Reports: The Reproductive Revolution Continues
INFO. Baltimore (USA): The Johns Hopkins Bloomberg School of
Public Health, 2003 Series M, No. 17, 3.
[2] National Health Surveys, Undersecretary for Research. 1st edition.
Tehran (Iran), Ministry of Health and Medical Education in Iran,
2001, 18.
[3] Demographic and Health Survey in Iran. Undersecretary for Health
Affairs, Family Health and Population Department, Demographic
and Health Survey in Iran/DHS-2000. 1st edition. Tehran (Iran):
Family Health and Population Department and UNICEF in Tehran;
2002, 30.
[4] UNICEF, WHO, UNFPA. Maternal and neonatal tetanus elimination by 2005. Strategies for achieving and maintaining elimination.
Geneva: WHO, 2000, 28.
[5] Senlet P., Curtis S.L., Mathis J., Raggers H.: The role of changes
in contraceptive use in the decline of abortion in Turkey. Studies
Fam. Plann., 2001, 32, 41.

M. KARIMI-ZARCHI, M.D.
Gynecology Oncology Department
Shahid Sadoughi Hospital
University of Medical Science
Shahid Ghandi BLV
Yazd (Iran)
e-mail: drkarimi2001@yahoo.com
26 1177-30 - Frequency of ovarian:1648_29 Incidence of multiple 15/11/11 14:52 Pagina 394
[789/27]
[1177/30]
394
Frequency of ovarian endometriosis in epithelial ovarian

cancer patients
O. Dzatic-Smiljkovic, M. Vasiljevic, M. Djukic, R. Vugdelic, J. Vugdelic
University of Belgrade, School of Medicine, Clinic of Gynaecology and Obstetrics Narodni Front, Belgrade (Serbia)
Summary
Purpose: The aim of this study was to determine the frequency of endometriosis in epithelial ovarian cancer patients. Methods:
Patients who had undergone epithelial ovarian cancer surgery between 2000 and 2004 were subjected to a retrospective analysis. The
analysis focused on the presence of ovarian endometriosis, histological types and stages of ovarian cancer, treatment types and fiveyear survival rate. Results: Out of the 210 operated ovarian cancer patients, 23 had coexisting ovarian endometriosis. Ovarian
endometriosis was detected in 3.5% (4 of 113 patients) of cases with serous ovarian cancer, in 31.6% (12 of 38 patients) of cases with
endometrioid, and in 36.8% (7 of 19 patients) of cases with clear cell ovarian cancer. The treatment of ovarian cancer patients was a
combination of surgery and chemotherapy. Conclusion: Endometriosis was most frequently present in patients with clear cell (36.8%)
and endometrioid ovarian cancers (31.6%). The five-year survival rate for ovarian cancer patients in all stages was 39.1%.
Key words: Ovarian cancer; Endometriosis; Serous ovarian cancer; Clear cell ovarian cancer; Endometrioid ovarian cancer;
Chemotherapy; Surgery.
Introduction
Out of all gynecological cancers, ovarian cancer is still

the most frequent common cause of death of women in
the United States and West Europe [1]. The incidence of
ovarian cancer is higher in the Scandinavian countries
14.9/100,000 and the United States - 13.3/100,000, and
lower in Japan - 2.7/100,000 [2]. Ovarian cancer is of
epithelial origin in 90% of cases. The most frequent
epithelial ovarian cancers are serous, endometrioid, mucinous and clear cell cancers. Serous ovarian cancer
accounts for about 40% of all epithelial carcinomas,
mucinous for 6-10%, endometrioid for 16-25% and clear
cell for about 6% [3].
Endometriosis can be a precursor of clear cell and
endometrioid ovarian cancers. In 1925 Sampson described
the malignant transformation of endometriosis [4]. Other
authors have noted the malignant transformation of
endometriosis in the genital and extragenital tracts [5].
Cancers arising from the transformation of ovarian
endometriomas are predominantly of the clear cell and
endometrioid types [6]. The high prevalence of
endometriosis in clear cell and endometrioid types of cancer is a consistent finding in Japan and West European
countries [7]. Ovarian cancer is usually detected in more
developed stages. The modern treatment of ovarian cancer consists of a combination of surgery and chemotherapy and, in rare cases, even radiation therapy. The five-year
survival rate for all stages of ovarian cancer is 39% [8].
This is a retrospective study conducted at the University

Clinic of Gynecology and Obstetrics Narodni Front in Belgrade between 2000 and 2004. In this period 210 epithelial
ovarian cancer patients underwent surgery. Twenty-three
ovarian cancer patients who had coexisting ovarian endometriosis were subjected to the analysis. The patients were between 25
and 69 years of age. The analysis covered anamnestic data, age,
education, presence of endometriosis, time elapsed between the
endometriosis and ovarian cancer diagnosis dates, symptoms of
disease, applied diagnostic methods, types of surgical interventions, stages of the disease, histological cancer subtypes, types
of administered chemotherapy and five-year survival rate upon
completion of treatment. Ovarian cancer was diagnosed on the
basis of bimanual gynecological examination, rectal examination, determination of serum concentration of CA 125 tumor
marker and color Doppler ultrasonography (US) with a transvaginal probe; magnetic resonance imaging (MRI) of the pelvis
minor and abdomen was performed on some patients. Stages of
the disease are described using the FIGO ovarian cancer surgical staging on the basis of intraoperative findings through
laparotomy [9]. The tissue removed during laparotomy was subjected to histological examination. Histological diagnosis and
grades of ovarian cancer were established using the World
Health Organization criteria [10]. Parameters of descriptive statistics were determined in the statistical analysis (mean value,
standard deviation) and in order to determine statistical significance, the chi-square and Fisher exact tests were used, with a
statistical significance of 95% where frequencies were less than
5; the level of significance was set at 0.05.
The aim of this study was to examine the frequency of
endometriosis in epithelial ovarian cancer patients.
Results

XXXVIII, n. 4, 2011
Out of the 210 epithelial ovarian cancer patients, 113

(53.8%) had serous ovarian cancers, 40 (19.0%) had
mucinous, 38 (18.1%) had endometrioid and 19 (9.0%)
had clear cell cancers. Of the 210 ovarian cancer patients,
coexisting ovarian endometriosis was diagnosed in 23

(10.9%) cases. Nine (39.1%) of the 23 patients had unilateral and 14 (60.9%) others had bilateral cancers. The
patients were between 25 and 76 and the mean age was
56.5. Three (13.0%) patients had ovarian cancer in their
family anamnesis. Twenty-one (91.3%) patients were
overweight and two (8.7%) were obese. Thirteen (56.5%)
patients had a high school education, six (26.1%) higher
education, and four (17.4%) had not completed any
school. The most frequent symptoms were: bloating and
distension in seven (30.4%) cases, abdominal pain in six
(26.1%) cases, loss of appetite in five (21.7%) cases, postmenopausal bleeding in three (13.0%) cases and urinary
tract symptoms in two (8.7%) cases. Eleven (47.8%)
patients had elevated CA 125 values before surgery. The
values ranged from 85 IU/l to 611 IU/l, with an average
median value of 105.35 IU/l.
In 86.9% (20 of 23 patients) of cases US detected ovarian tumors, 70% of which were multilocular and 30%
unilocular cysts. Color Doppler examination uncovered
suspect and pathological circulation in 60.8% (14 of 23
patients) of cases. MRI showed that six (75%) of the eight
examined patients had infiltrative ovarian tumors. Four
(17.4%) of the 23 patients with ovarian cancer and
endometriosis had serous, 12 (52.2%) endometrioid and
seven (30.4%) clear cell cancers. Nine (39.1%) ovarian
cancer patients had FIGO Stage I, eight (34.8%) had
FIGO Stage II, five (21.7%) had FIGO Stage III and one
(4.3%) had FIGO Stage IV (Table 1).
Observing the frequency of some FIGO stages in some
subtypes of ovarian cancer, it was established that serous
ovarian cancer was diagnosed in Stages I and II in 25.0%
(1 of 4 patients) of cases, endometrioid in 83.3% (10 of
12 patients) of cases and clear cell in 57.1% (4 of 7
patients) of cases. Unlike serous cancer, endometrioid
and clear cell cancers were much more frequently diagnosed in Stages I and II. The differences were statistically significant (p < 0.05) (Table 2).
Thirteen (56.5%) of the 23 patients with ovarian cancer
and coexisting endometriosis had well differentiated G1,
seven (30.4%) had moderately differentiated G2 and three
(13.0%) had low differentiated G3 cancers. There were
eight (66.6%) well differentiated endometrioid ovarian
cancers, five (71.4%) well differentiated clear cell cancers, and no well differentiated serous cancers. Well differentiated endometrioid and clear cell cancer are much
more frequent than those of the serous subtype (p < 0.05)
(Table 3).
The serous ovarian cancer patients were aged between
42 and 76 and the mean age was 62, while the endometrioid and clear cell cancer patients were aged between 25
and 56, with a the mean age of 48. In a significantly more
frequent number of cases, serous ovarian cancer patients
were older than endometrioid and clear cell cancer
patients (p < 0.05). According to the anamnesis, eight
(34.8%) of the 23 ovarian cancer and endometriosis
patients had been previously treated for ovarian
endometriosis. Time elapsed between the date of the
endometriosis and ovarian cancer diagnoses was between
395
Table 1. FIGO staging and histological subtypes of ovarian

cancers.
FIGO Serous cancer
Stage
N
%
Ia
Ib
Ic
IIc
IIIc
IV
Total
1
2
1
4
4.3
8.6
4,3
17.4
Endometrioid cancer
N
%
2
2
1
5
2
12
8.6
8.6
4.3
21.7
8.6
52.2
Clear cell cancer

N
%
2
1
1
2
1
8.6
4.3
4.3
8.6
4.3
30.4
Total
N
4 17.4
3 13.0
2
8.6
8 34.8
5 21.7
1
4.3
23 100.0
Table 2. Frequency of FIGO stages in some subtypes of

ovarian cancer.
FIGO
Stage
Serous cancer
N
%
Ia
Ib
Ic
IIc
IIIc
IV
Total
1
2
1
4
Endometrioid cancer
N
%
25.0
50.0
25.0
100.0
2
2
1
5
2
12
Clear cell cancer

N
%
16.6
16.6
8.3
41.6
16.6
100.0
2
1
1
2
1
28.6
14.3
14.3
28.6
14.3
100.0
Table 3. Grading differentiation of some subtypes of ovarian

cancer.
Grade
G1
G2
G3
Total
Serous cancer
N
%
2
2
4
Endometrioid cancer
N
%
50.0
50.0
100.0
8
3
1
12
66.6
25.0
8.3
100.0
Clear cell cancer

N
%
5
2
71.4
28.6
100.0
Total
N
13 56.5
7 30.4
3 13.0
23 100.0
Table 4. Frequency of endometriosis according to the

ovarian cancer subtype.
Type
of cancer
Serous cancer
Endometrioid cancer
Clear cell cancer
Mucinous cancer
Total
Endometriosis
N
Cancer
N
Frequency of endometriosis
%
4
12
7
0
23
113
38
19
40
210
3.5
31.6
36.8
0
10.9
five and nine years with the mean period being 7.5 years.
After the surgery, the histological examination of the surgically removed tissue detected ovarian endometriosis in
3.5% (4 of 113 patients) of cases with serous ovarian cancer, in 31.6% (12 of 38 patients) of cases with endometrioid, and in 36.8% (7 of 19 patients) of cases with clear
cell cancer. Endometriosis was detected much more frequently in clear cell and endometrioid ovarian cancer
patients than in serous ovarian cancer patients (p < 0.05).
The frequency of endometriosis in some ovarian cancer
subtypes is presented in Table 4.
Four (17.4%) Stage Ia G1 ovarian cancer patients were
subjected to unilateral salpingo-oophorectomy only, with
no other therapy. Patients wished to remain fertile. Total
abdominal hysterectomy with bilateral salpingo-
396
Table 5. Method of treatment of ovarian cancer patients.

FIGO
stage
Grade
Surgery
Ia
Ib
Ic
Ic
IIc
IIc
IIIc
IIIc
IV
G1
G1
G1
G1
G1
G2
G2
G3
G3
USO
HY+BSO+O
HY+BSO+O
HY+BSO+O
HY+BSO+O
HY+BSO+O
HY+BSO+O
HY+BSO+O
SSC
+
+
+
+
+
+
+
+
Chemotherapy
No chemotherapy
Carboplatin AUC 5
Carboplatin AUC 5
Carboplatin AUC 5
Taxol + Carboplatin
Taxol + Carboplatin
Taxol + Carboplatin
Taxol + Carboplatin
Taxol + Carboplatin
Cisplatin+Adriamycin
+Cyclophosphamid
4
3
1
1
5
3
3
2
1
USO: unilateral salpingo-oophorectomy; HY+BSO+O: total abdominal

hysterectomy with bilateral salpingo-oophorectomy and complete omentectomy;
SSC: suboptimal surgical cytoreduction.
oophorectomy, complete omentectomy and resection of

some metastatic lesions and retrieval of peritoneal cytological specimens for analysis was performed on 18
(78.3%) patients with Stage Ib, Ic, IIc and IIIc ovarian
cancer. After the surgery, all 18 patients were subjected to
chemotherapy. In one (4.3%) patient who had Stage IV
cancer, suboptimal surgical cytoreduction was performed,
followed by chemotherapy.
Three patients (13.0%) in Stage IbG1, one patient
(4.3%) in Stage IcG1 and one patient (4.3%) in Stage
IcG2 were subjected to monochemotherapy with carboplatin AUC 5 every four weeks.
Five patients (21.7%) with Stage IIcG1 ovarian cancer,
three patients (13.0%) with Stage IIcG2 and three patients
(13.0%) with Stage IIIcG2 were subjected to six cycles of
chemotherapy with taxol + carboplatin. Two patients
(8.7%) with Stage IIIcG3 were subjected to six cycles of
chemotherapy with taxol + carboplatin, followed by an
additional three cycles of cisplatin + adriamycin +
cyclophosphamid. One patient (4.3%) with Stage IVG3
cancer was subjected to six cycles of chemotherapy with
taxol + carboplatin. The method of treatment of ovarian
cancer patients is presented in Table 5.
The five-year survival rate of patients with ovarian cancer and endometriosis was 39.1% (9 of 23 patients). Fiveyear survival rate of patients with Stage I of the disease
was 66.6% (6 of 9 patients), those with Stage II 37.5% (3
of 8 patients), and those with Stages III and IV 0%.
Discussion
Out of all gynecological cancers, ovarian cancer is the
leading cause of death in women [11]. The American
Cancer Society estimates that 21,650 new cases of ovarian cancer were diagnosed and 15,520 women died of the
disease in the United States in 2008 [12].
In the United States, the lifetime risk of invasive ovarian cancer is approximately 1.4% (one in 71), and the lifetime risk of dying from invasive ovarian cancer is about
one in 95 [13].
The family history of ovarian or breast cancer in a firstdegree relative approximately triples the risk. The risk is
particularly high among carriers of a BRCA gene mutation, with a lifetime risk of 39-46% among women with
the BRCA1 mutation and a risk of 12-20% among those
with the BRCA2 mutation. In invasive ovarian cancer
patients, mutations of the BRCA1 and BRCA2 genes
were found in 15.3% of cases [14]. Ovarian cancer was
registered in the family anamnesis of 13% (3/23) of our
patients. Endometriosis may be the precursor of clear cell
or endometrioid ovarian cancer.
Women who receive a diagnosis of endometriosis early
in life and have endometriosis in their ovaries have the
highest risk for some types of ovarian cancer.
Approximately 0.7%-0.87% of patients with endometriosis subsequently developed ovarian cancer [15, 16].
Hysterectomy or tubal ligation in women with
endometriosis may have a preventive effect against these
types of ovarian cancer [17, 18]. The pathologic features
of atypical endometriosis may constitute a precancerous state. Women with atypical endometriosis may be at
increased risk of developing endometriosis-associated
ovarian cancer [19]. Other authors reported that atypical
endometriotic foci were observed in 61% of endometriosis associated with ovarian malignant tumors, while such
foci were seen in only 1.7% of endometriosis cases without cancers [20]. Other authors analyzed the risk factors
for the malignant transformation of endometriosis. They
found that older age, postmenopausal status and size of
the tumor were associated with a high prevalence of cancer development. Post-menopausal women with the ovarian endometrioma of 9 cm or more belong to the high-risk
group for the development of cancer and require surgical
treatment [21]. In our research, endometriosis was present in 23 of 210 epithelial ovarian cancer patients. Out of
the 23 ovarian cancer and endometriosis patients, eight
had been previously treated for ovarian endometriosis.
Time elapsed between the ovarian endometriosis and
ovarian cancer diagnoses in these patients was between
five and nine years, with the median time being 7.5 years.
Ovarian endometriosis was most frequently found in clear
cell ovarian cancer patients - in 36.8% of cases, in 31.6 %
of endometrioid cancer patients and in 3.5% of serous
ovarian cancer patients. Endometriosis was far more frequent in cases of clear cell and endometrioid ovarian cancer patients than in cases of serous cancer patients (p <
0.05).
Other authors found endometrioid ovarian cancer in
52%, 21.2%, 41.9% and 24.4% of endometriosis patients
[6, 7, 20, 22], clear cell ovarian cancer patients in 39.2%,
54%, 21.9%, 49% and 63% of endometriosis patients [7,
20, 22-24] and serous ovarian cancer in 20%, 3.3% and
30% of endometriosis patients [6, 7, 24]. Patients with
clear cell cancers arising in endometriosis were younger,
having a significantly lower stage and a better survival,
than those with clear cell cancers not arising in
endometriosis [16, 23].
Endometrioid ovarian cancer is a specific histological
entity, which accounts for between 16% and 25% of
epithelial ovarian cancers [3]. Women with a personal or

family history of colon or endometrial cancer (Lynch syndrome 2) have a higher risk of developing endometrioid
cancer of the ovary. Median age of diagnosis for patients
with endometrioid tumors was younger than those with
serous cancer of the ovary. Endometrioid ovarian cancer
is more frequently detected in Stages I and II of the disease [25]. This cancer was detected in Stages I and II in
83.3% (10 of 12 patients) of our patients, and in Stage III
in 16.6% of cases (2 of 12 patients), which represents a
significant difference (p < 0.05). Clear cell cancers comprise 5% to 10% of all ovarian cancers. Early, all clear
cell tumors are invasive cancers. In 85.7% (6 of 7
patients) of our clear cell cancer patients, cancer was
detected in Stages I and II and in 14.3% (1 of 7 patients)
of the cases in Stage III, which represents a significant
difference (p < 0.05). Serous ovarian cancer was diagnosed in Stage I in about 13% of cases; the diagnosing
predominantly took place in Stages III and IV [26]. In
25.0% (1 of 4 patients) of our cases serous ovarian cancer
was diagnosed in Stage II and in 75.0% (3 of 4 patients)
of patients in Stages III and IV, which represents a significant difference (p < 0.05). Unlike serous cancers,
endometrioid and clear cell cancers are much more frequently diagnosed in Stages I and II. Serous cancers are
much more frequently diagnosed in more developed
stages, i.e., in Stages III and IV. The median age of our
serous cancer patients was 62 and that of endometrioid
and clear cell cancer patients was 48. This difference was
statistically significant (p < 0.05). The symptoms of ovarian cancer are non-specific, so this type of cancer is more
frequently detected in more developed stages. In nine
(39.1%) of our patients, cancer was detected in Stage I, in
eight patients (34.8%) in Stage II, in five patients (21.7%)
in Stage III and in one patient (4.3%) in Stage IV. The
most frequent symptoms of the disease were bloating and
distension in seven patients patients, and abdominal pain
in six patients. The most commonly used technique in
screening for ovarian cancer is a bimanual pelvic examination, or US imaging of the ovaries plus testing for
serum CA 125, as a tumor marker, or sequential use of the
two modalities, US and CA 125 testing [21, 27].
Ultrasonography of our 23 patients with ovarian cancer
and endometriosis detected cystic ovarian tumors in
86.9% of cases, where 70% of the cysts were multilocular and 30% were unilocular. Cysts in epithelial ovarian
cancer were present in 83.7% of the patients and were
mostly multilocular (61%) [28]. In 47.8% of our ovarian
cancer patients, increased serum concentrations of the CA
125 tumor marker were found, with the median value of
105.35 IU/l. This antigen is not a specific tumor marker
and it is synthesized by normal and malignant cells of different origins. Recently it has been shown that various
diseases are associated with increased CA 125 levels,
especially in the presence of serosal fluid. Abnormal levels of serum CA 125 were observed in 76% of ovarian
cancer patients. CA 125 levels may be considered a sensitive tumor marker in patients with epithelial ovarian
cancer [29]. Current treatment of ovarian cancer entails a
397
combination of surgery and chemotherapy, and in some

rare cases, radiation therapy. Currently, first-line
chemotherapy consists of a combination of carboplatin
and paclitaxel to which approximately 80% of women
respond [30]. During our research, four patients diagnosed with Stage Ia ovarian cancer underwent only unilateral salpingo-oophorectomy with no other treatment.
Eighteen patients diagnosed with Stage Ib, Ic, IIc, and
IIIc cancer were subjected to total abdominal hysterectomy with bilateral salpingo-oophorectomy, omentectomy
and resection of some metastases. In the case of one Stage
IV cancer patient, a suboptimal reduction of the tumor
was performed. Nineteen operated patients were subjected to chemotherapy. Five patients were subjected to mono
chemotherapy with carboplatin AUC 5. Twelve patients
were given six cycles of combination chemotherapy of
taxol+carboplatin. Two patients were subjected to six
cycles of chemotherapy of taxol + carboplatin, followed
by an additional three cycles of cisplatin + adriamycin +
cyclophosphamid. A monthly carboplatin and weekly
paclitaxel regimen is highly active for women with recurrent platinum-resistant epithelial ovarian cancer [31].
Median overall survival for patients with endometriosis
and ovarian cancer was 196 months versus 34 months for
patients without endometriosis [23]. The five-year survival rate of our patients with all stages of ovarian cancer
and endometriosis was 39.1%. The five-year survival rate
for Stage I of the disease was 66.6%, 37.5% for Stage II,
and 0% for Stages III and IV. Other authors reported that
the five-year survival rate for all stages of epithelial ovarian cancer in women younger than 50 was 40%, and 15%
for women over 50 [32]. The crude 5-year survival rate
for one cohort was 39% [8].
References
[1] Gonzalez-Martin A., Toledo G., Chiva L.: Epithelial ovarian carcinoma: current evidences and future perspectives in the first-line
setting. Clin. Transl. Oncol., 2010, 12, 418.
[2] Van Nagell J., Gershenson D.: Ovarian Cancer: Etiology,
Screening, and Surgery. In: Rock A.J., Jones III. W.H. (eds.). Te
Lindes Operative Gynecology, 9th edition. Philadelphia,
Lippincott, Williams & Wilkins, 2003, 1487.
[3] Soliman P.T., Slomovitz B.M., Broaddus R.R., Sun C.C., Oh J.C.,
Eifel P.J. et al.: Synchronous primary cancers of the endometrium
and ovary: a single institution review of 84 cases. Gynecol.
Oncol., 2004, 94, 456.
[4] Mandai M., Yamaguchi K., Mastumura N., BabaT., Konishi I.:
Ovarian cancer in endometriosis: molecular biology, pathology,
and clinical management. Int. J. Clin. Oncol., 2009, 14, 383.
[5] Ogawa S., Kaku T., Amada S., Kobayashi H., Hirakawa T.,
Ariyoshi K. et al.: Ovarian endometriosis associated with ovarian
carcinoma: a clinicopathological and immunohistochemical
study. Gynecol. Oncol., 2000, 77, 298.
[6] Modesitt S.C., Tortolero-Luna G., Robinson J.B., Gershenson
D.M., Wolf J.K.: Ovarian and extraovarian endometriosis-associated cancer. Obstet. Gynecol., 2002, 100, 788.
[7] Yoshikawa H., Jimbo H., Okada S., Matsumoto K., Onda T.,
Yasugi T. et al.: Prevalence of endometriosis in ovarian cancer.
Gynecol. Obstet. Invest., 2000, 50, 11.
[8] Tingulstad S., Skjeldestad F.E., Halvorsen T.B., Hagen B.:
Survival and prognostic factors in patients with ovarian cancer.
Obstet. Gynecol., 2003, 101, 885.
398
[9] Petru E., Luck H.J., Stuart G., Gaffney D., Millan D., Vergote I.:
Gynecologic cancer intergroup (IGCIG) proposals for changes of
the current FIGO staging system. Eur. J. Obstet. Gynecol.
Reprod. Biol., 2009, 143, 69.
[10] Scully R.E., Sobin L.H.: Histological Typing of Ovarian
Tumours. New York, Berlin, Springer Verlag, 1999.
[11] Sood A.K., Abu-Rustum N.R., Barakat R.R., Bodurka D.C.,
Brown J., Donato M.L. et al.: Fifth international conference on
ovarian cancer. Challenges and apportunities. Gynecol. Oncol.,
2005, 97, 916.
[12] Jemal A., Siegel R., Ward E.: Cancer statistics, 2008. CA.
Cancer. J. Clin., 2008, 58, 71.
[13] Clarke-Perason D.L.: Screening for ovarian cancer. N. Engl. J.
Med., 2009, 36, 170.
[14] Pal T., Permuth-Wey J., Betts J.A., Krischer J.P., Fiorica J., Arango
H. et al.: BRCA1 and BRCA2 mutations account for a large proportion of ovarian carcinoma cases. Cancer, 2005, 104, 2807.
[15] Kobayashi H., Sumimoto K., Moniwa N., Imai M., Takakura K.,
Kuromaki T. et al.: Risk of developing ovarian cancer among
women with ovarian endometrioma: a cohort study in Shizuoka,
Japan. Int. J. Gynecol. Cancer, 2007, 17, 37.
[16] Lu Y., Liu M.H., Zheng Y., Guo S.W., Liu X.S.: Clinicopathological
features of 67 cases of endometriosis-associated epithelial ovarian
carcinoma. Zhonghua Fu. Chan. Ke. Za. Zhi., 2009, 44, 832.
[17] Melin A., Sparen P., Persson I., Berqvist A.: Endometriosis and
the risk of cancer with special emphasis on ovarian cancer. Hum.
Reprod. 2006, 21, 1237.
[18] Vlahos N.F., Kalampokas T., Fotiou S.: Endometriosis and ovarian cancer: a review. Gynecol. Endocrinol., 2010, 26, 213.
[19] Steed H., Chapman W., Laframoise S.: Endometriosis-associated
ovarian cancer: a clinicopathologic review. J. Obstet. Gynaecol.
Can., 2004, 26, 709.
[20] Fukunaga M., Nomura K., Ishikawa E., Ushigome S.: Ovarian
atypical endometriosis: its close association with malignant epithelial tumors. Histopathology, 1997, 30, 249.
[21] Kobayashi H.: Ovarian cancer in endometriosis: epidemiology,
natural history, and clinical diagnosis. Int. J. Clin. Oncol., 2009,
14, 378.
[22] Aris A.: Endometriosis-associated ovarian cancer. A ten-year
cohort study of women living in the Estrie region of Quebec,
Canada. J. Ovarian. Res., 2010, 3, 2.
[23] Orezzoli J.P., Russell A.H., Oliva E., Del Carmen M.G., Eichhorn
J., Fuller A.F.: Prognostic implication of endometriosis in clear
cell carcinoma of the ovary. Gynecol. Oncol., 2008, 110, 336.
[24] Stern R.C., Dash R., Bentley R.C., Snyder M.J., Haney A.F.,
Robboy S.J.: Malignancy in endometriosis: frequency and comparison of ovarian and extraovarian types. Int. J. Gynecol.
Pathol., 2001, 20, 133.
[25] Storey D.J., Rush R., Stewart M., Rye T., Al-Nafussi A., Williams
A.R.: Endometrioid epithelial ovarian cancer: 20 years of
prospectively collected data from a single center. Cancer, 2008,
112, 2108.
[26] Kaku T., Ogawa S., Kawano Y., Ohishi Y., Kobayashi H., Hirakawa
T. et al.: Histological classification of ovarian cancer. Med.
Electron. Microsc., 2003, 36, 9.
[27] Bosse K., Rhiem K., Wappenschmidt B., Hellmich M., Madeja M.,
Ortmann M. et al.: Screening for ovarian cancer by transvaginal
ultrasound and serum CA 125 measurement in women with a
familial predisposition: A prospective cohort study. Gynecol.
Oncol., 2006, 103, 1077.
[28] Kolwijck E., Lybol C., Bulten J., Vollebergh J.H.A., Wavers R.A.,
Massuger L.: Prevalence of cystis in epithelial ovarian cancer.
Eur. J. Obstet. Gynecol. Reprod. Biol., 2010, 151, 96.
[29] Topalak O., Saygili U., Soyturk M., Karaca N., Batur Y., Uslu T. et
al.: Serum, pleural effusion, and ascites CA-125 levels in ovarian
cancer and nonovarian benign and malignant diseases: A comparative study. Gynecol. Oncol., 2002, 85, 108.
[30] Eltabbakh G.H.: Recent advances in the management of women
with ovarian cancer. Minerva. Ginecol., 2004, 56, 81.
[31] Hoekstra A.V., Hurteau J.A., Kirschner C.V., Rodriguez G.C.:
The combination of montly carboplatin and weekly paclitaxel is
highly active for the treatment of recurrent ovarian cancer.
Gynecol. Oncol., 2009, 115, 377.
[32] Omura G.A., Brady M.F., Homesley H.D., Yordan E., Major F.J.,
Buchsbaum H.J. et al.: Long-term follow-up and prognostic factor analysis in advanced ovarian carcinoma: the Gynecologic
Oncology Group experience. J. Clin.Oncol., 1991, 9, 1138.

M. VASILJEVIC, M.D., PhD.
Omladinskih Brigada street 7V
11000 Belgrade (Serbia)
e-mail: dmdnmvas@eunet.rs
27 1227-31 - Evaluation of adolescent:1648_29 Incidence of multiple 15/11/11 14:53 Pagina 399
[1227/31]
399
Evaluation of adolescent pregnancies: 10-year experience

of a hospital in rural Turkey
B. Demir1, A.I. Guzel1, Y. Celik2, S. Demir1, F. Demir3
1
Department of Gynecology and Obstetrics, Ergani State Hospital, Diyarbakir

Department of Biochemistry and Medical Informatics, Dicle University, Medicine Faculty, Diyarbakir
3
Diyarbakir Childrens Hospital, Diyarbakir (Turkey)
Summary
Purpose: To evaluate the characteristics of adolescent pregnancies admitted to our clinic. Materials and Methods: This retrospective and descriptive study was performed at Ergani State Hospital from January 2000 to December 2010. This is an outpatient gynecology and obstetrics at government hospital in Southern Eastern Region of Turkey. A total of 15,210 pregnancies were delivered
during the study period, of whom 711 of them were adolescent pregnancies. Statistical analyses were carried out using the statistical packages for SPSS 15.0 for Windows (SPSS Inc., Chicago, IL, USA). Results: During the study period, of the total of 15,210
deliveries 711 (4.6%) were adolescent pregnancies (age range 14-19 years). The mean age (95% CI) of the patients was 17.90
1.12 (17.82-17.98) years old. Most of the patients were nulliparous (n = 559, 78.60%). Mean gestational weeks, fetal birth weight
and fetal birth length and 95% CI values were as follows: 37.11 2.53 (36.93-37.30), 3045.73 51.70 (3007.65-3083.79) and 48.68
2.31 (48.51-48.85), respectively. Six hundred and twenty (87.20%) of the patients delivered spontaneously by the vaginal route,
while 91 (12.80%) were delivered by cesarean section. Although the age range of the patients was not wide, there was a significant
correlation between maternal age, gestational age, fetal birth weight and fetal birth length (p < .01). Conclusion: According to this
study, the ratio of adolescent pregnancies was found to be 4.6% which was lower than other regions of Turkey. The majority of the
patients were nulliparous and most delivered spontaneously by the vaginal route. There was a significant correlation between maternal age, gestational age, fetal birth weight and fetal birth length.
Key words: Adolescent pregnancies; Clinical characteristics; Correlation coefficient.
Introduction
Adolescence is described as being age 10-19 years by
The World Health Organization (WHO) and 85% of adolescents have been reported to live in developing countries [1]. Adolescent pregnancies are associated with
adverse maternal and fetal outcomes such as prematurity,
low birth weight, mortality and increased instrumental
delivery and cesarean section [2, 3]. Lower socioeconomic and educational status were also reported be
highly associated with adolescent pregnancies [4, 5]. In
Turkey, the incidence of adolescent pregnancies was
reported as 9% in cities and 11% in rural areas. In the
south eastern region of Turkey the incidence was reported
to be higher than other areas due to the high ratio of lower
educational status [6].
In this study, we report our experience of adolescent
pregnancies managed at a government hospital in a rural
area of Turkey.
Maternal age was defined for adolescent pregnancies as

between 14 and 19 years. During the study period, a total of
15,210 deliveries were performed at the current clinic. Of these
patients 711 (4.6%) were adolescent pregnancies (age range
14-19).
The factors recorded for each study subject were; age, parity,
gestational weeks, birth weight, birth length, delivery type,
instrumental delivery, still birth and congenital anomalies. Gestational age (weeks) were assessed by ultrasound examination
(Schimadzu SDU-1100 color Doppler ultrasound device) or
according to last menstrual period, or both.
Results
During the study period, a total of 15,210 deliveries
were performed at the current clinic. Of these patients
711 (4.6%) were adolescent pregnancies with an age
range of 14-19 years.
The mean age (95% CI) of the patients was 17.90
1.12 (17.82-17.98) years. Most of the patients were nulliparous (n = 559, 78.60%). Mean gestational weeks,
fetal birth weight and fetal birth length and 95% CI
values follows were as 37.11 2.53 (36.93-37.30),
3045.73 51.70 (3007.65-3083.79) and 48.68 2.31
(48.51-48.85), respectively.
This retrospective study was performed at Ergani State Hospital, a government hospital in a rural area of Turkey from January
2000 to December 2010. Most of the people living in this region
have a lower socio-economic and educational status. Most of the
health services are provided free of charge by support of the government. Because this is a retrospective data analysis ethical
approval was not required but the study was conducted according
to the Declaration of Helsinki. All of the patients were Turkish
women with no tobacco, alcohol or drug use.

XXXVIII, n. 4, 2011
Statistical analyses were carried out using the statistical packages for SPSS 15.0 for Windows (SPSS Inc., Chicago, IL,
USA). The means, standard deviations (SD) and 95% confidence interval (CI) were calculated for descriptive variables.
Pearsons correlation coefficient was used to calculate the relationships among variables. Frequencies for parity of the cases
are presented in Table 2.
27 1227-31 - Evaluation of adolescent:1648_29 Incidence of multiple 15/11/11 14:53 Pagina 400
400
B. Demir, A.I. Guzel, Y. Celik, S. Demir, F. Demir
Table 1. Demographic and clinical characteristics of the

cases.
Cases
Age (years)
Parity
Gestational age (weeks)
Fetal birth weight (gram)
Fetal birth length (cm)
Delivery type*
Vaginal birth
Cesarean section
17.90
1.23
37.11
3045.73
48.68
SD
95% CI
1.12
17.82-17.98
0.48
2.53
36.93-37.30
51.70 3007.65-3083.79
2.31
48.51-48.85
620 (87.20)
91 (12.80)
*: Data presented as n (%), : Frequencies of parity are presented in Table 2.
Table 2. Frequencies for parity of the patients.

Valid
1.00
2.00
3.00
4.00
Total
Frequency
Percent
Valid percent
Cumulative percent
559
138
11
3
711
78.6
19.4
1.5
0.4
100.0
78.6
19.4
1.5
0.4
100.0
78.6
98.0
99.6
100.0
Of the patients 620 (87.20%) delivered spontaneously

by the vaginal route, while 91 (12.80%) delivered by
cesarean section.
Although the patient age range was not wide, there was
a significant correlation between maternal age, gestational age, fetal birth weight and fetal birth length (p <
0.01). The correlation coefficient values for these variables were 0.150, 0.174 and 0.81, respectively.
Discussion
Adolescent pregnancy is a major health problem
among teenagers. In Western countries studies report a
decline in adolescent pregnancies, but there also is a high
ratio in America with 750,000 pregnancies each year [7,
8]. Gupta et al. [9] reported that the highest ratio for adolescent pregnancies was in Sub-Saharan Africa throughout the world. In Turkey, the incidence of adolescent
pregnancies was reported to be 9% in cities and 11% in
rural areas. In the south eastern region of Turkey the incidence was reported as to be higher than the other areas
due to the high ratio of lower educational status [6].
In this study we evaluated the clinical and demographic
characteristics of adolescent pregnancies followed and
delivered at our clinic. This is a government supported
hospital obstetrics clinic, and most of the health services
are provided free of charge; therefore, the socioeconomic
and educational status of the patients are typically low.
During the study period a total of 711 adolescent pregnancies delivered at our clinic.
Al-Ramahi and Saleh [10] reported their experience of
adolescent pregnancies and compared them with reproductive age women. They found that the gravidity, parity
and the incidence of abortions were significantly lower in
the adolescent pregnancy group as most of them were
primigravidas. Most of our patients were nulliparous
patients as in Al-Ramahi and Salehs study with a frequency of 78.6%.
Lao et al. [3] reported in their study that adolescent

pregnancies have a higher incidence of preterm labor
whereas in contrast Raatikainen et al. [2] found no evidence of increased risk for preterm labor. Al-Ramahi et
al. [10] found an increased incidence of preterm delivery
among women with adolescent pregnancies when compared with reproductive age women. In the present study
the ratio of preterm delivery was 26.16% (n = 186).
Previous studies reported that being at an adolescent
maternal age was associated with decreased risk of
cesarean section [3, 11] and increased incidence of spontaneous vaginal delivery [12, 13]. In our study we also
found the incidence of spontaneous delivery type higher
than the cesarean section rate.
To the best of our knowledge, there are no studies evaluating the correlation coefficient in this pregnancy age.
According to Pearsons correlation coefficient method we
found a significant relation between maternal age when
compared with gestational age, fetal birth weight and
fetal birth length. We found the coefficients for these
variables as 0.150, 0.174 and 0.81, respectively.
References
[1] WHO World Health Organization: The second decade: improving adolescent health and development. Programme
brochure.Geneva: WHO, Department of Child and Adolescent
Health and Development, 1998.
[2] Raatikainen K., Heiskanen N., Verkasalo P.K., Heinonen S.:
Good outcome of teenage pregnancies in high-quality maternity
care. Eur. J. Public Health, 2006, 16, 157.
[3] Lao T.T., Ho L.F.: The obstetric implications of teenage pregnancy. Hum. Reprod., 1997, 12, 2303.
[4] Polit D.F., Kahn J.R.: Project Redirection: evaluation of a comprehensive program for disadvantaged teenage mothers. Fam.
Plann. Perspect., 1985, 17, 150.
[5] Finkelstein J.W., Finkelstein J.A., Christie M., Roden M., Shelton
C.: Teenage pregnancy and parenthood: outcomes for mother and
child. J. Adolesc. Health Care, 1982, 3, 1.
[6] Ozkara E., Altunyurt S., Unuvar T., Arsoy Y.: Effects of pregnancy on health among adolescents aged under 15 years: an evaluaton n the lght of turksh penal code artcle 103. Turk. J.
Forensic Sci., 2008, 7, 35.
[7] Anachebe N.F., Sutton M.Y.: ..Racial disparities in reproductive
health outcomes. Am. J. Obstet. Gynecol., 2003, 188, S37.
[8] Dangal G.: An update on teenage pregnancy. Internet J.
Gynecol. Obstet., 2005, 5, 1.
[9] Gupta N., Mahy M.: Sexual initiation among adolescent girls and
boys: trends and differentials in sub-Saharan Africa. Arch. Sex.
Behav., 2003, 32, 41.
[10] Al-Ramahi M., Saleh S.: Outcome of adolescent pregnancy at a
university hospital in Jordan. Arch. Gynecol. Obstet., 2006, 273,
207.
[11] Konje J.C., Palmer A., Watson A., Hay D.M., Imrie A., Ewings P.:
Early teenage pregnancies in Hull. Br. J. Obstet. Gynaecol.,
1992, 99, 969.
[12] Buitendijk S.E., van Enk A., Oosterhout R., Ris M.: Obstetrical
outcome in teenage pregnancies in The Netherlands. Ned Tijdschr Geneeskd., 1993, 137, 2536.
[13] Ziadeh S.: Obstetric outcome of teenage pregnancies in North
Jordan. Arch. Gynecol. Obstet., 2001, 265, 26.

B. DEMIR, M.D.
Peyas Mah. 282. Sokak
Diyarpark 1 Sitesi, E blok, No: 15
Kayapinar, Diyarbakir (Turkey)
e-mail: bulentdemirmd@hotmail.com
28 1228-31 - Morphologic and functional:1648_29 Incidence of multiple 15/11/11 14:56 Pagina 401
[1228/31]
401
Morphologic and functional vascular alterations in patients

with polycystic ovary syndrome
B. Demir1, S. Pasa2, S. Demir1, R. Buyukkaya3, A.E. Atay4, Y. Atamer5, T. Gul6
1
Department of Gyneacology and Obstetrics, Ergani State Hospital, Diyarbakir

Department of Internal Diseases, Adiyaman University, Medicine Faculty, Adiyaman
3
Department of Radiodiagnostics, Ergani State Hospital, Diyarbakir
4
Department of Internal Medicine, Diyarbakir Family Hospital, Diyarbakir
5
Department of Biochemistry, Dicle University, Medicine Faculty, Diyarbakir
6
Department of Gyneacology and Obstetrics, Dicle University, Medicine Faculty, Diyarbakir (Turkey)
2
Summary
Background: We aimed to investigate morphologic and functional alterations of common carotid arteries (CCA) and femoral arteries and the anteroposterior diameter of the abdominal aorta in patients with polycystic ovary syndrome (PCOS). Materials and
Methods: Fifty consecutive females with the complaint of oligoamenorrhea, infertility or hirsutismus, diagnosed with PCOS and 50
healthy females admitted to the Department of Gynecology and Obstetrics, Ergani State Hospital between January 2010 and January
2011 were included in the study. Results: The mean BMI of 50 patients with PCOS was higher than control subjects (CS) (25.89
3.3 vs 22.52 2.7 kg/m2, p < 0.0001). The mean arterial blood pressure was 88.93 6.4 mmHg in the patient group and was it
85.73 7.6 mmHg in CS (p = 0.02). The mean plasma glucose level (74.04 6.7 vs 70.5 6.4 mg/dl), total cholesterol level (167.88
30.1 vs 153.38 27.8 mg/dl), low density lipoprotein level (101.28 27.0 vs 79.56 25.5 mg/dl) and triglyceride level (121.22
49.2 vs 102.54 36.6 mg/dl) were higher; also the mean high density lipoprotein level (44.56 8.1 vs 50.90 12.3 mg/dl) was
lower in patients with PCOS than CS (p = 0.009, p = 0.014, p < 0.0001, p = 0.034 and p = 0.003, respectively). CCA-IMT (0.63
0.2 vs 0.52 0.1 mm), and CCA-PI (1.44 0.3 vs 1.28 0.22) were higher in patients with PCOS (p = 0.018 and p = 0.005, respectively). Femoral-IMT (0.62 0.6 vs 0.41 0.1 mm) and anteroposterior diameter of the infrarenal aorta (12.34 1.5 vs 11.4 1.0
mm) were higher in patients with PCOS (p = 0.024 and p = 0.001, respectively). Conclusion: The present study showed that IMT
and PI of CCA, and anteroposterior diameter of the infrarenal abdominal aorta and femoral-IMT were higher in patients with PCOS.
These results are probably related with increased androgens, their effects on insulin resistance and lipid profile, increased BMI and
blood pressure. Detection of these functional and/or structural abnormalities are important in predicting prognosis. Larger scale
prospective studies are needed to determine the effects of PCOS on the mortality and morbidity, and to clarify the relation between
the duration of the disease and development of these alterations.
Key words: Polycystic ovary syndrome; Vascular alterations; Vascular dysfunction.
Introduction
Polycystic ovary syndrome (PCOS) is one of the most
common endocrinopathies, affecting 5%-10% of women
in reproductive age [1]. It is characterized by chronic
anovulation, hyperandrogenism, insulin resistance, obesity,
infertility, and an increased risk of spontaneous abortion
[2]. Although it is important to recognize and address these
clinical problems, attention has also turned to the risk of
diabetes and cardiovascular disease due to central obesity,
dyslipidemia (low high-density lipoprotein [HDL] and
high cholesterol and triglyceride levels), hypertension,
endothelial dysfunction, and insulin resistance [3-11]. It
has been reported that women with clinical features of
PCOS have five years lower cardiovascular event-free survival due to hemodynamic changes related to hormonal
disturbances and their metabolic effects [12].
The intima-media thickness (IMT) of the arteries has
proven to be a good marker for both the presence of early
arteriosclerosis and degree of arteriosclerosis [13-18].
Prospective studies have shown a positive correlation
between increased common carotid artery (CCA) IMT

XXXVIII, n. 4, 2011
and risk for cardiovascular mortality [19-21]. The resistive index (RI) is not a morphological but a hemodynamic
parameter that can be easily determined by Doppler ultrasound (US). It reflects local wall extensibility and the
related vascular resistance. There is a clear correlation
between increasing RI values and arteriosclerosis risk
factors and manifestations [13, 14, 22-24].
Many vascular abnormalities have been demonstrated in
women with PCOS by using Doppler US. In particular,
several studies found increased CCA-IMT and/or IMT of
the internal carotid arteries [25-27], and some studies
found increased anteroposterior diameter of the infrarenal
abdominal aorta in women affected by PCOS [4].
In the present study we aimed to investigate whether
the IMT and flow parameters of CCA and femoral arteries would be higher in women with PCOS than in those
without this disease control subjects (CS) and if the
anteroposterior diameter of the abdominal aorta would
differ between the two groups.
Fifty consecutive females complaining of oligo-amenorrhea,
infertility or hirsutismus, diagnosed with PCOS according to
Rotterdam criteria [28] and 50 healthy females (CS) admitted to
the Department of Gynecology and Obstetrics, Ergani State
402
B. Demir, S. Pasa, S. Demir, R. Buyukkaya, A.E. Atay, Y. Atamer, T. Gul
Hospital between January 2010 and November 2010 were

included in the study. Patients and controls with diabetes mellitus, metabolic syndrome, dyslipidemia, hypertension, Cushing
syndrome, hyperprolactinemia, thyroid dysfunction, coronary
or chronic liver or kidney diseases, with a history of thromoembolic diseases, smoking, drug usage which might affect hormonal or biochemical tests or endothelial functions which
might effect imaging studies of arteries (oral contraceptives,
glucocorticoids, antiandrogens, or insulin sensitizers) were
excluded. The study was conducted in accordance with the
ethical standards for human experimentation established by the
Declaration of Helsinki. Informed written consent was obtained
from all participants.
Blood pressure (BP) of all participants was measured at rest in
a climatized room at 22C. Body mass index (BMI) of patients
was calculated as kg/m2. Serum and plasma samples were collected from patients between 08:00 and 10:00 a.m., after an
overnight fast of at least 12 hours during the early follicular phase
of the menstrual cycle, or on random days in amenorrheic
patients on the same day of US. Luteinizing hormone (LH), follicle stimulating hormone (FSH), estrodiol, prolactin and total
testosterone were determined by using an ADVIA Centaur XP
Immunoassay System (Siemens Healthcare Diagnostics, NY,
USA). Glucose, total cholesterol, HDL, low-density lipoprotein
(LDL) cholesterol, and triglycerides were measured by enzymatic colorimetric assay, using Ortho Clinical Diagnostics,
Johnson & Johnson VITROS products 5.1 FS Chemistry System
(Johnson & Johnson, NY, USA), and its original reagents.
Ultrasound and Doppler analyses were performed by the
same physician for all women during the follicular phase of the
menstrual cycle (between the third and fifth day) after resting a
minimum of 15 min in a quiet room. US studies of CCA and
femoral arteries were performed bilaterally. The value of CCA
and femoral arteries considered for statistical analyses was the
mean of the right and left measurements for each artery. All
studies were performed with a SDU-2200 pro (SDU-2200 Pro,
Shimadzu, Korea) using a 5-10 MHz high-resolution probe.
IMT was defined as a low-level echo grey band that does not
project into the arterial lumen. It was measured during end-diastole as the distance from the leading edge of the second
echogenic line of the far walls of the distal segment of the CCA,
the carotid bifurcation, and the initial tract of the internal
carotid artery on both sides, and similarly of the distal segment
of the common femoral artery on both sides. Measurements
were performed 0.5, 1, and 2 cm below the bifurcation (three
measurements on each side) for the carotid, and 0.5, 1, and 2
cm below the femoral (profunda and superficial; three measurements on each side), and the average measurement was taken as
the IMT. IMT measurements were always performed in plaquefree arterial segments. The peak systolic velocity, end-diastolic
velocity and mean velocity of eveluated arteries were measured,
then RI and pulsative index (PI) values calculated [29]; as RI =
(peak systolic velocity end-diastolic velocity)/peak systolic
melocity and PI = (peak systolic velocity end-diastolic velocity)/mean velocity. Evaluation of the infrarenal abdominal aorta
was performed in the supine position; an electronic probe was
placed 1 cm left of the umbilicus. The best image in long axis
projection of the abdominal aorta was then obtained. The
anteroposterior diameter of the aorta was defined as the
maximal external cross-sectional measurement. It was calculated as the distance between the near and the far walls of the
abdominal aorta. Measurements were performed at 0.5, 1, and
2 cm above the umbilicus and expressed in centimeters [4].
Statistical analysis: Results are presented as mean and standard deviation (SD) for all parameters. Statistical significance
was determined by the t-test. All tests were performed using the
SPSS statistical package version 11; p values 0.05 were considered significant.
Results
There was no statistically significant difference between
mean age of patients with PCOS and CS (24.76 5.2 and
23.94 4.8 years, respectively). Mean BMI of the patient
group was higher than CS (25.89 3.3 vs 22.52 2.7
kg/m2, p < 0.0001). Mean systolic BP was 116.0 8.3
mmHg in the patient group and 110.4 9.6 mmHg in CS;
mean diastolic BP was 75.4 7.8 mmHg in the patient
group and 73.4 7.9 mmHg in CS; and, the mean arterial
pressure was 88.93 6.4 mmHg in the patient group and
85.73 7.6 mmHg in CS. The systolic and mean arterial
BP were significantly higher in patients with PCOS than in
CS (p = 0.003 and p = 0.02, respectively). The mean diastolic BP was also higher in the patient group but this difference was not statistically significance.
The mean fasting plasma glucose level (74.04 6.7 vs
70.5 6.4 mg/dl), total cholesterol level (167.88 30.1
vs 153.38 27.8 mg/dl), LDL level (101.28 27.0 vs
79.56 25.5 mg/dl) and triglyceride level (121.22 49.2
vs 102.54 36.6 mg/dl) were higher, and mean HDL
level (44.56 8.1 vs 50.90 12.3 mg/dl) was lower in
patients with PCOS than CS (p = 0.009, p = 0.014, p <
0.0001, p = 0.034 and p = 0.003, respectively).
There were no statistically significant differences
between the groups in terms of FSH, estradiol and prolactin levels. However, mean LH level (8.23 5.6 vs 5.8
2.7 IU/l) and mean total testosterone level (70.38
20.7 vs 52.98 17.9 ng/dl) were higher in patients with
PCOS (p = 0.008 and p < 0.0001, respectively).
CCA-IMT (0.63 0.2 vs 0.52 0.1 mm), and CCA-PI
(1.44 0.3 vs 1.28 0.22) were higher in patients with
PCOS (p = 0.018 and p = 0.005, respectively). There was
no statistically significant difference between patients and
controls in terms of CCA-RI (0.71 0.1 vs 0.70). FemoralIMT (0.62 0.6 vs 0.41 0.1 mm) and anteroposterior
diameter of the infrarenal aorta (12.34 1.5 vs 11.4 1.0
mm) were higher in patients with PCOS (p = 0.024 and p
= 0.001, respectively). Results are shown in Table 1.
Discussion
In this study we aimed to investigate the alterations in
IMT (as a morphologic parameter) and functional flow
parameters (RI) of CCA and femoral arteries in 50 consecutive women with PCOS. The patients with PCOS had a
signicantly higher mean BMI, systolic blood and mean
arteriel pressure, plasma glucose, total cholesterol and
LDL levels and lower HDL levels than controls. Some hormonal differences were also detected in patients with
PCOS. LH and total testosteron levels were higher in
patients with PCOS as expected. In addition, we found
some vascular morphologic and functional alterations
(CCA-IMT, Ci CA-PI, femoral-IMT and anteroposterior
diameter of the infrarenal aorta were higher) in patients
with PCOS.
Morphologic and functional vascular alterations in patients with polycystic ovary syndrome
Table 1. Comparison of biochemical and hormonal

parameters and imaging studies of patients with PCOS and CS.
Age (years)
BMI (kg/m2)
Systolic blood pressure
(mmHg)
Diastolic blood pressure
(mmHg)
Mean arterial pressure
(mmHg)
Glucose (mg/dl)
Total cholesterol (mg/dl)
LDL (mg/dl)
HDL (mg/dl)
Triglyceride (mg/dl)
FSH (IU/l)
LH (IU/l)
Estradiol (pg/ml)
Prolactin (ng/ml)
Total testosterone (ng/dl)
Common Carotid
artery IMT (mm)
Common Carotid RI
Common Carotid PI
Femoral arterial
IMT (mm)
AP diameter of infrarenal
aorta (mm)
PCOS (n = 50)
CS (n = 50)
24.76 5.2
25.89 3.3
23.94 4.8
22.52 2.7
NS
< 0.0001
116 8.3
110.4 9.6
0.003
75.4 7.8
73.4 7.9
NS
88.93 6.4
74.04 6.7
167.88 30.1
101.28 27.1
44.56 8.1
121.22 49.2
4.12 1.4
8.23 5.6
55.8 12.8
9.64 5.1
70.38 20.7
85.73 7.6
0.02
70.5 6.4
0.009
153.38 27.8 0.014
79.56 25.5 < 0.0001
50.9 12.3
0.003
102.54 36.6 0.034
4.56 1.6
NS
5.84 2.7
0.008
54.95 14.4
NS
10.4 5.3
NS
52.98 17.9 < 0.0001
0.63 0.2
0.71 0.1
1.44 0.3
0.52 0.4
0.7 0.1
1.28 0.2
0.018
NS
0.005
0.62 0.6
0.41 0.1
0.024
12.34 1.5
11.41 1.1
0.001
NS: non significant.
It is known that cardiovascular disease (CVD) risk

factors such as obesity, dyslipidemia, glucose intolerance
diabetes and hypertension are encountered more frequently in patients with PCOS and the mortality rate are
higher in these patients related to CVD [30]. Similar to
previous reports, we found that mean BMI, blood pressure and glucose levels of patients were higher in patients
with PCOS. This study showed again that these patients
have a tendency for hypertension, obesity and glucose
intolerance. Hyperinsulinemic insulin resistance is a cardinal finding in the pathophysiology of PCOS, and
hyperinsulinemia plays a key role by circulating ovarian
androgen concentrations as we also demonstrated.
Hyperinsulinemia may also be used for dyslipidemia
related to decreased activity of lipoprotein lipase and
lipoproteins received by adiposis. In addition to the vasoconstructive effects of androgenes, endothelial dysfunction and increased arterial stiffness were also detected in
insulin resistance and hyperlipidemia, and both may play
a role in vascular morphologic alterations [2].
IMT, measured by B-image technology, is a morphological parameter and represents the histologically verified IMI segment of the vascular wall [31]. The RI is
instead based on Doppler technology, calculated by using
Pourcelots formula as shown above, and relates to the
elasticity or extensibility of the vessel and its vascular
resistance. Both are clearly correlated with age and other
CVD factors [13, 32-34]. As demonstrated in many previous reports, CCA-IMT and RI are surrogate markers
for the degree of atherosclerosis in an individual patient
403
[13]. In this study, we showed that CCA-IMT and PI

were higher in the study group. CCA-RI of patients with
PCOS was also higher, however this difference was not
statistically significant. Staub and collegues [13] showed
a similar result in their study; however, Lakhani et al. [3]
found decreased PI in their study group. It is not known
definitely why the carotid-PI was lower in the study of
Lakhani et al. but the authors postulated that the high
estrodiol levels of their study group might have been
responsible for these results. It was previously demonstrated that decreased estradiol levels in postmenopausal
women caused a decrement in PI [3]. The higher levels
of CCA-IMT and PI that were detected in our study are
probably the result of increased androgens associated
with insulin resistance and deteriorated lipid profile,
increased BMI and blood pressure. Before the appearance of morphological alterations that are detectable from
the thickening of the IMT complex, the early form of atherosclerosis leads to functional abnormalities that are associated with increased cardiovascular mortality. Detection
of these firstly functional and lately structural abnormalities is important in predicting the mortality of these
patients. It is not clearly known what the effects of PCOS
are on mortality, and larger scale prospective studies are
needed to determine the effects of PCOS and confounding
CVD factors that may be related to prognosis.
Ciccone et al. [4] studied the vascular effects of PCOS
in a young patient group aged between 17 and 27. They
did not find a statistical difference between femoral-IMT
of patients and controls, but detected a larger anteroposterior diameter of the infrarenal abdominal aorta. They
suggested that the similarity between femoral-IMT but
not between diameter of the infrarenal aorta may be
related to the younger ages of patients, and they postulated that the earliest vascular alteration in patients with
PCOS is increased diameter of the abdominal aorta.
Similar to Ciccione et al. we found that the mean anteroposterior diameter of the infrarenal abdominal aorta was
higher in these patients. In addition, we found a higher
femoral IMT in our study group. The mean age of our
patients was higher (24.7 5.2; range 18-33 years), and
the difference we found between IMT of the arteries
might be related with longer duration of the disease, as
Ciccone et al. suggested. Indeed, the alterations in IMT
may be detected in longer duraton of the disease.
However, larger scale studies that classify patients
according to age are needed to clarify the relation
between ages, duration of the disease and development of
these alterations.
In conclusion, in this study we showed that CCA-IMT
and PI, anteroposterior diameter of the infrarenal abdominal aorta and femoral-IMT were higher in patients with
PCOS. These results are probably related to increased
androgen levels, their effects on insulin resistance and
lipid profile, increased BMI and blood pressure. Detection of these functional and/or structural abnormalities
are important in predicting the mortality and morbidity of
these patients. Larger scale prospective studies are
needed to determine the effects of PCOS on mortality and
404
B. Demir, S. Pasa, S. Demir, R. Buyukkaya, A.E. Atay, Y. Atamer, T. Gul
to clarify the relation between the duration of the disease

and development of these alterations.
References
[1] Ehrmann D.A.: Polycystic ovary syndrome. N. Engl. J. Med.,
2005, 352, 1223.
[2] Adali E., Kolusari A., Adali F., Yildizhan R., Kurdoglu M., Sahin
H.G.: Doppler analysis of uterine perfusion and ovarian stromal
blood flow in polycystic ovary syndrome. Int. J. Gynaecol.
Obstet., 2009, 105, 154.
[3] Lakhani K., Constantinovici N., Purcell W.M., Fernando R.,
Hardiman P.: Internal carotid artery haemodynamics in women
with polycystic ovaries. Clin. Sci., 2000, 98, 661.
[4] Ciccone M.M., Favale S., Bhuva A., Scicchitano P., Caragnano V.,
Lavopa C. et al.: Anteroposterior diameter of the infrarenal
abdominal aorta is higher in women with polycystic ovary syndrome. Vasc. Health Risk Manag., 2009, 5, 561.
[5] Cho L.W., Randeva H.S., Atkin S.L.: Cardiometabolic aspects of
polycystic ovarian syndrome. Vasc. Health Risk Manage, 2007, 3,
55.
[6] Talbott E., Guzick D., Clerici A., Berga S., Detre K., Weimer K.,
Kuller L.: Coronary heart disease risk factors in women with
polycystic ovary syndrome. Arterioscler. Thromb. Vasc. Biol.,
1995, 15, 821.
[7] Meyer C., McGrath B.P., Teede H.J.: Overweight women with
polycystic ovary syndrome have evidence of subclinical cardiovascular disease. J. Clin. Endocrinol. Metab., 2005, 90, 5711.
[8] Berneis K., Rizzo M., Lazzaroni V., Fruzzetti F., Carmina E.:
Atherogenic lipoprotein phenotype and low-density lipoproteins
size and subclasses in women with polycystic ovary syndrome. J.
Clin. Endocrinol. Metab., 2007, 92, 186.
[9] Battaglia C., Mancini F., Cianciosi A., Busacchi P., Facchinetti F.,
Marchesini G.R. et al.: Vascular risk in young women with polycycstic ovary syndrome. Obstet. Gynecol., 2008, 111, 385.
[10] Arslanian S.A., Lewy V.D., Danadian K.: Glucose intolerance in
obese adolescents with polycystic ovary syndrome: roles of insulin
resistance and -cell dysfunction and risk of cardiovascular
disease. J. Clin. Endocrinol. Metab., 2001, 86, 66.
[11] Cheung L.P., Ma R.C., Lam P.M., Lok I.H., Haines C.J., So W.Y.
et al.: Cardiovascular risks and metabolic syndrome in Hong
Kong Chinese women with polycystic ovary syndrome. Hum.
Reprod., 2008, 23, 1431.
[12] Shaw L.J., Bairey Merz C.N., Azziz R., Stanczyk F.Z., Sopko G.,
Braunstein G.D. et al.: Postmenopausal women with a history of
irregular menses and elevated androgen measurements at high risk
for worsening cardiovascular event-free survival: results from the
National Institutes of Health - National Heart, Lung, and Blood
Institute sponsored Womens Ischemia Syndrome Evaluation. J.
Clin. Endocrinol. Metab., 2008, 93, 1276.
[13] Staub D., Meyerhans A., Bundi B., Schmid H.P., Frauchiger B.:
Prediction of cardiovascular morbidity and mortality: comparison
of the internal carotid artery resistive index with the common
carotid artery intima-media thickness. Stroke, 2006, 37, 800.
[14] Frauchiger B., Schmid H.P., Roedel C., Moosmann P., Staub D.:
Comparison of carotid arterial resistive indices with intimamedia thickness as sonographic markers of atherosclerosis.
Stroke, 2001, 32, 836.
[15] Simons P.C., Algra A., Bots M.L., Grobbee D.E., van der Graaf Y.:
Common carotid intima-media thickness and arterial stiffness:
indicators of cardiovascular risk in high-risk patients. The SMART
Study (Second Manifestations of ARTerial disease). Circulation,
1999, 100, 951.
[16] Ebrahim S., Papacosta O., Whincup P., Wannamethee G., Walker
M., Nicolaides A.N. et al.: Carotid plaque, intima media thickness, cardiovascular risk factors, and prevalent cardiovascular
disease in men and women: the British Regional Heart Study.
Stroke, 1999, 30, 841.
[17] Grobbee D.E., Bots M.L.: Carotid intima-media thickness as
indicator of generalized atherosclerosis. J. Intern. Med., 1994,
236, 567.
[18] Pignoli P., Tremoli E., Poli A., Oreste P., Paoletti R.: Intimal plus
medial thickness of the arterial wall: a direct measurement with
ultrasound imaging. Circulation, 1986, 74, 1399.
[19] Bots M.L., Hoes A.W., Koudstaal P.J., Hofman A., Grobbee D.E.:
Common carotid intima-media thickness and risk of stroke and
myocardial infarction. Circulation, 1997, 96, 1432.
[20] Hodis H.N., Mack W.J., LaBree L., Selzer R.H., Liu C.R., Liu
C.H., Azen S.P.: The role of carotid arterial intima-media thickness in predicting clinical coronary events. Ann. Intern. Med.,
1998, 128, 262.
[21] OLeary D.H., Polak J.F., Kronman R.A., Manolio T.A., Burke
G.L., Wolfson S.K. Jr.: Carotid-artery intima and media thickness
as a risk factor for myocardial infarction and stroke in older
adults. N. Engl. J. Med., 1999, 340, 14.
[22] Ishimura E., Nishizawa Y., Kawagishi T., Okuno Y., Kogawa K.,
Fukumoto S. et al.: Intrarenal hemodynamic abnormalities in diabetic nephropathy measured by duplex Doppler sonography.
Kidney Int., 1997, 51, 1920.
[23] Pontremoli R., Viazzi F., Martinoli C., Ravera M., Nicolella C.,
Berruti V. et al.: Increased renal resistive index in patients with
essential hypertension: a marker of target organ damage.
Nephrol. Dial. Transplant, 1999, 14, 360.
[24] Frauchiger B., Nussbaumer P., Hugentobler M., Staub D.: Duplex
sonographic registration of age and diabetes-related loss of renal
vasodilatory response to nitroglycerine. Nephrol. Dial. Transplant, 2000, 15, 827.
[25] Talbott E.O., Guzick D.S., Sutton-Tyrrell K., McHugh-Pemu K.P.,
Zborowski J.V., Remsberg K.E., Kuller L.H.: Evidence for association between polycystic ovary syndrome and premature carotid
atherosclerosis in middle-aged women. Arterioscler. Thromb.
Vasc. Biol., 2000, 20, 2414.
[26] Talbott E.O., Zborowski J.V., Boudreaux M.Y., McHugh-Pemu
K.P., Sutton-Tyrrell K., Guzick D.S.: The relationship between Creactive protein and carotid intima-media wall thickness in
middle-aged women with polycystic ovary syndrome. J. Clin.
Endocrinol. Metab., 2004, 89, 6061.
[27] Vryonidou A., Papatheodorou A., Tavridou A., Terzi T., Loi V.,
Vatalas I.A. et al.: Association of hyperandrogenemic and metabolic phenotype with carotid intima-media thickness in young
women with polycystic ovary syndrome. J. Clin. Endocrinol.
Metab., 2005, 90, 2740.
[28] The Rotterdam ESHRE/ASRM-sponsored PCOS ConsensusWorking Group: Revised 2003 consensus on diagnostic criteria
and long-term health risks related to polycystic ovary syndrome
(PCOS). Hum. Reprod., 2004, 19, 41.
[29] Kizkin S., Engin-Ustun Y., Ustun Y., Ozcan C., Serbest S., Ozisik
H.I.: Cerebral artery hemodynamics in polycystic ovary syndrome. Gynecol. Endocrinol., 2005, 21, 287.
[30] Talbott E.O.: Coronary heart disease risk factors in women with
polycystic ovary syndrome. Arterioscler. Thromb. Vasc. Biol.,
1995, 15, 821.
[31] Pignoli P., Tremoli E., Poli A., Oreste P., Paoletti R.: Intimal plus
medial thickness of the arterial wall: a direct measurement with
ultrasound imaging. Circulation, 1986, 74, 1399.
[32] Frauchiger B., Schmid H.P., Roedel C., Moosmann P., Staub D.:
Comparison of carotid arterial resistive indices with intimamedia thickness as sonographic markers of atherosclerosis.
Stroke, 2001, 32, 836.
[33] Simons P.C., Algra A., Bots M.L., Grobbee D.E., van der Graaf Y.:
Common carotid intima-media thickness and arterial stiffness:
indicators of cardiovascular risk in high-risk patients. The SMART
Study (Second Manifestations of Arterial disease). Circulation,
1999, 100, 951.
[34] Frauchiger B., Nussbaumer P., Hugentobler M., Staub D.: Duplex
sonographic registration of age and diabetes-related loss of renal
vasodilatory response to nitroglycerine. Nephrol. Dial. Transplant, 2000, 15, 827.

B. DEMIR, M.D.
Peyas Mah. 282. Sokak
Diyarpark 1 Sitesi, E blok, No: 15
Kayapinar, Diyarbakir (Turkey)
e-mail: bulentdemirmd@hotmail.com
29 1031-29 - Ultrasonography:1648_29 Incidence of multiple 15/11/11 14:57 Pagina 405
[1031/29]
405
Ultrasonography-guided amniocentesis in singleton

pregnancies: a review of the first 1,000 cases
G.O. Ajayi
Department of Obstetrics and Gynaecology, College of Medicine, University of Lagos, Idi-Araba, Lagos (Nigeria)
Summary
Objective: To assess factors that might influence the success rate, safety and reliability of amniocentesis. Design: A retrospective
study analyzing of the outcome of the first 1,000 cases of amniocenteses. Setting: The outpatient clinic of prenatal diagnosis and therapy
laboratory of a University tertiary care centre. Method and Material: A review of the first 1,000 amniocentesis procedures performed
at the Prenatal Diagnosis and Therapy Centre is presented. Medical records were reviewed for maternal age, indication, color of amniotic fluid, gestational age, frequency of needle insertion, complications of amniocentesis, pre delivery results of prenatal testing and
pregnancy outcome. Complete follow-up data were available for 968 (96.8%), and in 42 cases reports were not complete. Results: There
were 21 miscarriages before 28 weeks of gestation (2.2%), three losses after 28 weeks (0.3%) and six stillbirths (0.6%) (4 due to infections) resulting in a total post procedural loss rate of 3.1% (30). Miscarriage within two weeks of amniocentesis occurred in six patients
(0.62%). Conclusion: Amniocentesis is a relatively safe and reliable method of prenatal diagnosis. It must be done by experienced personnel.
Key words: Amniocentesis; Abortion; Still birth complication.
Introduction
Results
Prenatal diagnosis of chromosomal, biochemical and

neural tube defects has been widely accepted as a routine
procedure in the management of obstetric cases. A spectrum of diagnostic procedures is now available to meet
these demands and includes chorionic villus sampling
(transcervical or transabdominal), cordocentesis,
embryoscopy, earlier and conversional amniocentesis, and
recently analysis of fetal cells in maternal circulation [1,
2]. Experience performing amniocentesis with the use of
continuous ultrasound (US) guidance is presented [3-10].
The indications for amniocentesis are shown in Table

1. Complete follow-up data were available for 968 cases
(96.8%) and in 42 cases reports were not complete. There
were 21 (2.2%) miscarriages before 28 weeks of gestation, three (0.3%) losses after 28 weeks and six (0.6%)
still births (four of the cases due to viral infection,
cytomegalovirus, rubella and parvovirus). The total post
procedure loss rate was 30 (3.1%). Miscarriages within
two weeks of amniocentesis occurred in six (0.62%)
patients (Table 2).
The frequency of needle insertion is shown in Table 3.
A total of 879 (90.8%) amniocenteses were successfully
performed with a single needle insertion. Repeat tapping
was required in 77 (8%) patients because of inadequate fluid volume obtained during the procedure. The
volume of amniotic fluid obtained at amniocentesis was
between 3 ml and 45 ml with a mean of 18.2 ml. In those
patients with normal outcomes coloured amniotic fluid
was obtained in 49/968 (5%) of the amniocenteses. A
total of 22/968 (2.3%) of patients required rescheduling.
Table 2 shows the total number of patients who had
complications within two weeks of amniocentesis. A total
of 934 (96.5%) did not have any problems, while 11
(1.1%) had amniotic fluid leakage of several days duration.
The overall loss rate of desired pregnancies in the study
was 3.1% (30/968).
Material and Method

The prenatal diagnosis program at the College of Medicine of
the University of Lagos, Lagos started using the amniocentesis
procedure in 1988. Data were evaluated for amniocentesis indications, gestational age at the time of amniocentesis (weeks
since last menstrual period 1 week), color of amniotic fluid,
pregnancy complications before amniocentesis, delivery complications, amniocentesis complications and pregnancy
outcome. For comparison with published studies, pregnancy
loss data were divided into the following categories: two weeks
after amniocentesis, < 28 weeks gestation miscarriage, 28
weeks gestation (stillbirth) and neonatal death (within 1 week
of birth). Loss data were further evaluated as to a possible or
probable relationship to amniocentesis. The technique of
amniocentesis used in our program has previously been
reported by Holzgreve et al. [7] (Figure 1). Siemen Vidoson
(Siemens AG, Erlangen, KretzTechnik Combison 350S) Austria
Ultrasound equipment was used for this purpose with a 20 or 22
gauge spinal needle.

XXXVIII, n. 4, 2011
Discussion
Concern regarding the safety and hazards of prenatal
diagnostic procedures have resulted in numerous reports
with regard to mid-trimester amniocentesis [6, 11-14].
One report [15] evaluated the safety and efficacy of chori-
406
G.O. Ajayi
Table 1. Indications for amniocentesis.

Indication
Maternal age
Maternal anxiety
Family history of chromosome
abnormality
Oligohydramnious
Polyhydramnious
Pregnancy at risk of
metabolic disease
Family history/prior child
with neural tube defect
Rule out viral infection
No. of patients
458
47
47.3
4.86
11
88
238
1.14
9.1
23.4
102
10.54
10
33
1.03
3.42
Table 2. Complication of amniocentesis within two weeks of

the procedure.
Complication
None
Fluid leakage
Miscarriage < 2 weeks
Cramping
Bleeding
Total
No. of patients
934
11
6
8
9
968
96.5%
1.12%
0.62%
0.83%
0.93%
100
Table 3. Frequency of needle insertion.

No. of insertions
1
2
3
Total
Frequency
878.9
79.4
9.7
968
90.8%
8.2%
1.0%
100%
Table 4. Pregnancy outcome for 968 patients undergoing

amniocentesis.
Outcome
No. of patients
Male
501
Female
465
Other
2
Fetal abnormality-terminated
16
Abortion < 28 weeks gestation
21
Abortion > 28 weeks gestation
3
Miscarriage within
2 weeks after amniocentesis
6
Abnormal child not detected prenatally 2
Small for gestational age
2
Still birth
6
51.8%
48%
0.2%
1.7%
2.2%
0.3%
0.62%
0.2%
0. 2%
0.62%
onic villus sampling and showed a combined loss rate

(simultaneous and missed abortion, termination of abnormal pregnancies, stillbirths and neonatal deaths) for
desired pregnancy of 7.2% in the chorionic villus sampling group and 5.7% in the amniocentesis group. After
data adjustment it was concluded that the difference in
loss rate for the two groups was 0.8%.
In the present study overall loss rate of desired pregnancies was 3.1%, although it was difficult to establish an
entirely comparable figure for the study population.
It has long been considered that 15% to 20% of recognized pregnancies result in spontaneous abortion before
20 weeks of gestation. Lin et al. [16] followed-up 1,068

pregnancies that were confirmed to be normal by US
(before 14 weeks gestation) until 28 weeks gestation.
They reported an overall 2.7% spontaneous abortion rate
with 1.5% occurring before week 16 and 1.2% between
16 and 28 weeks of gestation. They suggested that there
was also a slightly higher spontaneous abortion rate
(1.8% vs 1.3%) between 11-16 weeks gestation for primigravid patients as compared with multiparous patients.
Threatened miscarriage was associated with a 38% fetal
loss rate. This may have been a factor in some of our
losses.
Gilmore and McNay [17] followed-up 2,144 pregnancies that were established as normal by US before ten
weeks of gestation. An overall 2.1% spontaneous abortion rate occurred. This rate tended to increase with
increasing maternal age, being 2.6% between ages 35 to
39 years and 13.6% at age 40 years.
It should be noted that the 1976 National Institution of
Child Health and Human Development study of amniocentesis published a 3.2% spontaneous abortion rate for
their control group of women matched for race, gravidity
and family income [11]. However, these pregnancies
were not shown to be normal by US before amniocentesis.
In conclusion, continuous US guidance appears to
decrease the risk of amniocentesis and add to the technical care of obtaining amniotic fluid samples. It is a relatively safe and reliable method in prenatal diagnosis and
therapy but must be done by experienced personnel.
Recent large uncontrolled studies suggested that procedure-related loss rates of around 0.5% can be achieved
[18-20].
References
[1] Holzgreve W., Miny P.: Chorionic villi sampling with an
echogenic catheter: experiences of the first 500 cases. J. Perinat.
Med., 1987, 3, 244.
[2] Brambati B., Oldrini A.: CVS for first-trimester fetal diagnosis.
Contemp. Obstet. Gynaecol., 1985, 94.
[3] Daffos F., Capella-Pavlovslay M., Forestier F.: Fetal blood sampling via the umbilical cord using a needle guided by ultrasound.
Prenatal. Diagn., 1983, 3, 271.
[4] Golbus M.S., Kan Y.W., Naglich-Craig N.: Fetal blood sampling
in midtrimester pregnancies. Am. J. Obstet. Gynecol., 1976, 124,
653.
[5] Golbus M.S.: The status of fetoscopy and fetal tissue sampling.
Prenat. Diagn., 1984, 4, 79.
[6] Golbus M.S., Loughmann W.D., Epstein C.J., Halbasch G.,
Stephen J.D., Hall B.D.: Prenatal genetic diagnosis in 3000
amniocentesis. N. Engl. J. Med., 1979, 300, 157.
[7] Miny P., Holzgreve W., Pawlowitzki I.H.: Amniozenteprogramm
Muenster: Erfahrungen nach 7000 Eingriffen. In: Holzgreve W.
(Hrsg) Praenatale, Medizin Springer, Berlin, Tokyo S., 1987, 1.
[8] Nicolaides K.H.: Cordocentesis. Clin. Obstet. Gynecol., 1988,
31, 123.
[9] Ganshirt-Ahlert D., Burschy M., Garritsen H.S. et al.: Magnetic
cell sorting and the transferrin receptor as potential means of prenatal diagnosis from maternal blood. Am. J. Obstet. Gynecol.,
1992, 166, 1350.
[10] Simpson J.L., Sherman E.: Isolating fetal cells from maternal
blood advances in prenatal diagnosis through molecular technology. JAMA, 1993, 270, 2357.
Ultrasonography-guided amniocentesis in singleton pregnancies: a review of the first 1,000 cases

[11] National Institute of Child Health and Human Development
National Registry for Amniocentesis study group: Mid-trimester
amniocentesis for prenatal diagnosis: safety and accuracy. Can.
Med. Assoc J., 1976, 115, 739.
[12] Simpson N.E., Dallaire L., Miller J.R., Siminovich L., Hamerton
J.L., Miller J., McKeen C.: Prenatal diagnosis of genetic disease
in Canada: report of a collaborative study. Can. Med. Assoc. J.,
1976, 115, 739
[13] Crandall B.F., Howard J., Lebher T.B., Rubenstein L., Sample
W.S., Sarti D.: Follow-up of 2000 second trimester amniocenteses. Obstet. Gynecol., 1980, 56, 625.
[14] Phillip J., Bang J.: Outcome of pregnancy after amniocentesis for
chromosome analysis. Brit. Med. J., 1978, 2, 1183.
[15] Rhoads G.G., Jackson L.G., Schlesselman S.E., de la Cruz F.F.,
Desnick R.J., Golbus M.S. et al.: The safety and efficacy of
chorionic villus sampling for early prenatal diagnosis of cytogenetic abnormalities. N. Engl. J. Med., 1989, 320, 609.
[16] Liu D.T., Jeavons B., Preston C., Pearson D.: A prospective study
of spontaneous miscarriage in ultrasonically normal pregnancies
and relevance to chorionic villus sampling. Prenat. Diagn., 1987,
7, 223.
407
[17] Gilmore D.H., McNay M.B.: Spontaneous fetal loss rate in early
pregnancy. Lancet, 1985, 1, 107.
[18] Tabor A., Phillip J. Madsen M., Bangs Obel E.B., Norgaard-Pedersen B.: Randomised controlled trial of genetic amniocentesis in
4606 low risk women. Lancet, 1986, 1, 1287.
[19] Horger E.O. 3rd, Finch H., Vincent V.A.: A single physicians
experience with four thousand six hundred genetic amniocenteses. Am. J. Obstet. Gynecol., 2001, 185, 279.
[20] Scott F., Peters H., Boogert T., Robertson R., Anderson J., McLennan A. et al.: The loss rates for invasive prenatal testing in specialized obstetrics ultrasound practice. Aust. M.Z.J. Obstet.
Gynecol., 2002, 42, 55.

G.O. AJAYI, M.D.
College of Medicine/University of Lagos
P.M.B. 12003 Idi-Araba Surulere, Lagos (Nigeria)
e-mail: prenataldiagnosiscentre@hotmail.com
30 1238-31 - Rate of use of contraceptive:1648_29 Incidence of multiple 15/11/11 14:59 Pagina 408
[789/27]
[1238/31]
408
Rate of use of contraceptive methods and risk factors

in Tehran, the capital of Iran, in 2010 compared to other
cities and regions
E. Barooti1, N. Sadeghi2, M. Karimi-Zarchi3, H.R. Soltani4
1
Functional Gynecology, Taleghani Hospital, Tehran; 2Functional Gynecology, Shahid Beheshti University MC, Tehran
3
Gynecology Oncology Department, Shahid Sadoughi University of Medical Science, Yazd
4
Azad University of Medical Science, Yazd (Iran)
Summary
Background: Unwanted pregnancies and deaths from abortion cost the lives of 500 women daily. This study was designed to
determine the rate of use of contraceptive methods and the risks. Material and Methods: This cross-sectional study was conducted
in 2010 in Tehran, Iran. Total sample size was 304 participants who all filled out a questionnaire which had two parts. Data were
analyzed by SPSS. Findings: The results showed that age (p = 0.003), employment status (p = 0.001), number of children (p =
0.001), and marriage (p = 0.01), had a significant relation with type of contraceptive method while, education did not correlate with
contraceptive methods. Discussion: New and often younger couples with no experience about different contraceptive methods may
tend to use natural methods because of their lack of knowledge of other techniques. Use of modern contraceptives early in marriage
or even before marriage could be a good strategy.
Key words: Unintended pregnancy; Contraceptive methods; Birth control.
Introduction
According to estimates published in 1998, 91,000
births occur worldwide each day; 50% of the pregnancies
are unplanned and 25% are completely unexpected.
Unwanted pregnancies and deaths from abortion cost the
lives of 500 women daily [1]. Pregnancies in the second
decade of life may interrupt and perhaps permanently
interfere with the training and education of young
women; young women in this age group may also not be
ready to accept the responsibilities of parenthood, leading
to severe psychological distress [2]. An investigation of
59% of patients with unwanted pregnancies who sought
care at 35 health centers in areas north of Tehran Medical
Hospital found that 35% of the patients had used the
withdrawal method for contraception [3]. In the rural
population covered by the Shahid Beheshti University
[4], most women with unwanted pregnancies had used
natural methods of contraception. Studies show that,
despite the high failure rate of natural methods in some
communities, there is much interest in their use, especially the withdrawal method. In our country, natural
methods are the second most popular type of contraception, [5] and withdrawal, with a rate of 5.17%, is considered the most natural method. The prevalence of this
method is 29.17% in Tehran [6], 25.75% in Tabriz [7],
20% in West Mazandaran [8], and 28.7% in Kashan [9].
In Bushehr [10], a 26.6% rate of use of the periodic
method has been reported. Because the rates of use of
natural methods of contraception are so high, we decided
Revised manuscript accepted for publication April 11, 2011

XXXVIII, n. 4, 2011
to investigate the factors associated with the use of

various types of contraception. The results may hopefully
influence the way in which health policy makers design
family planning programs.
Methods
This cross-sectional study was conducted in 2010. All
married women aged 15-49 years referred to health centers in
urban and rural areas in the vicinity of Tehran Boomehen made
up the study population. Sampling was multistage. In the first
stage, according to the number of household health records,
health centers in urban and rural areas in 217 villages were
selected, and 71 cases were selected. The three urban centers
and rural centers between two population centers were randomly selected. Then, in each center, systematic random sampling of the female population was conducted. Inclusion criteria were: not pregnant, menopausal, or infertile; no intention to
become pregnant; lack of time to use two methods of contraception; and married and living with the spouse. Before data collection, participants were informed about the objectives of the
research and told that their identities would be protected.
Trained personnel administered the study questionnaire. The
questionnaire included two parts: The first part contained 12
questions about demographics and obstetric history, and the
second section included six questions about contraceptive
methods, including natural methods. The validity of the questionnaire content was determined. The questionnaire was evaluated by eight faculty members of universities in Tehran and
modified in accordance with their recommendations. The consistency of the results of two questionnaires administered two
weeks apart was evaluated for 50 participants, and an r value of
0.84 was determined. For data analysis, SPSS software version
16 and descriptive statistics (frequency, mean, and standard
deviation), ANOVA, and Students t-test were used. A p value
less than 0.05 were considered significant.
Rate of use of contraceptive methods and risk factors in Tehran, the capital of Iran, in 2010 compared to other cities and regions
409
Table 1. Relationship between individual characteristics and types of contraceptive methods used by patients at health centers
in Tehran in 2010.
Personal characteristics
Age
Married
Number of children
Husbands education
Wifes education
Employment status
Location status
Withdrawal
method
Number = 15
Condoms
Number = 65
Method
Number = 98
Intrauterine
Number = 4
Permanent
Number = 17
Mean SD
30.22 7.27
9.93 7.8
1.7 0.86
Mean SD
27.49 5
7.07 5.55
1.6 0.8
Mean SD
30.12 6.83
9.88 6.83
1.81 0.83
Mean SD
32 6.05
10.25 7.8
2.25 0.5
Mean SD
34.17 4.99
13 7.33
2.87 0.8
Less than high school

High school
University
High school
University
Housewives
Employed
Rural
Urban
p value
0.003
0.01
0.0001
n (%)
n (%)
n (%)
n (%)
n (%)
p value
47 (40.9)
45 (39.1)
23 (20)
4 (34.8)
52 (45.2)
23 (20)
101 (87.8)
14 (12.2)
72 (66.6)
43 (37.4)
12
34
18
14
34
17
55
10
50
15
38
41
19
35
40
23
87
11
84
14
1
2
1
2
1
1
3
1
3
1
8 (47.1)
6 (35.3)
3 (17.6)
8 (47.1)
6 (35.3)
3 (17.6)
15 (88.2)
2 (11.8)
15 (88.2)
2 (11.8)
0.99
Results
In total, 304 participants were studied (more than 16
questionnaires were completed from each sample set).
Overall 39.5% (120 participants) used natural methods,
and 60.5% (184 participants) used medical contraceptive
methods. Withdrawal, which was used by 37.8% (115
participants), was the most common method. Other
natural methods had lower prevalence (periodic abstinence 0.7%; lactation 1%). Use of combined oral contraceptives was 27.3% (83 participants), condoms 21.4%
(65 participants), and oral progestogen 2.6% (8 participants). Intramuscular progesterone, intrauterine devices,
tubal ligation, and vasectomy were used by seven (2.3%),
four (1.3%), 15 (4.9%), and two (0.7%), respectively.
Significant differences in mean age, duration of marriage,
and number of children were found among users of different contraceptive methods. The relationships between
these characteristics and the use of withdrawal, hormonal
methods, permanent methods, condoms, and intrauterine
devices were also significant (Table 1). Overall use of
contraception and use of individual methods (Table 2)
were unrelated to womens educational level and employment status of both husband and wife. Natural methods
were more commonly used in the city than in the countryside (Table 2). Reasons for the use of natural methods
included fear of side-effects of other methods (50.6%),
ease of use (36.5%), partners reluctance to use other
methods (32.6%), belief that success was as likely as with
other methods (22.5%), and complications caused by
using other methods (20%). Most participants gave more
than one reason. Among those using natural methods, 23
patients (7.4%) had previously used other methods, most
commonly combined oral contraceptive tablets (61.5%),
and had discontinued them because of side-effects. The
most common complication (23.5%) reported was
nervous discomfort. The most common source of information about contraceptive methods were state employ-
(20)
(52.3)
(27.7)
(21.5)
(52.3)
(26.2)
(84.6)
(15.4)
(76.9)
(23.1)
(38.8)
(41.8)
(19.4)
(35.7)
(40.8)
(23.5)
(88.8)
(11.2)
(85.7)
(14.3)
(25)
(50)
(25)
(50)
(25)
(25)
(75)
(25)
(75)
(25)
0.78
0.0001
Table 2. Relationship between personal characteristics and

the use of natural and medical methods of contraception
among women at health centers in Tehran in 2010.
Personal characteristics
Age
Married
Number of children
Husbands education
High school
University
Wifes education
High school
University
Employment status
Housewives
Employed
Location status
Rural
Urban
Natural
methods
(number = 120)
Medical method
(number = 184)
p value
Mean SD
30 7.29
7.64 9.8
1.68 0.84
Mean SD
65.29 6.35 0.65
79.31 6.6 0.42
1.85 0.85 0.10
n (%)
n (%)
p value
48 (40)
60 (32.6)
0.25
48 (40)
24 (20)
42 (35)
83 (45.1)
41 (23.3)
52 (31.2)
0.49
53 (44.2)
25 (20.8)
104 (86.7)
81 (44)
44 (33.9)
160 (87)
0.45
16 (13.3)
76 (63.3)
24 (13)
152 (82.6)
0.0001
44 (36.7)
32 (17.4)
ees at health centers (63.4%), followed by neighbors and

relatives (39.2%), books and magazines (15%), media
(15%), doctors and midwives in private practice (13.9%),
and personal experience (10%). Most participants cited
more than one information source. Significant differences
in information sources were found between users of different types of contraception (p = 0.07). In comparison
to users of medical methods, those who used natural
methods were more likely to report personal experience
(5.1 vs 3.9%) and obtaining information from healthcare
workers (29.7% vs 22.8%) as information sources and
410
E. Barooti, N. Sadeghi, M. Karimi-Zarchi, H.R. Soltani
less likely to report obtaining information from books

and magazines (1.7% vs 9.3%) and doctors and midwives
in private offices (3.4% vs 4.4%).
Discussion
According to DHS, IMES percentage of unwanted
pregnancies in 2000 was equal to 24.1% compared to
18.6% in 2006. According to the Population Reference
Bureau (2006), the percentage of married women aged
15-49 years using modern and total contraceptive
methods is as follows:
Table 3. Percentage of contraceptive methods among
married women 15-49 years old in Iran, less developed regions
of Asia, and the developed world.
*Contraceptive
methods
World
%
Modern methods 54
Total methods
61
Iran
%
Asia
%
%
Less developed Developed

areas
areas
%
56
74
59
65
53
59
58
68
*Percentage of contraceptive methods.
Natural methods of contraception have been used for

centuries and are still a principal form of contraception in
many societies. In this study, although the overall prevalence of natural contraceptive use was less than that for
medical contraception, the nationwide rate of 17.8% [11]
is important. Moreover, in some regions, the prevalence
of natural methods is much higher than the national
average [12]. This may reflect cultural differences and
social and local beliefs. Withdrawal, at 37.88%, was the
most commonly used natural method. Other reports also
indicate a high prevalence of the use of withdrawal [6, 9,
12-14]. In our country, the prevalence of withdrawal in
Gilan, Mazandaran, Semnan, Qom, and Tehran has been
reported [11]. The frequency of use of this method in
some areas has been reported to be less than that in the
current study, including 28.7% in Kashan [9], 20% in
West Mazandaran (15), 29.17% in Tehran [6], and 25.7%
in Tabriz [7]. In Rasht, a prevalence of 38.8% [12] was
observed, which is close to the percentage found in the
current study. Differences in the quality of family planning implementation and training in different areas seem
to be important. The percentage of use of the withdrawal
method in Qazvin was 1.8%, which was much lower than
the national average [16]. The frequency of use of other
natural methods, including lactation (1%) and periodic
methods (0.7%), was very low in this study. According to
national studies, withdrawal is used by 17.5%, but other
natural methods are used only by 0.5% [11]. Because the
use of withdrawal is so prevalent, women may be less
familiar with other natural methods, including periodic
methods and those involving vaginal douching, and may
have difficulty using them. However, it seems that not
only enough knowledge and motivation should be needed
in people and also create barriers to the use of known and
reliable methods to deal with them is through the Occasion [9]. The rates in East Azarbaijan are 29.2 and 7%,
respectively [1], and those in ChaharMahal and Bakhtiari

are 12.5 and 5% [11]. Couples may use natural methods
of family planning because services that encourage their
use are present in their communities. This type of information resource center is especially active in this field.
The mean age in this study of women who used the withdrawal method coincided with the years of maximum fertility. Since these women did not want to conceive, the
importance of safe contraceptive methods for them is
obvious. Akbari A.A et al. reported that the average age
of people who were using the withdrawal method was
about 28 years [15]. Khalkhali et al. reported a sharp
reduction in the use of natural methods with increasing
age [17]. In general, more young people are dependent on
methods that require changes in sexual behavior, such as
natural methods [18]. As couples grow older and have
more children, they seem to take birth control more seriously. Similarly, other studies have shown that marriage
duration and number of children were significantly lower
among users of the withdrawal method than among users
of other methods [12, 19-21]. New and often younger
couples with no experience about different contraceptive
methods may tend to use natural methods because of
their lack of knowledge about other techniques. The
smaller size of their families may also be incentives for
them to use less reliable methods of contraception. Starting to use modern contraceptives early in marriage or
even before marriage could be a good strategy.
References
[1] Gahanfar M., Gahanfar S.H.: Population and family planning.
Printing, Publishing Dehkhoda, 1998, 40.
[2] Hillard A.J.: Oral contraception non compliance: the extent of
problem. Adv. Contracept, 1992, 8 (suppl. 1), 13.
[3] True Laden Zndfany song. Of unwanted pregnancies in women
referred to University Hospitals in Iran during the years 1377 until
1378. Iran University of Medical Sciences, 2002, 9, 38.
[4] Haghighi L., Frsar A.R.: The prevalence of pregnancies are not
planned in the rural population covered by Shaheed Beheshti
Medical University. J. Pajohande, 1998, 3, 23.
[5] Finger W.R.: Withdrawal popular in some cultures. Contraceptive update. Network, 1996 Fall, 17, 15.
[6] Ramezanzadeh F., Nahidi F., Tohidi M.: Contraception in women
over 35 years referred to the educational, health affiliated medical
universities in Tehran in 2005. J. Inquiring, 1999, 3, 65.
[7] Shaghaghi A., Farahbakhsh M., Alizadeh M., Nikniyaz A.R.,
MalekAfzali H.: Use of contraceptive methods in the North West
area of Tabriz, 2000. J. Med. Health Services, 2003, 59, 67.
[8] Nazarpor S., Azimi H.: Evaluate the use of various contraceptive
methods and attitudes of married women under 25 years referred
to health centers in West province to family planning in 2001. J.
Mazandaran University of Medical Sciences, 2002, 12, 54.
[9] Ramezani Y., Yadegar Far Q., Almasi H., Ershadi A.: Knowledge,
attitude and practice towards Kashan Mrdanmtahl rural family
planning methods in 1996. J. Med. Purificat., 1998, 28, 41.
[10] Barzegar R., Haghshenas N.: Assess knowledge and practice of
women aged 49-15 in family planning in the city of Bushehr. So.
Med. J. Med. Sci. Health Serv., Bushehr, 1997, 1, 138 (in Persian).
[11] Television Demographic and Health in Iran (2000 - DHS). Department of Health and Medical Education. Department of Health in
collaboration with center statistics, 2000, 81 (in Persian).
[12] Shvazi Abbasi M., Khadmzadh A.: Selected causes withdrawal
method to prevent pregnancy among women of reproductive age
in the city of Rasht. J. Reprod. Med. Infert., 2004, 5, 337 (in
Persian).
Rate of use of contraceptive methods and risk factors in Tehran, the capital of Iran, in 2010 compared to other cities and regions
[13] Sarabi A., Sadeghish H.A.R., Nikzad A.R., Dastgiri S.: Comparison of knowledge, attitude and practice of married women aged
45-15 Tabrizi towards family planning in the years 1976 and
1993. J. Tabriz Univ. Med. Sci., 1993, 28, 79 (in Persian).
[14] Bashardost N., Fadayi S., Bahadoran P.: Factors in choosing
methods of pregnancy prevention. Med. Res., 1998, 3, 19.
[15] Amir Ali Akbari S., Tofighiniyaki M., Ahmadi M., Alavi H.:
Reasons for not using contraceptive methods in women using the
withdrawal method, Amol, 2002. J. Mazandaran University of
Medical Sciences, 2005, 15, 98.
[16] Sefzadeh S., Ghasemibarghi R.: Evaluate patients for contraceptive services and family planning health centers in Qazvin.
Khanadh Health Magazine, 1996, 1, 65.
[17] Khalkhali H.R., Hajizadeh I., Mohammed K.: Polynomial
response models todetermine factors used in a variety of methods
to prevent pregnancy in women. Tehran Univ. Med. J., 2001, 59,
98.
[18] Wulff M., Lalos A.: Coitus-dependent and coitus-independent
contraceptive methods in women and men. Eur. J. Contracept.
Reprod. Health Care, 2002, 7, 114.
411
[19] Spinelli A., Talamanea I.F., Lauria L.: Patterns of contraceptive

use in 5 European countries. European Study Group on Infertility
and Subfecundity. Am. J. Public Health., 2000, 90, 1403.
[20] Mlkafzl I.H.: Knowledge, attitude and practice of women 49-15
years old Iranian cities to family planning programs. Quarterly
Health, 1991, 1, 60.
[21] Rastak L.: Relationship between personal characteristics - social
and contraceptive method. J. Univ. Med. Sci., 2006, 7, 28.

N. SADEGHI, M.D.
Functional Gynecology,
Taleghani Hospital, Velenjak Avenue
Tehran (Iran)
e-mail: nasimsadeghimd@yahoo.com
31 1169-30 - Case Reports:1648_29 Incidence of multiple 15/11/11 15:00 Pagina 412
[789/27]
[1169/30]
412
Case Reports
Sympathetic neural hyperalgesia edema syndrome,

a frequent cause of pelvic pain in women, mistaken
for Lyme disease with chronic fatigue
Summary
Purpose: To show that chronic fatigue syndrome can be mistakenly attributed to Lyme disease rather than considering sympathetic
neural hyperalgesia edema syndrome. This common disorder of women, frequently, but not always causing pelvic pain, can present
simply as chronic fatigue. Methods: A water load test was performed in a woman reactive for B-Burgdorferi with chronic fatigue whose
symptoms did not improve despite three months of treatment with doxycycline. A water load test was performed. Results: She failed
the water load test by excreting only 50% ingested load standing for four hours. She showed marked improvement following treatment
with dextroamphetamine sulfate. Conclusions: This very treatable disorder of the sympathetic nervous system should be considered in
women with an unknown cause of chronic fatigue or if the symptoms persist despite treatment of another potential cause.
Key words: Chronic fatigue; Sympathomimetic amines; Lyme disease; Water load test.
Introduction
A disorder of the sympathetic nervous system has been
found to be a significant cause of pelvic pain in women
including pelvic pain of bladder origin, persistent pelvic
pain, dyspareunia and dysmenorrhea frequently, but not
always associated with endometriosis [1-3]. This syndrome has been associated with a large variety of unexplained and refractory health problems in women [4].
These women respond quickly and very well to treatment
with sympathomimetic amines [4]. In order to encompass
the various presentations of this disorder of the sympathetic nervous system it has been recently named the
sympathetic neural hyperalgesia edema syndrome [3].
Case Report
A 40-year-old woman wanted to delay infertility treatment
despite her diminished oocyte reserve because she felt too ill
from Lyme disease despite antibiotic treatment. Her symptoms were generalized aches and pains, marked fatigue and hair
loss.
She consulted both rheumatology and infectious disease specialists. She tested positive for Lyme disease and was treated for
three months with doxycycline. She was reactive for BBurgdorferi antibody IgG 41 kD and B. Burgdorferi IgM 23 kD.
Unfortunately her symptoms failed to improve.
She sought our opinion not because of her chronic fatigue
ailment but for infertility therapy once her arthralgia and fatigue
issues that had been present for over a year were resolved. She
stated that she was too fatigued at present to carry the extra

XXXVIII, n. 4, 2011
burden of a pregnancy. Furthermore another course of intravenous antibiotic was being considered and this antibiotic may
have been contraindicated during pregnancy.
Her hemoglobin was 13.6 g/dl (nl 11.7-15.5), hematocrit 40.2
(nl 35-45.0%). The white blood count was 7.0x103/ml (nl 3.8010.8) and serum free thyroxin was 1.1 ng/dl (nl 0.8-1.8). The
thyroid stimulating hormone was 1.29 (nl 0.40-4.50). Her
fasting serum glucose was 93 ng/dl (nl 65-99) and serum insulin
was 8 uIU/ml (nl < 17). Epstein Barr virus was positive only for
EBV nuclear antigen IgG at 4.96 (nl .90) and for EPV VCA
IgG at 2.64 (positive equal 1.10). Liver function and kidney
function tests were normal. The Westergrin sedmental rate and
C-reactive protein were both negative. Liver and kidney function tests were negative. Electrolytes were also normal as were
the serum calcium and parthyroid hormone levels.
The patient performed a water load test where six cups of
water are ingested over a half-hour time-period on two consecutive days. The amount of urine excreted over four hours, the
first day supine for four hours and the second day erect found
6 cups excreted supine vs only three cups standing. This
abnormal free water clearance in the erect position was consistent as a defect in the sympathetic nervous system that does not
allow the proper closure of pre-capillary sphincters that inhibit
water transudation to extra-vascular spaces by the increase in
hydrostatic pressure [5].
The patient was treated with dextroamphetamine sulfate (15
mg a.m.). She recorded for the first time a significant improvement in her fatigue that had lasted three months to date.
Discussion
The gynecologist is generally the main treating physician of female patients. For problems outside the scope
of the gynecologist generally women are referred to specialists. In fact in the case reported, her gynecologist
31 1169-30 - Case Reports:1648_29 Incidence of multiple 15/11/11 15:00 Pagina 413
Sympathetic neural hyperalgesia edema syndrome, a frequent cause of pelvic pain in women, mistaken for Lyme disease etc.
referred her first to a rheumatologist and then to an infectious disease specialist.

Though this disorder of the sympathetic nervous
system is common, it remains an entity not considered in
most differential diagnoses. When there is pelvic pain
and some symptoms for which standard tests have failed
to identify the etiology, it behooves the gynecologist to
think of sympathetic neural hyperalgesia edema syndrome.
This case, however, did not have pelvic pain. Thus the
gynecologist should be aware that certain health issues
may evade the proper diagnosis and treatment of some
women because most specialists are not thinking of or are
not aware of this entity. Thus the gynecologist could
easily administer the water load test, which is usually but
not always abnormal, in women with this syndrome, and
could still refer to a specialist to rule out disease entities
outside the scope of practice of the gynecologist.
However, that same gynecologist, who is the quarterback
of that womans care, should keep a close eye on treatment suggestions or invasive diagnostic tests and could
intervene and treat with sympathomimetic amines if in
the gynecologists opinion the treatment with sympathomimetic amines is likely to be less risky and more efficacious than the proposed therapy or suggested testing by
the consultants.
Some chronic debilitating illnesses other than already
mentioned that are refractory to various therapies but
respond quickly and effectively to sympathomimetic
amine therapy include gastrointestinal pain syndromes,
e.g., esophageal pain, gastroparesis and pseudointestinal
obstruction [6-8]. We even presented a case of very
severe Crohns disease at the 2009 Advances in Inflammatory Bowel Diseases Crohns & Colitis Foundations
Research & Clinical Conference who failed to respond to
mesalamine, prednisone, cyclophosphamide and infliximab and who was recommended to have a diverting
ileostomy, but who dramatically responded to sympathomimetic amine therapy. Other pain syndromes include
headaches [9, 10], rheumatoid arthritis [11], and backache, saving the woman from a proposed laminectomy
[12]. Other conditions that defied diagnosis and treatment
yet responded to treatment with sympathomimetic
amines include chronic urticaria [13-15], vasomotor
symptoms not responding to estrogen [16, 17], and
inability to lose weight despite dieting [18].
The present case cautions the treating physicians that if
a case of chronic fatigue tests positive for Lyme disease
this sympathomimetic disorder should be considered if
the fatigue does not respond to antibiotic therapy. This
condition should also be considered when the etiology of
the chronic fatigue is obscure or does not respond to standard treatment for another possible etiology.
References
[1] Check J.H., Katsoff B., Citerone T., Bonnes E.: A novel highly
effective treatment of interstitial cystitis causing chronic pelvic
pain of bladder origin: case reports. Clin. Exp. Obstet. Gynecol.,
2005, 32, 247.
413
[2] Check J.H., Wilson C.: Dramatic relief of chronic pelvic pain
with treatment with sympathomimetic amines case report. Clin.
Exp. Obstet. Gynecol., 2007, 34, 55.
[3] Check J.H., Cohen R.: Chronic pelvic pain Traditional and
novel therapies: Part II medical therapy. Clin. Exp. Obstet.
Gynecol., 2011, 38, 113.
[4] Check J.H., Katsoff D., Kaplan H., Liss J., Boimel P.: A disorder
of sympathomimetic amines leading to increased vascular permeability may be the etiologic factor in various treatment refractory
health problems in women. Med. Hypoth., 2008, 70, 671.
[5] Streeten D.H.P.: Idiopathic edema: pathogenesis, clinical features
and treatment. Metabolism, 1978, 27, 353.
[6] Leskowitz S.C., Shanis B.S., Check J.H.: Resolution of atypical
chest pain during treatment for idiopathic orthostatic edema. Am.
J. Gastroenterol., 1990, 89, 621.
[7] Boimel P., Check J.H., Katsoff D.: Sympathomimetic amine
therapy may improve refractory gastroparesis similar to its effect
on chronic pelvic pain: case study. Clin. Exp. Obstet. Gynecol.,
2007, 34, 185.
[8] Check J.H., Cohen R.: Successful treatment of a female with
chronic pseudo-intestinal obstruction with sympathomimetic
amines and thyroid hormone replacement. Clin. Exp. Obstet.
Gynecol., 2010, 37, 115.
[9] Check J.H., Cohen R., Check D.: Evidence that migraine
headaches in women may be related to a common defect in the
sympathetic nervous system as evidenced by marked improvement
following treatment with sympathomimetic amines. Clin. Exp.
[10] Check J.H., Cohen R.: Marked improvement of headaches and
vasomotor symptoms with sympathomimetic amines in a woman
with the sympathetic hyperalgesia-edema syndrome. Clin. Exp.
[11] Boimel P., Check J.H.: Marked improvement of intractable
arthritic pain in a woman with rheumatoid arthritis with sympathomimetic amine treatment despite previous failure with standard
therapy and possible implications for last trimester unexplained
fetal demise. Clin. Exp. Obstet. Gynecol., 2007, 34, 254.
[12] Check J.H., Wilson C., Cohen R.: A sympathetic nervous system
disorder of women that leads to pelvic pain and symptoms of interstitial cystitis may be the cause of severe backache and be very
responsive to medical therapy rather than surgery despite the presence of herniated discs. Clin. Exp. Obstet. Gynecol., 2011, 38, 175.
[13] Check J.H., Gentlesk M.J., Falanga V.: Sympathomimetic amines
in the treatment of chronic urticaria: Two case reports. CUTIS,
1984, 34, 388.
[14] Check J.H., Amadi C., Kaplan H., Katsoff D.: The treatment of
idiopathic edema, a cause of chronic pelvic pain in women effectively controlled chronic refractory urticaria. Clin. Exp. Obstet.
Gynecol., 2006, 33, 183.
[15] Check J.H., Cohen R., Check D.: Idiopathic edema, a condition
associated with pelvic pain and other symptoms in women as a
remedial cause of chronic cold induced urticaria. Clin. Exp.
[16] Check J.H., Katsoff D., Kaplan H.: Idiopathic orthostatic cyclic
edema as a unique etiology for vasomotor flushing in a normal
estrogenic woman with normal day 3 follicle stimulating hormone
case report. Clin. Exp. Obstet. Gynecol., 2006, 33, 125.
[17] Check J.H., Cohen R., Check D.: A novel highly effective therapy
for severe vasomotor symptoms in an estrogen deficient woman
case report. Clin. Exp. Obstet. Gynecol., 2010, 37, 229.
[18] Check J.H., Shanis B.S., Shapse D., Adelson H.G.: A randomized
comparison of the effect of two diuretics, a converting enzyme
inhibitor, and a sympathomimetic amine on weight loss in dietrefractory patients. Endo Pract., 1995, 1, 323.

7447 Old York Road
32 1178-30 - Swyer syndrome:1648_29 Incidence of multiple 15/11/11 15:03 Pagina 414
[789/27]
[1178/30]
414
Swyer syndrome, 46,XY gonadal dysgenesis, a sex reversal

disorder with dysgerminoma:
a case report and literature review
Jing Zhu, Xishi Liu, Hongyan Jin, Xin Lu
Obstetric and Gynecology Hospital at Fudan University, Shanghai (China)
Summary
Background: Swyer syndrome, 46,XY gonadal dysgenesis, is a sex reversal disorder with a female phenotype. Germ cell tumors,
including dysgerminoma, may arise in streak gonads of patients with gonadal dysgenesis. Case: A 22-year-old female patient with a
46,XY karyotype was admitted to hospital for primary amenorrhea and a pelvic mass. Laparotomy exploration revealed a hypoplastic
uterus and a 80 70 60 mm mass in the right gonad with extension to the pelvic peritoneum. Histologic finding in frozen section
was dysgerminoma. Debulking surgery with pelvic lymphadenectomy was subsequently performed and the patient was given four
cycles of chemotherapy (bleomycin, etoposide, and cisplatin) post-operation. Conclusion: The presence of Y chromosome in patients
with 46,XY gonadal dysgenesis may increase the risk of gonadal tumors. A prophylactic bilateral salpingo-gonadenectomy should be
advised to those patients.
Key words: Swyer syndrome; Gonadal dysgenesis; Dysgerminoma.
Introduction
The XY gonadal dysgenesis is a sex reversal disorder
and the result of embryonic testicular regression
sequences. Pure XY gonadal dysgenesis, Swyer syndrome, has a 46,XY karyotype and streak gonads. Most
of those phenotypically females present with primary
amenorrhea, female type infantile external genitalia,
normal stature, and normal Mllerian structures. Mutations in the sex-determining region on the Y chromosome
(SRY) gene are found in this syndrome.
Dysgerminoma is occasionally seen in patients with
gonadal dysgenesis. About 5% of dysgerminomas are
found in phenotypic women patients with chromosomal
abnormalities such as 46,XY or 45,X/46,XY mosaic. For
those patients, dysgerminomas often arise in benign
gonadolblastomas [1]. Therefore, whether the karyotype
shows the presence of a Y chromosome, it still has the risk
of malignancy developing from the abnormal gonads [2].
We report a case with 46,XY karyotype which resulted
in dysgerminoma. The literature is reviewed to discuss
the necessity of preventive gonadectomy in order to
decrease the risk of gonadal malignancy.
Case Report
In May 2009, a 22-year-old phenotypically female individual
was admitted to the Obstetrics and Gynecology Hospital of
Fudan University for primary amenorrhea. The physical examination revealed normal breast development, absence of axillary
hair, infantile female-type external genitalia, and sparse pubic

XXXVIII, n. 4, 2011
hair. The vagina, 6 cm in length, was explored. The rectal examination revealed a rudimentary cervix and uterus. An irregular,
fixed, solid pelvic mass on the right side was palpable.
Endocrinological studies revealed elevated follicle-stimulating
hormone (FSH, 97.75IU/l), with normal range of estradiol (58.5
ng/l), testosterone (1.29 nmol/l) and prolactine (18.47 ug/l).
Adrenal function was normal. Tumor marker examination
revealed a slightly elevated -fetoprotein (AFP, 11.16 ng/ml,
normal value, < 10 ng/ml) level, while the other tumor markers
were all in normal ranges (CA125: 27.80 u/ml, CA153: 3.80
u/ml, CA199: 4.68 u/ml, CEA: 0.52 ng/ml, lactic dehydrogenase, LDH: 202 U/l). Pelvic ultrasound examination indicated a
pre-pubertal uterus and a solid mass the size of 79 68 64
mm. Computed tomography (CT) scan showed absence of the
uterus, and gonads of normal size in the pelvis, and neither
testis in the inguinal canal. The peripheral blood karyotype was
46, XY. The patient was diagnosed with gonadal dysgerminoma
with Swyer syndrome, thus surgical treatment was planned.
Laparotomy exploration showed a hypoplastic uterus, long
slender fallopian tubes, a streak gonad on the left, and a
gray/white, nodular neoplasm in the right gonad, measuring 8
7 6 cm in diameter with implants on the right pelvic peritoneal surface. No metastasis was found in the posterior cul-desac, paracolic gutters, right hemidiaphragm, liver capsule,
omentum, bowel serosa and its mesenteries. There was no
pelvic or paraaortic lymphatic dissemination. Histologic
finding in frozen section was dysgerminoma (right gonadal
and right pelvic peritonium). Then total abdominal hysterectomy, bilateral salpingo-gonadectomy, infracolic omentectomy, resection of peritoneal metastases, and pelvic lymphadenectomy were performed. Final histologic examination
demonstrated right gonadal dysgerminoma with Swyer syndrome (complete form), FIGO Stage IIc.
Following the cytoreductive surgery, four cycles of combined chemotherapy was given, BEP (bleomycin, etoposide,
and cisplatin). The patient is disease free after two years of
follow-up.
Swyer syndrome, 46,XY gonadal dysgenesis, a sex reversal disorder with dysgerminoma: a case report and literature review
415
Fig. 1a
Fig. 1b
Fig. 1c
Fig. 1d
Figure 1. Histologic finding of tumor tissue from the right gonad of the patient:
a) H&E stain (original magnification 100);
b) H&E stain (original magnification 200);
c) Immunohistochemical stain, HPL positive immunoreactivity;
d) Immunohistochemical stain, HCG positive immunoreactivity.
Discussion
Individuals with Swyer syndrome (complete form)
usually present an unambiguous female-type external
genitalia, hypoplastic uteri, bilateral streak gonads, a
46,XY karyotype and hypergonadotropic hypogonadism.
Germ cell tumors, like gonadalblastoma, arise in streak
gonads in 30% of XY sex-reversed patients [3, 4]. In
some cases, gonadoblastoma can develop into dysgerminoma [5]. Thus it is hypothesized that the expression of
the Y chromosome in these patients increases the high
risk factor of developing gonadal tumors, such as
gonadoblastoma or dysgerminoma. The testis-determining gene SRY is a Y-chromosome gene essential for testicular development. The incidence of gonadal tumor formation in patients with SRY abnormalities was 50%. And
the result of the meta-analysis concerning the relationship
between SRY aberrations and gonadal tumor formation
has shown that benign and malignant gonadal tumors
were observed in 21 out of 40 (52.5%) patients with SRY
abnormalities [6]. Funato et al. suggested that somatic

mutations of multiple genes might involved in dysgerminoma of patients with pure gonadal dysgenesis [7].
We have reviewed 22 available reported cases of XY
gonadal dysgenesis with gonadal tumors since 1993
(Table 1) (6 cases published in Chinese, 14 cases published in English) [7-18]. Among 22 cases the age was
from a month to 28 years old in variation; 14 cases were
karyotype 46,XY, seven cases were 45,X/46 XY, and
there were one a true hermaphroditism 46,XX/46,XY. Of
14 patients with karyotype 46,XY, two dysgerminomas,
four gonadoblastomas, five gonadoblastomas with dysgerminomas, two gonadoblastomas with mixed germ cell
tumors, and one yolk sac tumor (YST) were found. Of
seven patients with karyotype 45,X/46,XY, six
gonadoblastomas and one gonadoblastoma with dysgerminoma were reported. A patient with karyotype
46,XX/46,XY had dysgerminoma. The size of the tumors
varied from a minimal lesion in a streak gonad to a mass
measuring 14 cm in diameter. The rearing gender of most
416
Table 1. Literature summary of gonadal tumors with the presence of a Y chromosome.

Reference
Country
Age
Karyotype
Treatment
Pathology
Prognosis
Lou Liandi,
et al. 1993
China
3 yr
45,X/46,XY
45,X/46,XY
GB with sertoli
cell tumor
GB
ND
8 yr
ND
24 yr
45,X/46,XY
GB
ND
46,XY
hysterectomy and bilateral

annessectomy
annessectomy
annessectomy
bilateral gonadectomy
GB with
malignant mixed
germ cell tumor
46,XY
GB
Follow-up 13 yr,
disease free,
a pregnancy
with donor oocyte
ND
46,XY
GB
ND
45,X/46,XY
46,XY

annessectomy
right gonadectomy
GB
GB
ND
ND
46,XY
bilateral annessectomy
46,XY
bilateral annessectomy,
and chemotherapy
right salpingo-oophorectomy,
left ovarian wedge resection,
and omentectomy,
and chemotherapy
Excision of the right testicular
tumor, and the left orchiectomy,
and chemotherapy
GB with focal
malignant DG
DG
Follow-up 12 mo,
disease free
ND
DG
Follow-up 9 mo,
and a pregnancy
in term
YST
Follow-up 4 yr,
disease free
GB
ND
bilateral gonadectomy,
and chemotherapy
left GB+ right DG
ND
total hysterectomy,
annessectomy, pelvic and
para-aortic lymphadenectomy,
and chemotherapy
GB+ a mixed tumor

composed of malignant
teratoma (50% of the
tumor), chondrosarcoma
(10%), neuroglial cancer
(10%), dysgerminoma
(b5%) and yolk sac
tumor (20%)
bilateral oophorectomy
and the pelvic tumors
and internal genitalia
biopsy
gonadectomy
left DG+ right DG+GB
2 yr after a
histologic diagnosis
of GB, a mixed
germ cell tumor
developed,
then 6 mo after
surgery, progression
occurred, 3 mo later,
died
Follow-up 3 yr,
no progression
ND
Chen M.J.,
et al. 2005
Taiwan, 18 yr
China
Jin Lina,
et al. 2007
China
18 y
20 yr
+24 yr
28 yr
Joki-Erkkil
Finland 16 yr
M.M., et al.2002
Morerio C
Italy
11 yr
et al. 2002
Tanaka Y.
Japan 17 yr
et al. 2000
Complaint
primary
amenohrrea
primary
amenohrrea
primary
amenohrrea
primary
amenohrrea
primary
amenohrrea
abdominal
mass
mass, lower
abdominal
20%
46,XX/80%
46,XY
Handa Y.,
et al. 1995
Japan
17 mo mass
Hong JR
et al. 1995
USA
Love JD
et al. 2006
USA
Caponetti G
et al. 2006
Italy
38 mo multiple
46,XY
congenital
anomalies
17 yr nephrotic
46,XY
syndrome and
progressive
renal failure,
primary
amenorrhea
19 yr primary
46,XY
amenohrrea
Kildal W
et al. 2003
Alonso RP
et al. 2005
Norway 16 yr abdominal
pain
Mexico 1 mo
11 mo
02 mo
28 mo
15 yr
Funato T.
et al. 2002
Japan
46,XY
46,XY
45,X/46,XY
45,X/46,XY
45,X/46,XY
46,XY
45,X/46,XY
15 yr primary
46,XY
amenorrhea
and an intrapelvic mass
18 yr primary
46,XY
amenorrhea
GB = gonadoblastoma; DG = dysgerminoma; ND: no data.
focal GB
ND
ND
ND
ND
GB
GB
GB
right DG with burned
out GB+ left GB with focal transformation to DG
DB+DG
left DB+DG+ right GB
ND
ND
Swyer syndrome, 46,XY gonadal dysgenesis, a sex reversal disorder with dysgerminoma: a case report and literature review
Table 2. Gonadal dysgenesis: patients with germ cell

tumors.
Karyotype histology
DG
GB+DG
GB
46,XY*
45,X/46,XY
46,XX/46,XY
Total
2
0
1
3
5
1
0
6
4
6
0
10
GB = gonadoblastoma; DG = dysgerminoma.
*2 cases of gonadoblastoma and malignant mixed germ cell tumor with
karyotype 46,XY a YST with karyotype 46,XY.
patients was female, except a two-month and a eight-year

old boy karyotyping 45,X/46, XY. The tumors of 11/20
patients were unilateral and 9/20 were bilateral (no
description in the other two cases).
In the literature, primary amenorrhea was the main
reason for medical consultation, and lower abdominal
pain and pelvic mass were also the chief complaints. The
external genitalia of the patient in our report was unambiguous female type with immature vulva lacking pubic
hair, while in the other reports a slight clitoromegaly or
immature vulva was usually described. LDH was found
to be elevated in patients with ovarian dysgerminoma and
dropped after treatment. In the literature, a dysgerminoma, a gonadoblastoma, and a YST patient with elevated LDH were reported. The LDH remained at a
normal level in our case.
The treatment of patients with XY gonad dysgenesis
with gonadal mass was primarily surgical. As shown in
Table 1, unilateral or bilateral salpingo-gonadetomy, hysterectomy and bilateral salpingo-gonadectomy, or a
tumor debulking with or without pelvic and paraaortic
lymphadenectomy were undertaken in the those patients.
In patient with YST an excision was performed of the
right testicular tumor and left orchiectomy. Surgical
staging was undertaken for the present case. The FIGO
staging was IIc. Tumor debulking and pelvic lymphadenectomy were performed.
Chemotherapy should be regarded as an option for the
treatment of gonadal malignancies. For patients with
Stage I dysgerminoma, no additional chemotherapy is
indicated. However, patients with advanced stage disease
require adjuvant treatment with bleomycin, etoposide and
cisplatin [19]. In the literature, the following chemotherapeutic regimens have been recommended: BEP
(bleomycin, etoposide, and cisplatin), VBP (vinblastine,
bleomycin, and cisplatin), VAI (vincristine, actinomycin,
and iphosphamide), EP (etoposide and cisplatin) [20, 21].
In addition, dysgerminomas are also radiosensitive. Panel
radiotherapy was the adjuvant treatment option, but now
it is reserved for patients with recurrent or chemoresistant
disease.
Survival rate for patients with the disease varied
according to the stage at operation and the subsequent
treatment. Of all 22 cases in the literature we reviewed,
prognosis information was only recorded in six cases.
Follow-up time varied from a year to 13 years. A 46,XY
gonadal dysgenetic female with gonadoblastoma and
417
malignant mixed germ cell tumor underwent bilateral

gonadectomy, and had been free from recurrence for 13
years [8]. As for another four case reports, the patients
with gonadal gonadoblastoma and dysgerminoma (a
patient with YST) showed no sign of recurrence after
surgery (with or without adjuvant chemotherapy). Two
patients achieved successful pregnancies (one through
oocyte donation and IVF programme) [8, 12]. However,
one case of gonadal dysgenesis XY female type with
gonadoblastoma was reported to have progressed and the
patient died six months after surgery [16].
In summary, the relationship between a Y-chromosome
gene and gonadal tumor formation in XY gonadal dysgenesis needs to be further investigated. A prophylactic
bilateral salpingo-gonadenectomy is necessary for those
patients with SRY abnormalities.
References
[1] Zalel Y., Piura B,. Elchalal U., Czernobilskyb B., Antebid S.,
Dgani R.: Diagnosis and management of malignant germ cell
ovarian tumors in young females. Int. J. Gynecol. Obstet., 1996,
55, 1.
[2] Page D.C.: Hypothesis: a Y-chromosome gene causes gonadoblastoma in dysgenetic gonads. Development, 1987, 101 (suppl.) 151.
[3] Scully R.E.: Gonadoblastoma: a review of 74 cases. Cancer,
1970, 25, 1340.
[4] Verp M.S., Simpson J.L.: Abnormal sexual differentiation and
neoplasia. Cancer Genet. Cytogenet., 1987, 25, 191.
[5] Manuel M., Katayama K.P., Jones H.W.: The age of occurrence
of gonadal tumors in intersex patients with a Y chromosome. Am.
J. Obstet. Gynecol., 1976, 124, 293.
[6] Uehara S., Hashiyada M., Sato K., Nata M., Funato T., Okamura
K.: Complete XY gonadal dysgenesis and aspects of the SRY
genotype and gonadal tumor formation. J. Hum. Genet., 2002,
47, 279-284.
[7] Funato T., Uehara S., Takahashi M., Kozawa K., Satoh J., Sasaki T.
et al.: Microsatellite instability in gonadal tumors of XY pure
gonadal dysgenesis patients. Int. J. Gynecol. Cancer, 2002, 12, 192.
[8] Jin L.N., Tian Q.J., Lang J.H., Sun A.J., Chen R., Zhou Y.Z. et al.:
Clinical analysis of gonadoblastoma in 4 cases of disorders of
sexual development. J. Reprod. Med. (Chinese), 2007, 16, 400.
[9] Chen M.J., Yang J.H., Mao T.L., Ho H.N., Yang Y.S.: Successful
pregnancy in a gonadectomized women with 46,XY gonadal dysgenesis and gonadoblastoma. Fertil. Steril., 2005, 84, e5.
[10] Lou L.D., He F.F., Ye L.Z., Xu L., Gu C.X., Ma S.W. et al.:
XO/XX gonadal dysgenesis: report of 9 cases. J. Reprod. Med.
(chinese), 1993, 2, 33.
[11] Joki-Erkkil M.M., Karikoski R., Rantala I., Lenko H.L., Visakorpi T., Heinonen P.K.: Gonadoblastoma and dysgerminoma associated with XY gonadal dysgenesis in an adolescent with chronic
renal failure: a case of frasier syndrome. J. Pediatr. Adolesc.
Gynecol., 2002, 5, 145.
[12] Morerio C., Calvari V., Rosanda C., Porta S., Gambini C.,
Panarello C.: XY female with a dysgerminoma and no mutation
in the coding sequence of the SRY gene. Cancer Genet. Cytogen.,
2002, 136, 58.
[13] Tanaka Y., Fujiwara K., Yamauchi H., Mikami Y., Kohno I.: Pregnancy in a women with a Y chromosome after removal of an
ovarian dysgerminoma. Gynecol. Oncol., 2000, 79, 519.
[14] Hong J.R., Barber M., Scott C.I., Guttenberg M., Wolfson P.J.: 3year-old phenotypic female with campomelic dysplasia and bilateral gonadoblastoma. J. Pediatr. Surg., 1995, 30, 1735.
[15] Love J.D., Dermartini S.D., Coppola C.P.: Prophylactic bilateral
salpingo-oopherectomy in a 17-year-old with Frasier syndrome
reveals gonadoblastoma and seminoma: a case report. J. Pediatr.
Surg., 2006, 41, E1.
418
[16] Caponetti R., Caponetti T., Delogu D., Gravante G.: Multiple
ovarian cancer histotypes in a patient affected by Swyer syndrome. Gynecol. Oncol., 2006, 102, 411.
[17] Kildal W., Kraggerud S.M., Abeler V.M., Heim S., Trop C.G.,
Kristensen G.B. et al.: Genome profiles of bilateral dysgerminomas a unilateral gonadoblastoma, and a metastasis from a 46,XY
phenotypical female. Hum. Pathol., 2003, 34, 946.
[18] Alonso R.P., Nieto K., Alvarez R., Palma I., Njera N., Eraa L.
et al.: Distribution of Y-chromosome-bearing cells in gonadoblastoma and dysgenetic testis in 45,X/46,XY infants. Modern
Pathol., 2005, 18, 439.
[19] Lu K.H., Gershenson D.M.: Update on the management of
ovarian germ cell tumors. J. Reprod. Med., 2005, 50, 417.
[20] Dimopoulos M.A., Papadimitriou C., Hamilos G., Efstathiou E.,
Vlahos G., Rodolakis A. et al.: Treatment of ovarian germ cell
tumors with a 3-day bleomycin, etoposide, and cisplatin regimen:
a prospective multicenter study. Gynecol. Oncol., 2004, 95, 695.
[21] Williams S.D., Kauderer J., Burnett A.F., Lentz S.S., Aghajanian
C., Armstrong D.K.: Adjuvant therapy of completely resected
dysgerminoma with carboplatin and etoposide: a trial of the Gynecologic Oncology group. Gynecol. Oncol., 2004, 95, 496.

XIN LU, M.D.
Obstetrics and Gynecology
Hospital at Fudan University
No. 419 Fang-Xie Road
Shanghai, 200011 (P. R. China)
e-mail: xinlu98@yahoo.com
33 1179-30 - Gynandroblastoma:1648_29 Incidence of multiple 15/11/11 15:05 Pagina 419
[1179/30]
419
Gynandroblastoma with the symptoms of infertility

and secondary amenorrhea: a case report
S. Xiao1, M. Xue1, Y. Wan1, Z. Su2
1
Department of Obstetrics and Gynecology, 2Department of Pathology,

The Third Xiangya Hospital, Central South University, Hunan Province (China)
Summary
The case of a female patient who failed to get pregnant due to delayed menstruation is reported. Gynecological examination showed
that the patient had a male pubic distribution, hypertrophic clitoris, unobstructed vagina and hypertrophic cervices with smooth and
medium texture. B ultrasonic examination detected a 42 30 mm in size medium echo mass. This mass had irregular shape, smooth
surface, relatively clear boundary and hard texture. Examination with paraffin-embedded section indicated that the tumor was composed of supporting cells and to a lesser amount of interstitial components. Some regions had particle-like cell differentiation. These
results suggested that the tumor was gynandroblastoma. We found that the increased level of serum testosterone in the patient was the
reason for amenorrhea and infertility. The diagnosis and treatment for patients with gynandroblastoma is also discussed.
Key words: Amenorrhea; Female; Gynecological; Ovarian tumor; Pathological examination.
Introduction
Gynandroblastoma can occur at all ages, particularly in
reproductive age of women with a mean age of 31 years
[1]. Clinical symptoms depend on the proportion of tumor
cells and hormone secretion. Symptoms may be associated
with high estrogen, e.g., menorrhalgia, and endometrial
hyperplasia psychosis. Masculine symptoms, e.g., hirsutsm, clitoral hypertrophy, amenorrhea, and low voice
may also occur. In some cases there might be co-existence
of both masculine and feminine symptoms. The tumors are
normally present in one side and exhibit an oval shape and
solid texture with a diameter of less than 6 cm.
Case Report
A 31-year-old woman (G0P0) was not able to get pregnant
after five years of marriage due to delayed menstruation. She
was admitted to the hospital years three after amenorrhea. No
special past disease or family history was noted. The husband's
semen was normal. Menarche had occurred when the patient
was 14 years old. The menstrual cycle ranged from one to six
months and the menstrual period was five to six days with a
medium volume of menstruation. Since March 2006, amenorrhea occurred without any obvious reasons. From 2007 to 2009,
multiple times artificial cycle therapy (estradiol valerate: 1 ~ 2
mg/day or a combination with estrogen: 0.625 mg/day for 21
days; progesterone < 0.2 g, once/day for 6 days administered 16
days after estrogen was used) was performed. After all these
treatments, there was still no menstruation.
Physical examination showed that the patient had a body temperature of 36.8, pulse rate of 72/min, breathing rate of 20
times/min and blood pressure of 116/70 mmHg. The patient had
a relatively low voice, thick skin and slight laryngeal prominence. Heart, lung and abdomen examinations were negative.
Gynecological examination showed that the patient had a male
pubic distribution, hypertrophic clitoris, unobstructed vagina

XXXVIII, n. 4, 2011
and hypertrophic cervices with smooth and medium texture.

The uterus exhibited an anterior position with a normal size and
medium texture. A mass with a size of about 3 cm in diameter
was palpable in the left attachment zone. Obvious palpable
abnormality was not found in the right attachment area.
Pelvic B ultrasonic examination showed that the size of the
uterus was normal and the thickness of the endometrium was
3.9 mm. A strong linear echo was observed in B ultrasonic
examination. A 42 30 mm in size medium echo mass was
detected in the left ovary (total follicle counts were 11 with 8
follicles in the right ovary). Female hormone examination
showed that FSH was 2.35 IU/l, LH was 22.76 IU/l, E was
2172.1 pmol/l, P was 2.51 ng/ml, PRL was 10.46 g/l and T2 was
41.4 ng/dl (female reference value of T2 is 6-82 ng/dl). Threedimensional CT showed both adrenal glands were normal.
Horseshoe changes were observed in both kidneys.
After careful preoperative preparation on August 27, 2009
uterine laparoscopy was performed under general anesthesia.
No abdominal ascites was observed. The uterus and oviduct
appeared normal. The right ovary was negative while the left
ovary showed a mass with the size of approximately 4 cm 3
cm 3 cm. This mass had an irregular shape, smooth surface,
relatively clear boundary and hard texture and could be fully
stripped out. Hysteroscopy examination showed that the uterine
cervix and cavity had a normal shape without adhesion. The
endometrium was thin and flat. Both the uterine horn and
oviduct could be seen. Tubal patent test showed that the oviduct
was unblocked. Pathology examination showed that the left
ovarian had a mass the size of 3.5 cm 3 cm 2.5 cm. The
section of the mass was solid with a pale and sallow color.
Frozen section collected during surgery suggested an ovarian
stromal tumor and this tumor tended to be well differentiated.
Tumor cells were not found in peritoneal washes. Examination
with paraffin-embedded sections indicated a sex (ovarianderived) cord tumor, which was mainly composed of supporting cells and to a lesser amount interstitial components. Some
regions had particle-like cell differentiation. These results indicated that the tumor was consistent with gynandroblastoma.
Immunohistochemistry examination showed that LCK was positive, CA125 was positive, CD99 was negative, inhibin was positive, CK was negative, EMA was negative and HCK was negative. Four days after surgery, the concentration of testosterone
33 1179-30 - Gynandroblastoma:1648_29 Incidence of multiple 15/11/11 15:05 Pagina 420
420
S. Xiao, M. Xue, Y. Wan, Z. Su
Fig. 1
Fig. 2
Figure A and B. The tumors contained well-differentiated granule cells and supporting cells with glandular-like distribution.
Transparent Call-Exner bodies were formed in the granule cells. Proficient eosin-stained interstitial cells and thecal cells can be seen
in the tumor mesenchymal tissues (HE 100).
dropped to normal levels (7.16 ng/dl). The patient returned to

normal life after one month. Five months later, she was naturally pregnant. Follow-up examination on the outcome of the
pregnancy is currently ongoing.
Discussion
Gynandroblastoma was first reported by Meyer in 1930
and it was listed as a sex cord-stromal tumor based on the
International Classification of Ovarian Tumors [2].
According to the WHO, gynandroblastoma refers to a
granular cell tumor and the tumor components contain
typical well-differentiated Call-Exner bodies or well differentiated supporting tumor cell components [3]. Only
ten cases of this type of tumor have been reported and the
origin of the tumor was unclear. It is possible that this
type of tumor derives from gonadal mesenchymal tissue
that has sex differentiation potential [4].
Since menarche, the patient reported in this study had
the symptom of delayed menstruation accompanied by
masculine signs, e.g., laryngeal prominence, low voice
and clitoral hypertrophy. She was infertile and
menopausal in reproductive age. Menstruation cannot be
recovered after multiple times of artificial cycle treatment. Hysteroscopy confirmed that there was no organic
disease such as intrauterine adhesions. Serum testosterone was returned to normal level several days after the
mass was removed. One month after the surgery, the
patient had normal menstruation, suggesting that the
increased level of serum testosterone was the reason for
amenorrhea and infertility.
The tumor in the patient was confirmed based on the
pathological examinations. Identification of the granule
and supporting cells are keys to the diagnosis. Although
the majority of the tumor was benign in morphology, it
was still regarded as a low-grade malignant tumor [5].
Close follow-up examinations should be performed. For

the treatment of this disease, most scholars suggest
removal of the attachment in the affected side or hysterectomy. For younger patients who need to keep their
reproductive function, surgical removal of the affected
side should be limited to the annex. However, due to the
low number of cases and short period of follow-ups,
accumulation of more information is needed to draw final
conclusions on the treatment (Figure A and B).
References
[1] Lee K.R., Tavassoli F.A., Pratt J., Dietel M., Gersell D.J., Karseladze A.I. et al.: Surface epithelial-stromal tumors. In: Tavassoli
F.A., Devilee P. (eds.). Pathology and Genetics of Tumours of the
Breast and Female Genital Organs. Lyon, IARC, France, 2002,
159.
[2] McGluggage W.G., Loan J.M., Urnaghan M.: Gynandblastoma of
the ovary with juvenile granulosa cell component and heterologous
intestinal type glands. Histopathology, 1996, 29, 253.
[3] Cheng H., Dai L., Guo S.P.: World Health Organization tumor
classification and diagnostic criteria series: pathology and genetics
of tumours of breast and female genital organs. In: Tavassoli F.A.,
Devilee P. (eds.). Who Publication Center Albany, 2003, 146.
[4] Zhang J.M.: Ovarian pathology. Chinese J. Clin. Path. Jiangxi
Science and Technology, 2006, 398.
[5] Russell P., Robboy S.l., Anderson M.C.: Sex cord-stromal andsteroid cell tumors of the ovaries. In: Robboy S.J., Anderson M.C.,
Russell P. (eds.). Pathology of the Female Reproductive Tract.
London, Churchill Livingstone, 2002, 633.

M. XUE, M.D.
The Third Xiangya Hospital
Central South University
Hunan Province (China)
e-mail: xiaosquirrel@163.com
34 1162-30 - Vasa previa and postpartum:1123-30 15/11/11 15:14 Pagina 421
[1162/30]
421
Vasa previa and postpartum hysterectomy in maternal Rh

alloimunization
I. Babovic1, D. Plecas2, S. Plesinac2, O. Antonovic2
1
Institute for Gynecology and Obstetrics, Clinical Center of Serbia

2
Belgrade University School of Medicine, Belgrade (Serbia)
Summary
Velamentous insertion of the cord, or vasa previa, is a malady where fetal vessels tranverse membranes ahead of the fetal part.
The incidence of vasa previa is 1: 2000-3000 deliveries. Fetal mortality is over 50-75%. Early diagnosis is needed because these
deliveries require emergency cesarean section; it is especially more common with placenta percreta, uterine atony and hemorrhage.
Intravascular infusion of red blood cells (RBCs) into the fetus is one of the most successful means of in utero therapy for severe
fetal anemia caused by RBC alloimmunization. We performed four fetal intrauterine intravascular transfusions (IVT) as therapy for
severe fetal anemia. The patient underwent elective cesarean section. After delivery, profound uterine atony and vaginal hemorrhage
were noted and the patient underwent hysterectomy. Pathological examination of the placenta and umbilical cord documented velamentous insertion of the cord. Before intrauterine IVT a detailed US examination is necessary to exclude vasa previa or placenta
previa. Uterine atony may be result after a diagnosis of placenta previa or vasa previa. Intrauterine IVT is an irreplaceable diagnostic procedure in the treatment of severe fetal anemia
Key words: In-utero intravascular transfusion; Placenta previa completa; Vasa previa; Total abdominal hysterectomy.
Introduction
Velamentous insertion of the cord, or vasa previa, is a
malady where fetal vessels transverse membranes ahead
of the fetal part. The incidence of vasa previa is 1: 20003000 deliveries and it is more common in multiple gestations. Fetal mortality is over 50-75%. Early diagnosis is
needed because these deliveries require emergency
cesarean section, especially in cases with rupture of the
membranes, which are complicated by signs of fetal distress due to hypoxia and bleeding. Maternal risk is small,
especially if the velamentous insertion is associated with
anomalous insertion of the placenta, e.g., percreta. Fetal
exchange transfusion of about 250 ml has also been
described [1]. The discovery of the rhesus (Rh) factor by
Landsteiner and Wiener [2] in 1940 led to further findings of the condition by Levine and colleagues [3] who
established that erythroblastosis fetalis was caused by
immunization of an Rh negative mother by the red blood
cells (RBC) from an Rh-positive fetus. A major cause of
fetal or neonatal hemolytic disease is an incompatibility
of the Rh blood group between the mother and fetus. The
D antigen most commomly triggers hemolytic disease,
although other Rh antigens, such as c, C, E, e can also
cause problems. As a consequence of the hemolytic
process, anemia, extramedullary hematopoesis and
neonatal hyperbilirubinemia sometimes result in fetal
loss or neonatal death or disability. In 1961, Liley [4]
demonstrated the prognostic value of amniotic fluid spectrophotometry in identifying infants at risk and then
showed intrauterine transfusions could prevent fetal
death. Antenatal diagnostic methods identify fetuses at
Revised manuscript accepted for publication October 14, 2010
XXXVIII, n. 4, 2011
risk of developing hemolysis and assess disease severity

in affected fetuses. Severely affected fetuses who in the
past died before birth, secondary to severe anemia and
hydrops, are now saved by antenatal monitoring and
intrauterine transfusions.
The next major advance was in 1981 when Rodeck et al.
[5] performed intravascular transfusion (IVT) by inserting
the transfusion needle directly into a fetal vessel on the placental plate. The intravascular technique offers precise
diagnostic evaluation of the fetal status and is effective,
even in hydropic fetuses. The shorter procedure time associated with direct simple intrauterine IVT has made it the
procedure of choice at most centers [6]. At the Institute of
Gynecology and Obstetrics of Belgrade this procedure is
generally timed, so that delivery can be carried out at about
36 or 37 weeks. Using this approach, neonatal survival in
the nursery approaches 100% and long-term morbidity
from prematurity is exceedingly low.
Previous cesarean section, velamentous umbilical cord
insertion, an existing uterine scar and manual removal of
the placenta increased frequencies of obstetric complications such as the most difficult postpartum uterine atony
treated with total abdominal hysterectomy [7].
Case Report
A 32-year-old, gravida 2, was referred to our department at
26 weeks/3 days of gestation. Maternal blood type was A, Rhnegative anti D positive, with a titer 1: 128. Paternal blood type
was A, Rh-positive. Weekly ultrasound (US) evaluation was
important for early detection of fetal hydrops especially polyhydramnios as the first sign. Serial US and peak middle cerebral artery (MCA) velocities using Doppler advancements have
indicated that IVT could prolong pregnancy and improve the
422
I. Babovic, D. Plecas, S. Plesinac, O. Antonovic
outcome. Amniocentesis was performed to confirm fetal

anemia. The amniotic fluid sample had on optical density (the
OD 450-0.250 reading) of 7.18 (lower portion of zone 2 of
the Liley graph). The sample of amniotic fluid was not contaminated by meconium. These findings indicated the first
intrauterine IVT fetal as therapy of fetal anemia. The mother
was sedated by diazepam during the procedure. First US assessment of the placental position was completed. A 22 gauge
spinal needle was inserted into the umbilical vein at the level of
cord insertion into the placenta, under US guidance. The initial
fetal hematocrit (Hct1) was 35%, the donor hematocrit (Hct2)
was 81% and the final fetal hematocrit (Hct3) was 40%. The
volume of infusion was 20 ml of freshly ultra packed O Rh-negative red blood cells. Fenoterol (Partusisten Boehringer Ingelheim) was administered via an infusion pump. The initial infusion was 0.5-1 g/min, with the rate increased when necessary
every 30-60 min to a maximum of 3.0 g/min. Cephalexin (2 g
per os every 12 hours) was started after the procedure until 27
weeks/3 days. At 28 weeks of gestation indirect antiglobulin
(Coombs/test) indicated that her titer was 1: 128 repeatedly and
50 ml of ultra packed RBCs were intravascularly transfused
(Hct1 = 24%, Hct2 = 82%, and Hct 3 = 40%) in the free umbilical cord loop, respectively. There were not any complications.
US diagnosed anterior placenta previa and Doppler assessment
of velocity in MCA diagnosed intermediate fetal anemia, but
the biophysical profile determined fetal well-being. After four
weeks her titer was 1: 256. The third IVT was performed and
82 ml ultra packed RBC was intravascularly transfused (Hct1 =
22% Hct2 = 82%, and Hct 3 = 42%) at the level of cord insertion into the placenta and umbilical vein. The non-stress test
before and after the procedure was reactive.
In the workup no sign of hydrops or ascites was detected, but
amniotic fluid was increased (amniotic fluid index = 20.5 cm)
at the 35th week. Screening tests for gestational diabetes or
TORCH were negative. The final IVT was done at the 35th week
of gestation. Ultra packed RBC (70 ml) was transfused at the
level of cord insertion into the placenta in the umbilical vein
repeatedly, without any complications. Fetal Hct was 28%
before IVT and at the end it was 39%. The procedure time was
approximately 10 min for every intervention.
The patients first pregnancy was cesarean section and finally
at the 36 th week of this pregnancy she underwent elective
cesarean section. A male fetus weighing 3250 g was born with
an Apgar score of 7 at the first minute and 8 at the fifth minute.
The cord Hct level was 39%, direct bilirubin 120 mol/l and
direct Coombs test was positive. He required two exchange
blood transfusions and was discharged on the 17th day of life.
Four hours after delivery postpartal uterine atony and vaginal
hemorrhage were diagnosed in the patient. Administration of
oxytocin 5 IU IV slowly, 10 IU IM and F2 dinoprost trometamol 500 g/ml IM every 15 min, with compression of the
uterus was not successful. The patient was tachycardic and
hypotensive (TA 90/60 mm Hg pulls > 100 beats/min), anemic
(Er 2.06 Hgb 59 g/l Hct 18.4 Tr 77) and needed blood as
quickly as possible (7 units). Administration of clotting factors
should be based on coagulation results (aPTT 30.5 and PTT
54% fibrinogen 4.09 g/l and decreased values of clotting
factors II, V, VII). The patient was treated by ten doses of cryoprecipitate used to replace fibrinogen and three units of fresh
frozen plasma.
Finally, cesarean hysterectomy with ligation of the bilateral
internal iliac arteries had to be considered. The pathological
examinations of the placenta excluded placenta percreta, but
documented a velamentous insertion of the umbilical cord.
Discussion
Previous cesarean section and manual removal of the
placenta increase the frequency and size of fetomaternal
transplacental hemorrhage, increasing the risk of immunization if the fetus is Rh positive. Amniocentesis for the
determination of degree of fetal anemia or pulmonary
maturity carries a 2% risk of immunization if performed
under constant US guidance [1].
There is yet no agreement on the hematological criteria
for IVT. In most fetal medicine units, as in our Institute, a
Hct value between 25-30% or less is usually used as the
indication for IVT [8]. The fall in Hct is rapid in fetuses
with severe hemolytic disease, often necessitating a second
transfusion within 7-14 days. The interval between subsequent transfusions usually is 21-28 days [9].
The intravascular method requires fewer procedural
attempts, has fewer failures, results in better pregnancy
outcomes and reduces the number of traumatic deaths.
We performed all IVT via cordocentesis. From 1990,
Plecas et al. performed 592 IVTs complicated by neonatal death in 9/161 (5.6%) versus 19/161 (19%) cases of
fetal demise in utero. Four interventions of 592 intrauterine IVT were complicated by fallout of the needle, and in
one case the IVT was complicated by tamponade of the
umbilical cord and need for urgent cesarean section.
Our patient had not had any episodes of vaginal bleeding throughout the pregnancy.
Doppler and color Doppler with endovaginal imaging
when necessary detected vasa previa in asymptomatic
women as early as the second trimester. Other situations
that might mimic vasa previa probably include a normal
cord loop [10].
We use our complete protocol for treatment of uterine
atony before hysterectomy. Placenta previa and vasa
previa particularly in a patient with a previous uterine
scar may be associated with uncontrollable hemorrhage
at delivery and hysterectomy may be necessary. This is a
momentous decision in an atonic uterus consuming clotting factor faster than can be transfused.
Intrauterine IVT can be considered a safe procedure in
the hands of an experienced perinatologist with continuous US control of fetal well-being. It is a nessessary to
review all relevant data (anamnestic and obstetric/related)
in pregnancy to decide the time of delivery.
Although placenta previa and vasa previa may be independent etiological factors for uterine atony, we are not
sure that repeated procedures such as IVT can be sufficient trauma for the uterus.
References
[1] Moise K.J. Jr.: Management of rhesus alloimunization in pregnancy. Obstet. Gynecol., 2002, 600, 110.
[2] Landsteiner K., Wiener A.S.: An agglutinable factor in human
blood recognized by immune sera for Rhesus blood. Proc. Soc.
Exp. Biol., 1940, 223, 43.
[3] Levine P., Katzin E.M., Burnham L.: Isoimmunization in pregnancy:Its possible bearing on the etiology of erythroblastosis
fetalis. JAMA, 1941, 825, 116.
Vasa previa and postpartum hysterectomy in maternal Rh alloimunization

[4] Liley A.W.: The use of amniocentesis and fetal transfusion in
eythroblastosis fetalis. Pediatrics, 1965, 836, 35.
[5] Rodeck C.H., Kemp J.R., Holman C.A., Whitmore D.N., Karnicki
J., Austin M.A.: Direct intramuscular fetal blood transfusion by
fetoscopy in Rhesus isoimmunisation. Lancet, 1981, 1, 625.
[6] Schonewille H., Klumper F.J., van de Watering L.M., Kanhai
H.H., Brand A.: High additional maternal red cell-alloimmunization after Rhesus and K-matched intrauterine intravascular transfusions for hemolytic disease of the fetus. Am. J. Obstet.
Gynecol., 2007, 196, 143.
[7] Van Kamp I.L., Klumper F.J., Oepkes D., Meerman R.H., Scherjon S.A., Vandenbussche F.P., Kanhai H.H.: Complications of
intrauterine intravascular transfusions for fetal anemia due to
maternal red-cell alloimmunizatiion. Am. J. Obstet. Gynecol.,
2005, 192, 171.
[8] Poissonnier M.H., Picone O., Brossard Y., Lepercq J.: Intravenous exchange transfusion before 22 weeks of gestation in early
and severe red cell fetomaternal alloimmunization. Obstet.
Gynecol. Surv., 2004, 59, 327.
423
[9] Plecas D.V., Chitkara U., Berkowitz G., Lapinski R.H., Alvarez
M., Berkowitz R.L.: Intrauterine intravascular transfusion for
severe erythroblastosis fetalis: how much to transfuse. Obstet.
Gynecol., 1990, 75, 965.
[10] Wesley L.: Vasa previa: prenatal diagnosis, natural evalolution
and clinical outcome. Obstet. Gynecol., 2000, 95, 572.

I. BABOVIC, M.D.
63/27 Luke Vojvodica Street
Belgrade (Serbia)
e-mail: ivana.r.babovic@gmail.com
35 INDEX vol. XXXVII n. 1-4-2011:INDEX vol. XXXVI n. 1-4/2009 15/11/11 15:16 Pagina 424

Editors-in-Chief: A. Onnis - Montral (CND), J.H. Check - Canden, NJ (USA)
General index - Volume XXXVIII, 2011

No. 1, January-February-March
EDITORIAL ARTICLES
A practical approach to the prevention of miscarriage: Part 5 antiphospholipid syndrome as a cause of spontaneous
abortion - J.H. Check . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chronic pelvic pain syndromes traditional and novel therapies: Part I surgical therapy - J.H. Check . . . . . .
10
REVIEW ARTICLE
Maternal obesity and pregnancy outcome - K. Sameera Begum, K. Sachchithanantham, S. Somsubhra De .
14
ORIGINAL ARTICLES
About 13% of women may have the wrong method of oocyte insemination when undergoing in vitro fertilization by failure
to evaluate the abnormal hypo-osmotic swelling test score - G. Citrino, J.H. Check, A. Bollendorf, W. Hourani, A. Diantonio
Comparison of the efficacy of treating sperm with low hypoosmotic swelling test scores with chymo-trypsin followed by
intrauterine insemination vs in vitro fertilization with intracytoplasmic sperm injection - A. Bollendorf, D. Check, J.H.
Check, W. Hourani, K. McMonagle . . . . . . . . . . . . . . . . . . . . . . . .
Comparison of pregnancy outcome following frozen embryo transfer (ET) in a gestational carrier program according to
source of the oocytes - J.H. Check, B. Katsoff, D. Brasile, C. Wilson, D. Summers-Chase . . . . . . . . .
General Section
Chronic action of association of zidovudine, lamivudine and ritonavir on pregnant rats. A biologic assay - A. Wagner,
M. Uchiyama Nakamura, R.S. Simes, R.M. Oliveira-Filho, T.M. Pereira Fontes, L.P. Fogarolli de Carvalho, S. Espiridiao,
L. Kulay Jr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
A comparative study between microwave endometrial ablation and conventional surgical procedures for treatment of
menorrhagia - K. Nakayama, S. Yeasmin, A. Katagiri, M.T. Rahman, M. Rahman, M. Ishikawa, K. Iida, N. Nakayama,
S. Aoki, K. Miyazaki . . . . . . . . . . . . . . . . . . . . . . . . . . .
Apoptosis and expression of Bcl-2, Bax, p53, caspase-3, and Fas, Fas ligand in placentas complicated by preeclampsia I. Mendilcioglu, S. Karaveli, G. Erdogan, M. Simsek, O. Taskin, M. Ozekinci . . . . . . . . . . . .
Doppler assessment between pathological examination of the placenta and late fetal intrauterine demise - I. Babovic,
J. Tadic, S. Plesinac, Z. Radojicic, D. Plecas . . . . . . . . . . . . . . . . . . . . .
Intravaginal misoprostol reduces intraoperative blood loss in minimally invasive myomectomy: a randomized clinical trial
- I. Kalogiannidis, P. Xiromeritis, N. Prapas, Y. Prapas . . . . . . . . . . . . . . . . . . .
The golden ratio of nasal width to nasal bone length - G. Goynumer, M. Yayla, B. Durukan, L. Wetherilt . . . . .
The effect of low-dose combined oral contraceptive containing 100 ug levonorgestrel on plasma plasminogen activator
inhibitor-1 concentrations - M. Kk, S.D. Sezer, A.R. Odabasi, Z. Gner, H. Yksel, M. Serter . . . . . . .
A prospective randomized study for evaluation of wound retractors in the prevention of incision site infections after cesarean
section - T.D. Theodoridis, K.N. Chatzigeorgiou, L. Zepiridis, A. Papanicolaou, D. Vavilis, F. Tzevelekis, B.C. Tarlatzis
Troponin I, C-reactive protein and fibrinogen levels in missed abortions - L. Mollamahmutoglu, S. Kalyoncu, Y. Engin-stn,
. Moraloglu, R. Deveer, N. Dansman, U. Buyukkagnici . . . . . . . . . . . . . . . . . .
Emergent surgical treatment of radiation-induced enteropathies for patients with urogynecological and colorectal
carcinomas - A. Parlakgumus, K. Calskan, H. Ayse Parlakgumus, F. Kayaselcuk, A. Ezer, T. Colakoglu, S. Belli, S. Yildirim
Ectopic pregnancy; risk factors and comparison of intervention success rates in tubal ectopic pregnancy - M. Kazandi,
V. Turan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Multiparity, perinatal morbidity and mortality - A. Andrejevic, S. Cvetkovic, Z. Vitosevic, L. Andrejevic, G. Relic . . .
Effect of GnRH antagonist therapy on the expression of MUC-1 and heparin binding growth factor expression in the
endometrium of hyperstimulated rats - H.T. Ozcakir, A.G. Taman, C. Kose, K. Ozbilgin, S. Inan, H. Caglar . . . . .
Low molecular weight heparin and first trimester maternal PAPP-A and hCG levels, fetal nuchal translucency in the first
trimester of pregnancy - E. Tarim, T. Cok, S. Hacivelioglu, T. Bagis . . . . . . . . . . . . . . .
21
24
26
28
33
38
43
46
50
54
57
60
63
67
71
76
81
Contents - Volume XXXVIII, 2011
425
CASE REPORTS
A case of disseminated peritoneal leiomyomatosis and diffuse uterine leiomyomatosis - G. Rosica, G. Santilli, D. Bucari, B.
Amici, F. Bulletti, F. Patacchiola, A. Spagnoli, G. Falcocchio . . . . . . . . . . . . . . . . .
Marked improvement of headaches and vasomotor symptoms with sympathomimetic amines in a woman with sympathetic
hyperalgesia-edema syndrome - J.H. Check, R. Cohen . . . . . . . . . . . . . . . . . . .
Lost intrauterine contraceptive device inserted 42 years before: a case report - S.D. Sezer, A.R. Odabasi, M. Kk,
H. Yksel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Labial fusion first diagnosed during pregnancy with voiding difficulty and its management: a case report - M. Kck,
S. Halil, F. Ocer, E. Oral . . . . . . . . . . . . . . . . . . . . . . . . . . .
Placement of a vena cava filter in term pregnancy: case report and review of the literature - B. Zeybek, M.C. Terek,
C. Guven, C. Cinar . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Successful management of a high-risk pregnancy with polyhydramnios, IUGR and recurrent pregnancy loss in a chronic
renal failure patient: a case report - C. Baykal, S. Kaya, M.K. Takal, . Yakupoglu . . . . . . . . . . .
Infected tuboovarian hydatid cyst: a rare cause of tuboovarian abcess - H. Ayse Parlakgumus, A. Parlakgumus,
B. Haydardedeoglu, F. Bolat . . . . . . . . . . . . . . . . . . . . . . . . . .
84
88
90
94
96
99
102
No. 2, April-May-June
EDITORIAL ARTICLE
Chronic pelvic pain - traditional and novel therapies: Part II medical therapy - J.H. Check, R. Cohen .
113

Anti-mllerian hormone is the best predictor of poor response in ICSI cycles of patients with endometriosis - B. Ramalho
de Carvalho, A.C. Japur de S Rosa-e-Silva, J.C. Rosa-e-Silva, R.M. dos Reis, R.A. Ferriani, M.F. Silva de S . . . .
119
ORIGINAL ARTICLES
General Section
Fetal heart rate monitoring during nocturnal polysomnography - J. Reid, R. Skomro, J. Gjevre, D. Cotton, H. Ward, O.
Olatunbosun . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Effects of the association zidovudine plus ritonavir on the liver and kidneys of pregnant rats. Morphological and biochemical
aspects - T.M. Pereira Fontes, M.U. Nakamura, R. Mattar, R.S. Simes, A. Wagner, A. Moreira de Carvalho, S. Espiridio,
L. Kulay Jr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Effectiveness of emergency cervical cerclage in patients with cervical dilation in the second trimester - S. elen, Y.
Simsek, S. Ozyer, A. Sucak, O. Kaymak, F. Turkcapar, A. Oksuzoglu, E. Akbaba, N. Danisman . . . . . . . .
Correlation between asymmetric dimethylarginine maternal plasma levels and preeclampsia - A. Savvidis, A. Daniilidis,
C. Giannoulis, T. Tantanasis, K. Koiou, V. Zournatzi, J. Tzafettas . . . . . . . . . . . . . . . .
Changes in ultrasound shear wave elastography properties of normal breast during menstrual cycle - P. Rzymski,
A. Skrzewska, T. Opala . . . . . . . . . . . . . . . . . . . . . . . . . . .
Efficacy of vaginal use of topical estriol in postmenopausal women with urogenital atrophy - A.C.S. Chuery, N.M. de Gis
Speck, K.F.Q. de Moura, P.N. Belfort, C. Sakano, J.C.L. Ribalta . . . . . . . . . . . . . . . .
Parity affects pregnancy outcomes in women of 35 and older - I. Kalogiannidis, C. Margioula-Siarkou, S. Petousis,
S. Masoura, A. Goutzioulis, A. Traianos, N. Prapas, T. Agorastos . . . . . . . . . . . . . . . .
Maternal hemoglobin level and red cell indices as predictors of gestational diabetes in a multi-ethnic Asian population P.C. Tan, J.N. Chai, L.P. Ling, S.Z. Omar . . . . . . . . . . . . . . . . . . . . . .
Exteriorized versus in-situ repair of the uterine incision at cesarean delivery: a randomized controlled trial - K. zbay
Total infusion of low molecular weight iron-dextran for treating postpartum anemia - A. Daniilidis, C. Giannoulis, A.
Pantelis, T. Tantanasis, K. Dinas . . . . . . . . . . . . . . . . . . . . . . . . .
Is there any effect of fetal gender on the markers of first trimester Downs Syndrome screening? - G.O. Ajayi . . . .
Comparison of single versus multiple courses of antenatal betamethasone in patients with threatened preterm labor N. Bontis, D. Vavilis, D. Tsolakidis, D.G. Goulis, P. Tzevelekis, D. Kellartzis, B.C. Tarlatzis . . . . . . . . .
Marked hyperandrogenemia and acne associated with polycystic ovaries in Greek women with polycystic ovary syndrome N. Skampardonis, A. Kouskoukis, A. Karpouzis, G. Maroulis . . . . . . . . . . . . . . . .
Seroprevalence of other antibodies (herpes, CMV, rubella, varicella, hepatitis B and C, syphilis, chlamydia, mumps,
toxoplasmosis) in HIV-positive patients - G.O. Ajayi, S.A Omilabu, D. Alamu, Y. Balogun, S. Badaru . . . . . .
123
126
131
134
137
143
146
150
155
159
162
165
168
172
426
CASE REPORTS
Sympathetic nervous system disorder of women that leads to pelvic pain and symptoms of interstitial cystitis may be the
cause of severe backache and be very responsive to medical therapy rather than surgery despite the presence of herniated
discs - J.H. Check, C. Wilson, R. Cohen . . . . . . . . . . . . . . . . . . . . . .
Two cases of measles in pregnant women immediately preceding delivery (case reports) - M. Yoshida, H. Matsuda, K.
Furuya . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Evidence that migraine headaches in women may be related to a common defect in the sympathetic nervous system as
evidenced by marked improvement following treatment with sympathomimetic amines - J.H. Check, R. Cohen, D. Check
Successful water birth in a woman with vaginismus - . Moraloglu, Y. Engin-stn, G. zaksit, L. Mollamahmutoglu
Nobel medical management of primary bladder endometriosis with dienogest: a case report - H. Takagi, K. Matsunami,
S. Ichigo, A. Imai . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Endometrial tuberculosis: a clinical case - P. Iovenitti, G. Ruggeri, R. Tatangelo, P. Palermo, G. Carta . . . . . .
Outcome of arterial embolization of uterine leiomyoma: case report - C.E. Bonduki, C. Yokohama, J.M. Soares Jr.,
E.L. Alves da Motta, M.J.B.C. Giro, E.C. Baracat . . . . . . . . . . . . . . . . . . . .
175
177
180
182
184
186
188
No. 3, July-August-September
EDITORIAL ARTICLE
The importance of sonographic endometrial parameters in influencing success following embryo transfer in the modern era
and therapeutic options - Part 1: the importance of late proliferative phase endometrial thickness - J.H. Check . . . .
ORIGINAL ARTICLES
A case whose outcome is consistent with the possibility that if slow embryo cleavage is related to a male factor the
prognosis is far greater than if it was related to an egg factor - J.H. Check, B. Katsoff, C. Wilson, A. Bollendorf . . .
Effect of method of oocyte fertilization on fertilization, pregnancy and implantation rates in women with unexplained
infertility - J.H. Check, W. Yuan, M.C. Garberi-Levito, K. Swenson, K. McMonagle . . . . . . . . . . .
Matched controlled study to evaluate the effect of endometrial polyps on pregnancy and implantation rates following in
vitro fertilization-embryo transfer (IVF-ET) - J.H. Check, C.A. Bostick-Smith, J.K. Choe, J. Amui, D. Brasile . . . .
Successful pregnancy following in vitro fertilization embryo transfer in a 46-year-old woman with diminished oocyte
reserve as evidenced by a high day 3 serum estradiol - J.H. Check, R. Chern, J. Amui . . . . . . . . . .
Serum adiponectin levels are significantly reduced during the second half of normal pregnancy - H. Elshoreya,
F. Steinberg, R. Perry, C. Hansen, B. Milcareck, S. Elkouachi, J.H. Check . . . . . . . . . . . . .
General Section
Single umbilical artery: fetal and placental histopathological analysis of 24 cases - A. Kondi-Pafiti, K.C. Kleanthis,
P. Mavrigiannaki, C. Iavazzo, K. Bakalianou, D. Hassiakos, A. Liapis . . . . . . . . . . . . . . .
Urinary complications of gynecologic surgery: iatrogenic urinary tract system injuries in obstetrics and gynecology
operations - E. Ozdemir, U. Ozturk, S. Celen, A. Sucak, M. Gunel, G. Guney, M.A. Imamoglu, A.N. Danisman . . . .
Effect of epidural analgesia on operative vaginal birth rate - U. Indraccolo, D. Di Filippo, R. Di Iorio, E. Marinoni,
D. Roselli, S.R. Indraccolo . . . . . . . . . . . . . . . . . . . . . . . . . .
The role of oral contraception use in the occurrence of breast cancer. A retrospective study of 405 patients - G. Iatrakis,
C. Iavazzo, S. Zervoudis, A. Koumousidis, C. Sofoudis, T. Kalampokas, N. Salakos . . . . . . . . . . .
Thrombin activatable fibrinolysis inhibitor (TAFI) is not associated with recurrent miscarriage - S.D. Sezer, A. Baz,
M. Kk, A.R. Odabas, M. Serter, H. Yksel . . . . . . . . . . . . . . . . . . . . .
Transdermal estrogen therapy effects on fibrinogen levels in women with a past history of venous thromboembolism:
a pilot study - P.F.R. Margarido, V.R. Bagnoli, . Maggio da Fonseca, G.A.R. Maciel, J.M. Soares Jr., .A. DAmico,
E.C. Baracat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Resistin may not associate with gestational diabetes mellitus although insulin resistance - N. Akdeniz, U. Kuyumcuoglu,
A. Kale, S. Arikan, E. Kale, M. Erdemoglu . . . . . . . . . . . . . . . . . . . . . .
Amniocentesis-related adverse outcomes according to placental location and risk factors for fetal loss after midtrimester
amniocentesis - I. Kalogiannidis, S. Prapa, T. Dagklis, A. Karkanaki, S. Petousis, Y. Prapas, N. Prapas . . . . . .
A new approach in the first-line treatment of bacterial and mycotic vulvovaginitis with topical lipohydroperoxides and
glycyrrhetic acid: a comparative study - G. Mainini, M. Rotondi, C. Scaffa . . . . . . . . . . . . .
Optimal dose of an anesthetic in epidural anesthesia and its effect on labor duration and administration of vacuum
extractor and forceps - N. Cutura, V. Soldo, S.R. Milovanovic, Z. Orecanin-Duic, A. Curkovic, B. Tomovic, S. JankovicRanatovic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The attitudes of menopausal women and their spouses towards menopause - H. Aksu, L. Sevinok, M. Kck, S.D. Sezer,
N. Ogurlu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
197
201
203
206
209
211
214
217
221
225
228
232
236
239
243
247
251
Two-year experience of obstetric cholestasis: outcome and management - R. Deveer, Y. Engin-Ustun, S. elen, .G.
Erylmaz, E. Tongu, L. Mollamahmutoglu, A. Oksuzoglu, N. Danisman . . . . . . . . . . . . . .
Emergency contraception: knowledge, attitudes and practice of the pharmacy staff in Aydn, Turkey - H. Aksu, O. Basak,
M. Kck, N. Yeniceri, S. Kaya . . . . . . . . . . . . . . . . . . . . . . . . .
Postmenopausal palpable ovary and ovarian cancer - M. Gojnic, M. Brankovic, M. Maksimovic, B. Parapid, V. Dugalic,
K. Jeremic, B. Gutic . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CASE REPORTS
Amniocentesis can be useful during the third trimester of pregnancy for antenatal diagnosis of Pallister-Killian syndrome:
a case report - M. Murakami, T. Iwasa, Y. Takahashi, M. Morine . . . . . . . . . . . . . . . .
Isolated tubal torsion in pregnancy - a rare case - H. Isi, N. Gdc, G. Gnen, A.Y. Basgul . . . . . . . .
Combination of B-Lynch and modified Cho sutures for postpartum hemorrhage caused by low-lying placenta and placenta
accreta - JP. Xiao, B. Zhang . . . . . . . . . . . . . . . . . . . . . . . . . .
A giant cervical nabothian cyst compressing the rectum, differential diagnosis and literature review - I. Temur, K. Ulker,
B. Sulu, M. Karaca, A. Aydn, B. Gurcu . . . . . . . . . . . . . . . . . . . . . . .
Subtle ultrasonographic appearance of Downs syndrome: a case report of prenatal diagnosis of isolated simple fetal
syndactyly - G. Di Luigi, I. DEmilio, A. Marcozzi, L. Gennaccaro, P. Palermo, G. Carta . . . . . . . . . .
Prenatal diagnosis of congenital harlequin ichthyosis with 2D, 3D, and 4D ultrasonography - A.Y. Basgul, Z.N. Kavak,
N. Guducu, B. Durukan, H. Isci . . . . . . . . . . . . . . . . . . . . . . . . .
Uterine rupture during pregnancy - X. Xia, L. Fan, Y. Xia, Y. Fang . . . . . . . . . . . . . . .
Abdominal wall endometriosis following cesarean section: report of five cases - B. Demir, Z. Senerbahce, A.I. Guzel,
S. Demir, N. Kilinc . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Extraovarian mature cystic teratoma of the mesentery. A case report and literature review - E. Papakonstantinou,
C. Iavazzo, D. Hasiakos, C.K. Kleanthis, S. Fotiou, A. Kondi-Pafiti . . . . . . . . . . . . . . .
Gossypiboma: a rare abdominal lesion of women after cesarean section, usually misdiagnosed as a neoplasm - P.E.
Mavrigiannaki, C. Dastamani, E. Vouza, E. Lambropoulou, E. Kairi-Vassilatou, A. Kondi-Pafiti . . . . . . . .
Permanent pacemakers in pregnancy - J. Coolen, R. Turnell, I. Vonder Muhll, S. Chandra . . . . . . . . .
Giant prolapsed submucous leiomyoma: a surgical challenge for gynecologists - L.G.O. Brito, P.S. Magnani, A. Eugnio
de Azevedo Trapp, M.M. Sabino-de-Freitas . . . . . . . . . . . . . . . . . . . . . .
Diabetes insipidus and two consecutive pregnancies: a case report and review of the literature - G. Adonakis,
V. Kyriazopoulou, G. Androutsopoulos, V. Papadopoulos, G. Decavalas, N.A. Georgopoulos . . . . . . . . .
Prenatal diagnosis of a digynic triploid fetus in the second trimester: transvaginal two-dimensional ultrasound, color
Doppler and fetoplacental Doppler velocity waveform findings - A.Y. Basgul, Z.N. Kavak, H. Isci, N. Kutay, B. Durukan
427
256
260
265
269
272
274
276
280
283
286
288
291
294
297
299
301
303
No. 4, October-November-December
EDITORIAL ARTICLE
Choosing the right stimulation protocol for in vitro fertilization-embryo transfer in poor, normal, and hyper-responders J.H. Check, B. Slovis . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ORIGINAL ARTICLES
Evaluation of the importance of late follicular phase endometrial echo patterns and pregnancy outcome following embryo
transfer by evaluating infertile donor/recipient pairs - J.H. Check, J.K. Choe, J. Amui, D. Brasile, T. Jamison . . . .
Blastomere number and pregnancy rates in the succeeding in vitro fertilization cycle in women who formed all embryos
with 5 blastomeres - J.H. Check, J. Amui, J.K. Choe, D. Brasile, R. Cohen . . . . . . . . . . . . .
Effect of serum progesterone level on the day of human chorionic gonadotropin injection on outcome following in vitro
fertilization-embryo transfer in women using gonadotropin releasing hormone antagonists - B. Katsoff, J.H. Check, C.
Wilson, J.K. Choe . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Effect of multiple source vs single source of donor embryos on pregnancy and implantation rates per transfer - C. Wilson,
J.H. Check, J. Amui, J.K. Choe, D. Brasile . . . . . . . . . . . . . . . . . . . . . .
Evidence that the main adverse effect of ganirelix on pregnancy and implantation rates is on the embryo rather than the
endometrium - J.H. Check, R. Cohen, J. Amui, J.K. Choe, D. Brasile . . . . . . . . . . . . . . .
Successful twin pregnancy in a donor oocyte recipient despite a maximum endometrial thickness in the late proliferative
phase of 4 mm - J. Amui, J.H. Check, R. Cohen . . . . . . . . . . . . . . . . . . . . .
Live fetus following embryo transfer in a woman with diminished egg reserve whose maximal endometrial thickness was
less than 4 mm - J.H. Check, R. Cohen . . . . . . . . . . . . . . . . . . . . . . .
313
318
320
322
324
326
328
330
428
Speculum retention during embryo transfer does not improve pregnancy rates following embryo transfer - a randomized
study - J. Amui, J.H. Check, D. Brasile . . . . . . . . . . . . . . . . . . . . . . .
Successful pregnancy following a single fresh embryo transfer in a 45-year-old woman whose early follicular phase serum
follicle stimulating hormone was 29 mIU/ml - J.H. Check, J.K. Choe, R. Cohen . . . . . . . . . . . .
General Section
Kiwisch von Rotterau - a pioneer of European obstetrics, gynecology and gynecopathology - H. Pickel, O. Reich, R.H.
Young . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Induction of plasminogen activators in pregnant women with Toxoplasma gondii infection - C.S. Chou, M.C. Chou, K.M.
Chen, C.Y. Lu, S.C. Lai . . . . . . . . . . . . . . . . . . . . . . . . . . .
Effects of inherited trombophilia in women with recurrent pregnancy loss - Z. Habibovic, B. Zeybek, C. Sanhal, Z. Eroglu,
E. Karaca, M. Ulukus . . . . . . . . . . . . . . . . . . . . . . . . . . .
Infectious respiratory diseases in pregnancy - results of a 15-year study in Seoul - J.Y. Cheung, S.S. Shim, Y. Kim . . .
Serum osteoprotegerin correlates with age and bone mass in postmenopausal, but not in fertile age women - G. Mainini,
M. Incoronato, L. Urso, C. Scaffa . . . . . . . . . . . . . . . . . . . . . . . .
Clinical effects of transvaginal vesicovaginal fistula repair surgery mediated by the Foley catheter (64 cases) - L. Bingshu, H. Li, W. Qin, H. Min, C. Yan-xiang . . . . . . . . . . . . . . . . . . . . . .
Evaluation of clinical and cytogenetic fndings on 1,068 second-trimester amniocenteses in Southeast Turkey - M. Balkan,
H. Akbas, S. Kalkanli, M. Erdemoglu, M. Fidanboy, M.N. Alp, T. Budak . . . . . . . . . . . . . .
Distribution of etiological factors of hypergonadotropic amenorrhea - H. Meden-Vrtovec, K. Gerak, D. Franic. . .
Validation of ultrasound scan in the diagnosis of female stress urinary incontinence - A. Lukanovic, T.S. Patrelli . . .
A new classification for female infertility - A. Aflatoonian, B. Baghianimoghadam, P. Partovi, A. Abdoli, P. Hemmati,
N. Tabibnejad, M. Dehghani . . . . . . . . . . . . . . . . . . . . . . . . . .
Correlation between fetal movement revealed in actography and fetal-neonatal well-being: observational study on 3,805
pregnancies followed in a Northern Italy tertiary care hospital - T.S. Patrelli, F. DAddetta, S. Gizzo, L. Franchi, S. Di
Gangi, N. Sianesi, F. Peri, G. Pedrazzi, R. Berretta, G. Piantelli, A. Lukanovic, G.B. Nardelli, A. Bacchi Modena . . .
Factors associated with the success of external cephalic version (ECV) of breech presentation at term - N. Obeidat,
I. Lataifeh, M. Al-Khateeb, F. Zayed, W. Khriesat, Z. Amarin . . . . . . . . . . . . . . . . .
New results regarding trends in Iranian womens health and a comparison with WHO data - E. Barooti, N. Sadeghi,
M. Karimi-Zarchi, H.R. Soltani . . . . . . . . . . . . . . . . . . . . . . . . .
Frequency of ovarian endometriosis in epithelial ovarian cancer patients - O. Dzatic-Smiljkovic, M. Vasiljevic, M. Djukic,
R. Vugdelic, J. Vugdelic . . . . . . . . . . . . . . . . . . . . . . . . . . .
Evaluation of adolescent pregnancies: 10-year experience of a hospital in rural Turkey - B. Demir, A.I. Guzel, Y. Celik,
S. Demir, F. Demir . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Morphologic and functional vascular alterations in patients with polycystic ovary syndrome - B. Demir, S. Pasa, S. Demir,
R. Buyukkaya, A.E. Atay, Y. Atamer, T. Gul . . . . . . . . . . . . . . . . . . . . .
Ultrasonography-guided amniocentesis in singleton pregnancies: a review of the first 1,000 cases - G.O. Ajayi . . . .
Rate of use of contraceptive methods and risk factors in Tehran, the capital of Iran, in 2010 compared to other cities and
regions - E. Barooti, N. Sadeghi, M. Karimi-Zarchi, H.R. Soltani . . . . . . . . . . . . . . . .
CASE REPORTS
Sympathetic neural hyperalgesia edema syndrome, a frequent cause of pelvic pain in women, mistaken for Lyme disease
with chronic fatigue - J.H. Check, R. Cohen . . . . . . . . . . . . . . . . . . . . .
Swyer syndrome, 46,XY gonadal dysgenesis, a sex reversal disorder with dysgerminoma: a case report and literature
review - Jing Zhu, Xishi Liu, Hongyan Jin, Xin Lu . . . . . . . . . . . . . . . . . . . .
Gynandroblastoma with the symptoms of infertility and secondary amenorrhea: a case report - S. Xiao, M. Xue, Y. Wan,
Z. Su . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Vasa previa and postpartum hysterectomy in maternal Rh alloimunization - I. Babovic, D. Plecas, S. Plesinac, O.
Antonovic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
333
335
338
341
347
351
355
360
364
369
373
379
382
386
390
394
399
401
405
408
412
414
419
421
36 LIST OF AUTHORS Experimental:LIST OF AUTHORS Experimental 15/11/11 15:19 Pagina 429
429
Index of Authors
in alphabetical order
Abdoli A., 379

Adonakis G., 301
Aflatoonian A., 379
Agorastos T., 146
Ajayi G.O., 162, 172, 405
Akbaba E., 131
Akbas H., 364
Akdeniz N., 236
Aksu H., 251, 260
Alamu D., 172
Al-Khateeb M., 386
Alp M.N., 364
Alves da Motta E.L., 188
Amarin Z., 386
Amici B., 84
Amui J., 206, 209, 318, 320, 324,
326, 328, 333
Andrejevic A., 71
Andrejevic L., 71
Androutsopoulos G., 301
Antonovic O., 421
Aoki S., 33
Arikan S., 236
Atamer Y., 401
Atay A.E., 401
Aydn A., 276
Ayse Parlakgumus H., 63, 102
Babovic I., 43, 421
Bacchi Modena A., 382
Badaru S.., 172
Baghianimoghadam B., 379
Bagis T., 81
Bagnoli V.R., 232
Bakalianou K., 214
Balkan M., 364
Balogun Y., 172
Baracat E.C., 188, 232
Barooti E., 390, 408
Basak O., 260
Basgul A.Y., 272, 283, 303
Baykal C., 99
Baz A., 228
Belfort P.N., 143
Belli S., 63
Berretta R., 382
Bing-shu L., 360
Bolat F., 102
Bollendorf A., 21, 24, 201
Bonduki C.E., 188
Bontis N., 165
Bostick-Smith C.A., 206
Brankovic M., 265
Brasile D., 26, 206, 318, 320, 324,
326, 333
Brito L.G.O., 299
Bucari D., 84
Budak T., 364
Bulletti F., 84
Buyukkagnici U., 60
Buyukkaya R., 401
Curkovic A., 247
Cutura N., 247
Caglar H., 76
Calskan K., 63
Carta G., 186, 280

elen S., 131, 217, 256
Celik Y., 399
Chai J.N., 150
Chandra S., 297
Chatzigeorgiou K.N., 57
Check D., 24, 180
Check J.H., 5, 10, 21, 24, 26, 88,
113, 175, 180, 197, 201, 203,
206, 209, 211, 313, 318, 320,
324, 326, 328, 330, 333, 335,
412
Chen K.M., 341
Chern R., 209
Cheung J.Y., 351
Choe J.K., 206, 318, 320, 322,
324, 326, 335
Chou C.S., 341
Chou M.C., 341
Chuery A.C.S., 143
Cinar C., 96
Citrino G., 21
Cohen R., 88, 113, 175, 180, 320,
326, 328, 330, 335, 412
Cok T., 81
Colakoglu T., 63
Coolen J., 297
Cotton D., 123
Cvetkovic S., 71
DAddetta F., 382
DAmico .A., 232
DEmilio I., 280
Dagklis T., 239
Daniilidis A., 134, 159
Dansman N., 60, 131, 256
Danisman A.N., 217
Dastamani C., 294
de Gis Speck N.M., 143
de Moura K.F.Q., 143
Decavalas G., 301
Dehghani M., 379
Demir B., 288, 399, 401
Demir F., 399
Demir S., 288, 399, 401
Deveer R., 60, 256
Di Filippo D., 221
Di Gangi S., 382
Di Iorio R., 221
Di Luigi G., 280
Diantonio A., 21
Dinas K., 159
Djukic M., 394
dos Reis R.M., 119
Dugalic V., 265
Durukan B., 50, 283, 303
Dzatic-Smiljkovic O., 394
Elkouachi S., 211
Elshoreya H., 211
Engin-stn Y., 60, 182, 256
Erdemoglu M., 236, 364
Erdogan G., 38
Eroglu Z., 347
Erylmaz .G., 256
Espiridio S., 126
Espiridiao S., 28
Eugnio de Azevedo Trapp A., 299
Ezer A., 63
Falcocchio G., 84
Fan L., 286
Fang Y., 286
Ferriani R.A., 119
Fidanboy M., 364
Fogarolli de Carvalho L.P., 28
Fotiou S., 291
Franchi L., 382
Frani D., 369
Furuya K., 177
Garberi-Levito M.C., 203
Gennaccaro L., 280
Georgopoulos N.A., 301
Gerak K., 369
Giannoulis C., 134, 159
Giro M.J.B.C., 188
Gizzo S., 382
Gjevre J., 123
Gojnic M., 265
Gnen G., 272
Goulis D.G., 165
Goutzioulis A., 146
Goynumer G., 50
Gdc N., 272, 283
Gul T., 401
Gunel M., 217
Gner Z., 54
Guney G., 217
Gurcu B., 276
Gutic B., 265
Guven C., 96
Guzel A.I., 288, 399
Habibovic Z., 347
Hacivelioglu S., 81
Halil S., 94
Hansen C., 211
Hasiakos D., 291
Hassiakos D., 214
Haydardedeoglu B., 102
Hemmati P., 379
Hourani W., 21, 24
Imamoglu M.A., 217
Isi H., 272, 283, 303

Iatrakis G., 225
Iavazzo C., 214, 225, 291
Ichigo S., 184
Iida K., 33
Imai A., 184
Inan S., 76
Incoronato M., 355
Indraccolo S.R., 221
Indraccolo U., 221
Iovenitti P., 186
Ishikawa M., 33
Iwasa T., 269
Jamison T., 318
Jankovic-Ranatovic S., 247
Japur de S Rosa-e-Silva A.C., 119
Jeremic K., 265

Jin Hongyan, 414
Kairi-Vassilatou E., 294
Kalampokas T., 225
Kale A., 236
Kale E., 236
Kalkanli S., 364
Kalogiannidis I., 46, 146, 239
Kalyoncu S., 60
Karaca E., 347
Karaca M., 276
Karaveli S., 38
Karimi-Zarchi M., 390, 408
Karkanaki A., 239
Karpouzis A., 168
Katagiri A., 33
Katsoff B., 26, 201, 322
Kavak Z.N., 283, 303
Kaya S., 99, 260
Kayaselcuk F., 63
Kaymak O., 131
Kazandi M., 67
Kellartzis D., 165
Khriesat W., 386
Kilinc N., 288
Kim Y., 351
Kleanthis C.K., 291
Kleanthis K.C., 214
Koiou K., 134
Kondi-Pafiti A., 214, 291, 294
Kose C., 76
Koumousidis A., 225
Kouskoukis A., 168
Kck M., 54, 90, 94, 228, 251,
260
Kulay L. Jr., 28, 126
Kutay N., 303
Kuyumcuoglu U., 236
Kyriazopoulou V., 301
Lai S.C., 341
Lambropoulou E., 294
Lataifeh I., 386
Li H., 360
Liapis A., 214
Ling L.P., 150
Liu Xishi, 414
Lu C.Y., 344
Lu Xin, 414
Lukanovic A., 373, 382
Maciel G.A.R., 232
Maggio da Fonseca ., 232
Magnani P.S., 299
Mainini G., 243, 355
Maksimovic M., 265
Marcozzi A., 280
Margarido P.F.R., 232
Margioula-Siarkou C., 146
Marinoni E., 221
Maroulis G., 168
Masoura S., 146
Matsuda H., 177
Matsunami K., 184
Mattar R., 126
36 LIST OF AUTHORS Experimental:LIST OF AUTHORS Experimental 15/11/11 15:19 Pagina 430
430
Mavrigiannaki P.E., 214, 294
McMonagle K., 24, 203
Meden-Vrtovec H., 369
Mendilcioglu I., 38
Milcareck B., 211
Milovanovic S.R., 247
Min H., 360
Miyazaki K., 33
Mollamahmutoglu L., 60, 182,
256
Moraloglu ., 60, 182
Moreira de Carvalho A., 126
Morine M., 269
Murakami M., 269
Nakamura M.U., 126, 269
Nakayama K., 33
Nakayama N., 33
Nardelli G.B., 382
Obeidat N., 386
Ocer F., 94
Odabasi A.R., 54, 90, 228
Ogurlu N., 251
Oksuzoglu A., 131, 256
Olatunbosun O., 123
Oliveira-Filho R.M., 28
Omar S.Z., 150
Omilabu S.A., 172
Opala T., 137
Oral E., 94
Orecanin-Duic Z., 247
zaksit G., 182
zbay K., 155
Ozbilgin K., 76
Ozcakir H.T., 76
Ozdemir E., 217
Ozekinci M., 38
Ozturk U., 217
Ozyer S., 131
Palermo P., 186, 280
Pantelis A., 159
Papadopoulos V., 301
Papakonstantinou E., 291
Papanicolaou A., 57
Parapid B., 265
Parlakgumus A., 63, 102
Partovi P., 379

Pasa S., 401
Patacchiola F., 84
Patrelli T.S., 373, 382
Pedrazzi G., 382
Pereira Fontes T.M., 28, 126
Peri F., 382
Perry R., 211
Petousis S., 146, 239
Piantelli G., 382
Pickel H., 338
Plecas D., 43, 421
Plesinac S., 43, 421
Prapa S., 239
Prapas N., 46, 146, 239
Prapas Y., 46, 239
Qin W., 360
Radojicic Z., 43
Rahman M., 33
Rahman M.T., 33
Ramalho de Carvalho B., 119
Reich O., 338
Reid J., 123
Relic G., 71
Ribalta J.C.L., 143
Rosa-e-Silva J.C., 119
Roselli D., 221
Rosica G., 84
Rotondi M., 243
Ruggeri G., 186
Rzymski P., 137
Sabino-de-Freitas M.M., 299
Sachchithanantham K., 14
Sadeghi N., 390, 408
Sakano C., 143
Salakos N., 225
Sameera Begum K., 14
Sanhal C., 347
Santilli G., 84
Savvidis A., 134
Scaffa C., 243, 355
Senerbahce Z., 288
Serter M., 54, 228
Sevinok L., 251
Sezer S.D., 54, 90, 228, 251
Shim S.S., 351

Sianesi N., 382
Silva de S M.F., 119
Simes R.S., 28, 126
Simsek M., 38
Simsek Y., 131
Skampardonis N., 168
Skomro R., 123
Skrzewska A., 137
Slovis B., 313
Soares J.M. Jr., 188, 232
Sofoudis C., 225
Soldo V., 247
Soltani H.R., 390, 408
Somsubhra De S., 14
Spagnoli A., 84
Steinberg F., 211
Su Z., 419
Sucak A., 131, 217
Sulu B., 276
Summers-Chase D., 26
Swenson K., 203
Tabibnejad N., 379
Tadic J., 43
Takagi H., 184
Takahashi Y., 269
Takal M.K., 99
Taman A.G., 76
Tan P.C., 150
Tantanasis T., 134, 159
Tarim E., 81
Tarlatzis B.C., 57, 165
Taskin O., 38
Tatangelo R., 186
Temur I., 276
Terek M.C., 96
Theodoridis T.D., 57
Tomovic B., 247
Tongu E., 256
Traianos A., 146
Tsolakidis D., 165
Turan V., 67
Turkcapar F., 131
Turnell R., 297
Tzafettas J., 134
Tzevelekis F., 57
Tzevelekis P., 165
Uchiyama Nakamura M., 28

Ulker K., 276
Ulukus M., 347
Urso L., 355
Vasiljevic M., 394
Vavilis D., 57, 165
Vitosevic Z., 71
Vonder Muhll I., 297
Vouza E., 294
Vugdelic J., 394
Vugdelic R., 394
Wagner A., 28, 126
Wan Y., 419
Ward H., 123
Wetherilt L., 50
Wilson C., 26, 175, 201, 322, 324
Xia X., 286
Xia Y., 286
Xiao JP., 274
Xiao S., 419
Xiromeritis P., 46
Xue M., 419
Yakupoglu ., 99
Yan-xiang C., 360
Yayla M., 50
Yeasmin S., 33
Yeniceri N., 260
Yildirim S., 63
Yokohama C., 188
Yoshida M., 177
Young R.H., 338
Yuan W., 203
Yksel H., 54, 90, 228
Zayed F., 386
Zepiridis L., 57
Zervoudis S., 225
Zeybek B., 96, 347
Zhang B., 274
Zhu Jing, 414
Zournatzi V., 134
37 Imp.European+ced. 12:Imp.European+ced. 10 15/11/11 15:20 Pagina 431
ISSN: 0392-2936
european journal
of gynaecological oncology
www.irog.net
I.R.O.G. CANADA, Inc.

4900 Cte St-Luc - Apt # 212
Montral, Qu. H3W 2H3 (Canada)
Tel. +514-4893242 - Fax +514-4854513
E-mail: canlux@qc.aira.com - www.irog.net
ISSN: 0392-2936
Published bimonthly
Founding Editor
A. Onnis
The journal publishes original peer reviewed works, preferably briefly reported,
in the fields of female genital cancers and related subjects and also proceedings of
gynecologic oncology society meetings all over the world.
Founded in 1980 (ISSN 0392 2936) it is issued bi-monthly in English.
The Journal is covered by CURRENT CONTENTS, SCISEARCH, RESEARCH
ALERT, INDEX MEDICUS, MEDLINE (PUBMED), EMBASE/Excerpta Medica,
CURRENT ADVANCES IN CANCER RESEARCH, BIOSIS, INDEX COPERNICUS.
We hope to have you as a subscriber of our Journal which is improving its scientific and clinical interdisciplinary contributions on female genital cancer, year by year.
You can subscribe or renew your subscription by sending us the following form.
Yes, start my subscription.
"
EUROPEAN JOURNAL
OF GYNAECOLOGICAL ONCOLOGY
Montral (Canada)
Editors-in-Chief
M. Marchetti
P. Bosze
Montral (Canada)
Budapest (Hungary)
Associate Editor
T. Maggino
Padua (Italy)
Assistant Editor
J. Wilson
SUBSCRIPTION ORDER CARD 2012

ISSN 0392-2936. Published bimonthly. All subscriptions are entered on a calendar-year
basis. Individual rate is not applicable if payment is made through an Institution.
Subscriptions ARE ENTERED WITH PREPAYMENT ONLY.
Please enter my subscription at the rate Ive checked:
Institutional: 430 $US
Individual: 220 $US
Booksellers and subscription agencies 370 $US
Please send me a free sample copy
Editorial Board
Allen H.H., London, Ontario (Canada) - Ayhan
A., Ankara (Turkey) - Balat O., Graziantep (Turkey)
- Balega J., Birmingham, England (UK) - Banceanu G., Bucarest (Romania) - Basta A., Krakow
(Poland) - Bender H.C., Dusseldorf (Germany) Charkviani T., Tbilisi (Georgia) - Chiarelli S.,
Padua (Italy) - De Oliveira C.F., Coimbra
(Portugal) - Dexeus S. Jr., Barcelona (Spain) - Di
Paola G.R., Buenos Aires (Argentina) - Di Re F.,
Milan (Italy) - Di Saia P., Orange, CA (USA) - Elit
L., Hamilton (Canada) - Friedrich M., Krefeld
(Germany) - Geisler H.E., Indianapolis, IN (USA) Gorins A., Paris (France) - Heintz A.P.M.,
Utrecht (The Netherlands) - Ioannidou-Mouzaka
L., Athens (Greece) - Jordan J.A., Birmingham,
England (UK) - Klastersky J., Bruxelles (Belgium) Kubista E., Vienna (Austria) - Lee Y.S., Daegu
(South Korea) - Markowska J., Poznan (Poland) Mariani A., Rochester, MN (USA) - Marth C.,
Innsbruck (Austria) - Massuger Leon F.A.G.,
Nijmegen (The Netherlands) - Menczer J., Savyon
(Israel) - Monsonego J., Paris (France) - Plfalvi
L., Budapest, (Hungary) - Piura B., Beer Sheva
(Israel) - Piver S.M., Buffalo, NY (USA) - Rakar
S., Ljubljana (Slovenia) - Shepherd J.H., London,
England (UK) - Sikls P., Budapest (Hungary) Smit B.J., Tygerberg (South Africa) Stelmachw J., Warsaw (Poland) - Syrjnen K.,
Turku (Finland) - Tjalma W., Antwerpen (Belgium)
- Ungr L., Budapest (Hungary) - Vermorken
J.B., Edegem (Belgium) - Wang P.H., Taipei
(Taiwan) - Winter R., Graz (Austria) - Yokoyama
Y., Hirosaki (Japan)
Iam paying by: (U.S. CURRENCY ONLY)

Credit Card:
Check (enclosed)
Mastercard
American Express
Visa
Exp. Date
Signature
Date
Diners
INSTRUCTIONS FOR BANK TRANSFERS TO CANADA

Funds payable in USD from USA
Pay: The Bank of Nova Scotia - 1 Liberty Plaza - New
York, N.Y. U.S.A. - Fed Wire Routing 026002532 (this
number is the ABA number) - Swift Code. NOSCUS33
For further payment to: The Bank of Nova Scotia - BSC
Montral, Transit 63081 - 1800 Ave McGill College - 12th
Floor, Montral, Qubec, Canada
Beneficiary: I.R.O.G. Canada Inc. - 4900 Cte St-Luc,
# 212 - Montral, Qubec, Canada H3W 2H3 - Account
Number: 90001-0684716
Funds payable in USD from outside USA

Pay: The Bank of Nova Scotia - Toronto, Ontario - Swift
Code: NOSCCATT
Floor, Montral, Qubec
Number: 90001-0684716
Issues are to be mailed to:
I.R.O.G. CANADA, Inc. - 4900 Cte St-Luc - Apt # 212 - Montral, Qu. H3W 2H3 (Canada)
Tel. +514-4893242 - Fax +514-4854513 - E-mail: canlux@qc.aira.com - www.irog.net
38 Imp.Experimental+ced. 12:Imp.Experimental+ced. 10 15/11/11 15:21 Pagina 432
ISSN: 0390-6663

www.irog.net
Edited by:
A. ONNIS
I.R.O.G. CANADA, Inc. - 4900 Cte St-Luc - Apt # 212

ISSN: 0390-6663
Published three monthly
Founding Editor
A. Onnis
Montral (CND)
The Journal publishes original research and clinical contributions, preferably

briefly reported, in the fields of Gynaecology, Obstetrics, Foetal Medicine, Gynaecological Endocrinology, Fertility and Sterility, Menopause, Uro-gynaecology, Ultrasound, Sexually transmitted diseases and related subjects, from all over the world.
Founded in 1974 (ISSN 0390 6663) Issued quarterly in English, the Journal is
covered by INDEX MEDICUS, MEDLINE (PUBMED), EMBASE/Excerpta Medica,
INDEX COPERNICUS.
We hope to have you as a subscriber of our Journal which is improving its
scientific and clinical interdisciplinary activity and value and which is approaching its
XXXIII year of life.
You can subscribe or renew your subscription by sending us the following form.
Yes, start my subscription.
"
CLINICAL AND EXPERIMENTAL OBSTETRICS

AND GYNECOLOGY
Editors-in-Chief
M. Marchetti
J.H. Check
Montral (CND)
SUBSCRIPTION ORDER CARD 2012
Camden, NJ (USA)
Assistant Editor
J. Wilson
ISSN 0390-6663. Published threemonthly. All subscriptions are entered on a calendar-year

basis. Individual rate is not applicable if payment is made through an Institution.
Subscriptions ARE ENTERED WITH PREPAYMENT ONLY.
Please enter my subscription at the rate Ive checked:
Editorial Board
Audet-Lapointe P., Montral (Canada)
Axt-Fliedner R., Lbeck (Germany)
Basta A., Krakow (Poland)
Bender H.J., Dusseldorf (Germany)
Bhattacharya N., Calcutta (India)
Bonilla Musoles F., Valencia (Spain)
Charkviani T., Tbilisi (Georgia)
Dexeus S., Barcelona (Spain)
Di Paola G., Buenos Aires (Argentina)
Eskes T.K.A.B., Nijmegen (The Netherlands)
Farghaly S.A., New York (USA)
Friedrich M., Homburg (Germany)
Gomel V., Vancouver (Canada)
Gorins A., Paris (France)
Grella P.V., Padua (Italy)
Holub Z., Kladno (Czech Republic)
Jordan J.A., Birmingham, England (UK)
Kaplan B., Petach Tikva (Israel)
Kralj B., Ljubljana (Slovenia)
Markowska J., Poznan (Poland)
Marth C., Innsbruck (Austria)
Meden-Vrtovec H., Ljubljana (Slovenia)
Ohara N., Kobe (Japan)
Papadopoulos N., Alexandroupolis (Greece)
Rakar S., Ljubljana (Slovenia)
Sciarra J.J., Chicago, IL (USA)
Stelmachow J., Warsaw (Poland)
Varras M.N., Athens (Greece)
Winter R., Graz (Austria)
Institutional: 310 $US

Individual: 190 $US
Booksellers and subscription agencies 270 $US
Please send me a free sample copy
Iam paying by: (U.S. CURRENCY ONLY)
Credit Card:
Check (enclosed)
American Express
Mastercard
Visa
Exp. Date
Signature
Date
Diners
INSTRUCTIONS FOR BANK TRANSFERS TO CANADA

Funds payable in USD from USA
Pay: The Bank of Nova Scotia - 1 Liberty Plaza - New
York, N.Y. U.S.A. - Fed Wire Routing 026002532 (this
number is the ABA number) - Swift Code. NOSCUS33
Floor, Montral, Qubec, Canada
Number: 90001-0684716
Funds payable in USD from outside USA

Pay: The Bank of Nova Scotia - Toronto, Ontario - Swift
Code: NOSCCATT
Floor, Montral, Qubec
Number: 90001-0684716
Issues are to be mailed to:
I.R.O.G. CANADA, Inc. - 4900 Cte St-Luc - Apt # 212


A New Classification For Female Infertility

Enviado por

Dados do documento

Título original

Direitos autorais

Formatos disponíveis

Compartilhar este documento

Compartilhar ou incorporar documento

Opções de compartilhamento

Você considera este documento útil?

Este conteúdo é inapropriado?

Direitos autorais:

Formatos disponíveis

A New Classification For Female Infertility

Enviado por

Direitos autorais:

Formatos disponíveis

See

A new classification for female infertility

Babol University of Medical Sciences

Ministry of Health and Medical Education

All in-text references underlined in blue are linked to publications on ResearchGate,

Available from: Behnam Baghianimoghadam

01 Frontespizio n. 4-2011:01 Frontespizio n. 3/2009 15/11/11 14:05 Pagina 309

Vol. XXXVIII, no. 4, 2011

CLINICAL AND EXPERIMENTAL

Farghaly S.A., New York (USA)

Grella P.V., Padua (Italy)

Publishing Organization (M. Morsani):

02 Contents 4-2011:02 Contents 2/2009 15/11/11 14:07 Pagina 310

02 Contents 4-2011:02 Contents 2/2009 15/11/11 14:07 Pagina 311

Induction of plasminogen activators in pregnant women with Toxoplasma gondii infection

Plasminogen activators involved in toxoplasmosis of pregnant women.

Effects of inherited trombophilia in women with recurrent pregnancy loss

Infectious respiratory diseases in pregnancy - results of a 15-year study in Seoul

Evaluation of clinical and cytogenetic fndings on 1,068 second-trimester amniocenteses in Southeast

Distribution of etiological factors of hypergonadotropic amenorrhea

Validation of ultrasound scan in the diagnosis of female stress urinary incontinence

A new classification for female infertility

02 Contents 4-2011:02 Contents 2/2009 15/11/11 14:07 Pagina 312

Frequency of ovarian endometriosis in epithelial ovarian cancer patients

Evaluation of adolescent pregnancies: 10-year experience of a hospital in rural Turkey

Ultrasonography-guided amniocentesis in singleton pregnancies: a review of the first 1,000 cases

A case of Swyer syndrome is reported together with a review of the literature.

Vasa previa and postpartum hysterectomy in maternal Rh alloimunization

03 1187-30 - Editorial :1648_29 Incidence of multiple 15/11/11 14:08 Pagina 313

Choosing the right stimulation protocol for in vitro

Diminished oocyte reserve

Revised manuscript accepted for publication December 15, 2010

03 1187-30 - Editorial :1648_29 Incidence of multiple 15/11/11 14:08 Pagina 314

J.H. Check, B. Slovis

Table 1. Pregnancy rates according to day 3 serum FSH

There are several possible explanations for the relatively

03 1187-30 - Editorial :1648_29 Incidence of multiple 15/11/11 14:08 Pagina 315

tor is especially susceptible to down regulation [11]. The

03 1187-30 - Editorial :1648_29 Incidence of multiple 15/11/11 14:08 Pagina 316

J.H. Check, B. Slovis

03 1187-30 - Editorial :1648_29 Incidence of multiple 15/11/11 14:08 Pagina 317

Address reprint requests to:

04 1118-30 - Original articles:1648_29 Incidence of multiple 15/11/11 14:10 Pagina 318

Reproductive Biology Section

Evaluation of the importance of late follicular phase

04 1118-30 - Original articles:1648_29 Incidence of multiple 15/11/11 14:10 Pagina 319

Table 1. Potential confounding factors by pregnancy group*.

Table 2. Distribution of late follicular phase echo patterns

TL: triple-line; IE: isoechogenic; *p = .026.

Table 3. Distribution of late follicular phase echo patterns

TL: triple-line; IE: isoechogenic.

Table 4. Pregnancy rates by echo pattern in donors vs

TL: triple-line; IE: isoechogenic.

donors who had an IE echo pattern; however, statistically

Address reprint requests to:

05 1125-30 - blastomere number:1648_29 Incidence of multiple 15/11/11 14:12 Pagina 320

Blastomere number and pregnancy rates in the succeeding

Revised manuscript accepted for publication June 22, 2010

pregnancy rates were determined in cycle 1 when no embryos

05 1125-30 - blastomere number:1648_29 Incidence of multiple 15/11/11 14:12 Pagina 321

Table 1. Pregnancy outcome according to blastomere size

29.7 28.6 31.0 0.0 53.8

28.4 28.6 27.6 0.0 50.0