Publications by authors named "Engin Oral"

38 Publications

Different segmental resection techniques and postoperative complications in patients with colorectal endometriosis: A systematic review.

Acta Obstet Gynecol Scand 2022 07 6;101(7):705-718. Epub 2022 Jun 6.

European Endometriosis League, Bordeaux, France.

Introduction: The aim of this study was to analyze the available literature by conducting a systematic review to assess the possible effects of nerve-sparing segmental resection and conventional bowel resection on postoperative complications for the treatment of colorectal endometriosis.

Material And Methods: Pubmed, Clinical Trials.gov, Cochrane Library, and Web of Science were comprehensively searched from 1997 to 2021 in order to perform a systematic review. Studies including patients undergoing segmental resection for colorectal endometriosis including adequate follow-up, data on postoperative complications and postoperative sequelae were enrolled in this review. Selected articles were evaluated and divided in two groups: Nerve-sparing resection (NSR), and conventional segmental resection not otherwise specified (SRNOS). Within the NSRs, studies mentioning preservation of the rectal artery supply (artery and nerve-sparing SR - ANSR) and not reporting preservation of the artery supply (NSR not otherwise specified - NSRNOS) were further analyzed.

Prospero Id: CRD42021250974.

Results: A total of 7549 patients from 63 studies were included in the data analysis. Forty-three of these publications did not mention the preservation or the removal of the hypogastric nerve plexus, or main rectal artery supply and were summarized as SRNOS. The remaining 22 studies were listed under the NSR group. The mean size of the resected deep endometriosis lesions and patients' body mass index were comparable between SRNOS and NSR. A mean of 3.6% (0-16.6) and 2.3% (0-10.5%) of rectovaginal fistula development was reported in patients who underwent SRNOS and NSR, respectively. Anastomotic leakage rates varied from 0% to 8.6% (mean 1.7 ± 2%) in SRNOS compared with 0% to 8% (mean 1.7 ± 2%) in patients undergoing NSR. Urinary retention (4.5% and 4.9%) and long-term bladder catheterization (4.9% and 5.6%) were frequently reported in SRNOS and NSR. There was insufficient information about pain or the recurrence rates for women undergoing SRNOS and NSR.

Conclusions: Current data describe the outcomes of different segmental resection techniques. However, the data are inhomogeneous and not sufficient to reach a conclusion regarding a possible advantage of one technique over the other.
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http://dx.doi.org/10.1111/aogs.14379DOI Listing
July 2022

Comparison of Isolated Sciatic Nerve and Sacral Nerve Root Endometriosis: A Review of the Literature.

J Minim Invasive Gynecol 2022 Aug 29;29(8):943-951. Epub 2022 May 29.

Department of Obstetrics and Gynecology, Dr. Lütfi Kırdar City Hospital (Drs. Kale and Gündoğdu), Department of Biostatistics, Hamidiye Faculty of Medicine (Mr. Baydili); Department of Gynecologic Oncology, Zeynep Kamil Women and Children's Disease Training and Research Hospital (Dr. Keles), University of Health Sciences Turkey, Department of Obstetrics and Gynecology, Endometriosis and Pelvic Pain Center, Acibadem Altunizade Hospital, Acibadem Mehmet Ali Aydinlar University (Dr. Usta); Department of Obstetrics and Gynecology, Bezmialem Vakıf University (Dr. Oral), Istanbul, Turkey.

Objective: This review aimed to compare isolated sciatic and sacral nerve root endometriosis in terms of anatomic distribution, patients' symptoms and history, diagnostics, treatments, and outcomes.

Data Source: We searched PubMed, MEDLINE, Web of Science, and Embase from inception to October 2021 using a combination of keywords including "sciatic nerve endometriosis," "sacral nerve root endometriosis," and associated Medical Subject Headings. Relevant publications and references were also checked for further articles.

Methods Of Study Selection: Two independent researchers performed the study selection. We included all original research articles, case reports, and case series in English that reported on the isolated sciatic nerve and sacral nerve root endometriosis.

Tabulation, Integration, And Results: The initial search identified 92 articles, and 40 articles, mostly case reports and case series, were included. The review included 362 patients: with 256 and 106 patients in the sacral and the sciatic groups, respectively. In both groups, most patients had right-sided endometriosis. In the sciatic group, most of the patients presented with foot drop, leg motor weakness, and sciatic dermatome hypoesthesia. The frequencies of all these symptoms were significantly higher in the sciatic group (all p <.001). By contrast, in the sacral group, most of patients presented with pudendal neuralgia (p <.001). Intraoperative, early, late, and 1-year postoperative complications did not differ significantly between the 2 groups.

Conclusion: This study indicated that isolated sciatic and sacral nerve root endometrioses were more common on the right side. Laparoscopic surgery was more commonly performed over traditional open or transgluteal surgery techniques. Sacral nerve root endometriosis is often accompanied by deep infiltrating endometriosis. Magnetic resonance imaging and myelography may be useful diagnostic tools in the preoperative workup. There was usually no significant improvement after surgery in cases of isolated sciatic nerve endometriosis presenting with foot drop.
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http://dx.doi.org/10.1016/j.jmig.2022.05.017DOI Listing
August 2022

Dietary supplements for treatment of endometriosis: A review.

Acta Biomed 2022 03 14;93(1):e2022159. Epub 2022 Mar 14.

Turkish Endometriosis&Adenomyosis Society, Founding President, Istanbul, Turkey.

As search for optimal therapy continues for endometriosis, aid of dietary supplements is gaining attention. Supplements can be used for their anti-inflammatory, anti-oxidant, anti-proliferative and immune modulatory charactheristics. We reviewed the literature, evaluated and synthesized effects of vitamin D, zinc, magnesium, omega 3, propolis, quercetin, curcumin, N-acetylcysteine, probiotics, resveratrol, alpha lipoic acid, vitamin C, vitamin E, selenium and epigallocatechin-3-gallate. Based on results of in vitro, animal and human studies, it might be safe to say that dietary supplements can be used as a complementary treatment for endometriosis.
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http://dx.doi.org/10.23750/abm.v93i1.11237DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8972862PMC
March 2022

Protocol for the Cultural Translation and Adaptation of the World Endometriosis Research Foundation Endometriosis Phenome and Biobanking Harmonization Project Endometriosis Participant Questionnaire (EPHect).

Front Glob Womens Health 2021 26;2:644609. Epub 2021 Mar 26.

Cyprus Women's Health Research Society (CoHERS), Nicosia, Cyprus.

Endometriosis affects 10% of women worldwide and is one of the most common causes of chronic pelvic pain and infertility. However, causal mechanisms of this disease remain unknown due to its heterogeneous presentation. In order to successfully study its phenotypic variation, large sample sizes are needed. Pooling of data across sites is not always feasible given the large variation in the complexity and quality of the data collected. The World Endometriosis Research Foundation (WERF) Endometriosis Phenome and Biobanking Harmonization Project (EPHect) have developed an endometriosis participant questionnaire (EPQ) to harmonize non-surgical clinical participant characteristic data relevant to endometriosis research, allowing for large-scale collaborations in English-speaking populations. Although the WERF EPHect EPQs have been translated into different languages, no study has examined the cross-cultural translation and adaptation for content and face validity. In order to investigate this, we followed the standard guidelines for cross-cultural adaptation and translation of the minimum version of the EPQ (EPQ-M) using 40 patients who underwent laparoscopic surgery in Turkey and 40 women in Northern Cyprus, aged between 18 and 55. We assessed the consistency by using cognitive testing and found the EPHect EPQ-M to be comprehensive, informative, and feasible in these two Turkish-speaking populations. The translated and adapted questionnaire was found to be epidemiologically robust, taking around 30-60 min to complete; furthermore, participants reported a similar understanding of the questions, showing that common perspectives were explored. Results from the cognitive testing process led to minor additions to some items such as further descriptive and/or visuals in order to clarify medical terminology. This paper illustrates the first successful cross-cultural translation and adaptation of the EPHect EPQ-M and should act as a tool to allow for further studies that wish to use this questionnaire in different languages. Standardized tools like this should be adopted by researchers worldwide to facilitate collaboration and aid in the design and conduction of global studies to ultimately help those affected by endometriosis and its associated symptoms.
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http://dx.doi.org/10.3389/fgwh.2021.644609DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8593963PMC
March 2021

Thoracic Endometriosis: A Review Comparing 480 Patients Based on Catamenial and Noncatamenial Symptoms.

J Minim Invasive Gynecol 2022 01 8;29(1):41-55. Epub 2021 Aug 8.

Department of Obstetrics and Gynecology, Bezmialem Vakif University (Dr. Oral), Istanbul, Turkey.

Objective: This review aimed to categorize thoracic endometriosis syndrome (TES) according to whether the presenting symptoms were catamenial and to evaluate whether such a categorization enables a better management strategy.

Data Sources: An electronic search was conducted using the PubMed/Medline database.

Methods Of Study Selection: The following keywords were used in combination with the Boolean operators AND OR: "thoracic endometriosis syndrome," "thoracic endometriosis," "diaphragm endometriosis," and "catamenial pneumothorax."

Tabulation, Integration, And Results: The initial search yielded 445 articles. Articles in non-English languages, those whose full texts were unavailable, and those that did not present the symptomatology clearly were further excluded. After these exclusions, the review included 240 articles and 480 patients: 61 patients in the noncatamenial group and 419 patients in the catamenial group. The groups differed significantly in presenting symptoms, surgical treatment techniques, and observed localization of endometriotic loci (p <.05).

Conclusion: This review points out the significant differences between patients with TES with catamenial and noncatamenial symptoms. Such categorization and awareness by clinicians of these differences among patients with TES can be helpful in designing a management strategy. When constructing management guidelines, these differences between patients with catamenial and noncatamenial symptoms should be taken into consideration.
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http://dx.doi.org/10.1016/j.jmig.2021.08.005DOI Listing
January 2022

Fertility issue in early stage endometrial cancer patients.

Transl Cancer Res 2020 Dec;9(12):7797-7808

Private Clinic, Obstetrics and Gynecology, Istanbul, Turkey.

Endometrial cancer (EC) is the most common cancer of the female reproductive system in developed countries. The incidence of EC has been increasing in young women. Approximately 4% of cases are aged <40 years. These young women may wish to delay therapy until after they have children. Common complaints in patients with EC include irregular vaginal bleeding, pelvic pain, and enlarged uterus. Imaging techniques such as transvaginal ultrasound (TVUS) or magnetic resonance imaging (MRI) can be utilized in detecting EC. Although the recommended treatment of EC is hysterectomy and bilateral salpingo-oophorectomy with or without systemic lymph node dissection, loss of reproductive function is the primary limiting factor of this surgical approach. Some studies have reported favorable results with high-dose oral progestins or levonorgestrel-releasing intrauterine system or hysteroscopic tumor resection followed by treatment with high-dose oral progestins. The most widely utilized medical treatment regimens are medroxyprogesterone acetate (MPA) 250-600 mg/day or megestrol acetate (MA) 160-480 mg/day. However, there is still a lack of evidence to establish the optimal dose and duration of progestin treatment. Patients with complete remission (CR) who wish to conceive must be encouraged, and referral to a fertility clinic should be offered as soon as possible. The key aspect of fertility-sparing management in women with EC appears to be the selection of appropriate candidates. Owing to the rarity of this condition, management may often be suboptimal. The aim of this review is to assess the current approaches to management of young women with EC who wish to preserve their fertility.
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http://dx.doi.org/10.21037/tcr-20-2232DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8797551PMC
December 2020

The COVID-19 pandemic and patients with endometriosis: A survey-based study conducted in Turkey.

Int J Gynaecol Obstet 2020 Nov 1;151(2):249-252. Epub 2020 Sep 1.

Endometriosis & Adenomyosis Society, İstanbul, Turkey.

Objective: To apply rapid online surveying to determine the knowledge and perceptions of the COVID-19 pandemic on patients with endometriosis in Turkey.

Methods: An online survey was conducted by the Turkish Endometriosis & Adenomyosis Society and administered to patients with endometriosis who agreed to participate in the study. The survey included 25 questions prepared by an expert committee of four professionals (two gynecologists and two endometriosis specialists).

Results: Of the 290 questionnaires sent out, 261 (90%) were returned. A total of 213 (83.86%) patients reported that they were afraid of having endometriosis-related problems during the pandemic period. In addition, 133 (53.63%) patients thought the management of their endometriosis was affected because of the pandemic.

Conclusion: Clinical studies clearly indicate that endometriosis is a condition associated with high levels of chronic stress. The COVID-19 pandemic has led the public to experience psychological problems such as post-traumatic stress disorder, psychological distress, depression, and anxiety. The majority of patients with endometriosis were afraid of having endometriosis-related problems during the pandemic period. The majority of elective endometriosis surgeries have not been postponed. Patients were highly aware of the pandemic and practiced social distancing and hygiene. Only 4 (1.59%) patients with endometriosis required hospitalization.
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http://dx.doi.org/10.1002/ijgo.13339DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9087654PMC
November 2020

Relation between educational reliability and viewer interest in YouTube® videos depicting endometrioma cystectomy surgical techniques.

J Gynecol Obstet Hum Reprod 2021 Mar 16;50(3):101808. Epub 2020 May 16.

Private Obstetrics and Gynecology Clinic, Istanbul, Turkey.

Objective: To assess the reliability of YouTube® endometrioma cystectomy videos based on technical video analysis and considering the surgical steps.

Material And Method: The present study yielded 756 videos after a search on YouTube® with the keywords "endometriosis cystectomy, endometrioma cystectomy, chocolate cyst cystectomy, and endometrioma surgery'' during the period from January 7, 2007 to January 7, 2019. The viewer interest parameters such as total number of subscribers, views, likes, dislikes, comments, source of the videos, and the date of upload were assessed. Besides, the surgical steps were also evaluated considering committee suggestions.

Results: There were 140 (78.7 %) videos in Group 1 (not useful and slightly useful) and 38 (21.3 %) videos in Group 2 (useful and very useful). The mean numbers of subscribers, views, and likes were 5737.843 ± 15741.302, 10614.257 ± 32702.339, and 17.7 ± 43.57, respectively, in Group 1, and 851.052 ± 1613.599, 8192.55 ± 15989.955, and 11.92 ± 27.52, respectively, in Group 2. The type of surgery was significantly different between the study groups. The videos of cases with robotic surgeries presented more useful descriptive information (p =  0.003). There was a significant difference between the study groups regarding the type of hemostasis. The presence of didactic steps was higher in Group 2 (47.4 %) compared to Group 1 (28.6 %) (p =  0.02) CONCLUSIONS: Overall, only around 21 % of YouTube videos presenting endometrioma surgery were defined as useful or very useful. The interest rates of the viewers may not compatible with the usefulness rate of the videos.
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http://dx.doi.org/10.1016/j.jogoh.2020.101808DOI Listing
March 2021

The prevalence of endometrioma and associated malignant transformation in women over 40 years of age.

J Gynecol Obstet Hum Reprod 2020 May 12;49(5):101725. Epub 2020 Mar 12.

Saglik Bilimleri University Istanbul Kanuni Sultan Suleyman Training and Research Hospital, Department of Obstetrics and Gynecology, Istanbul, Turkey. Electronic address:

Objective: Endometriosis is an estrogen-dependent chronic disease, which is regarded as a disease of reproductive-aged women. Endometriosis is most frequently diagnosed during reproductive period. We aimed to determine the frequency of endometrioma in women over 40 years of age who were operated for adnexial mass.

Materials And Methods: A total of 1100 women over 40 years of age underwent surgery for adnexal mass were included in this cohort study between 2006 and 2016. Women who met the criteria were compared regarding the type of adnexial mass, age groups, menopausal status and malignant transformation.

Results: A total of 299 women (27.2 %) with benign ovarian mass were determined to have endometrioma. Women with endometrioma were younger and nulliparous more frequently comparing women without endometrioma. Although 20 % of the patients in the endometrioma group were postmenopausal, 70 % of the patients in the control group were postmenopausal. Endometrioma-associated ovarian tumors were developed in nearly 11 % of women with endometrioma.

Conclusions: Even though endometriosis is accepted as a disease of reproductive-aged women, it can occur over 40 years of age. Detailed anamnesis and careful gynecological examination provide key information for differential diagnosis. Accurate information about the risk of malignant transformation should be informed.
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http://dx.doi.org/10.1016/j.jogoh.2020.101725DOI Listing
May 2020

Raman spectroscopy as a non-invasive diagnostic technique for endometriosis.

Sci Rep 2019 12 24;9(1):19795. Epub 2019 Dec 24.

Istanbul Technical University, Physics Engineering Department, Istanbul, 34469, Turkey.

Endometriosis is a condition in which the endometrium, the layer of tissue that usually covers the inside of the uterus, grows outside the uterus. One of its severe effects is sub-fertility. The exact reason for endometriosis is still unknown and under investigation. Tracking the symptoms is not sufficient for diagnosing the disease. A successful diagnosis can only be made using laparoscopy. During the disease, the amount of some molecules (i.e., proteins, antigens) changes in the blood. Raman spectroscopy provides information about biochemicals without using dyes or external labels. In this study, Raman spectroscopy is used as a non-invasive diagnostic method for endometriosis. The Raman spectra of 94 serum samples acquired from 49 patients and 45 healthy individuals were compared for this study. Principal Component Analysis (PCA), k- Nearest Neighbors (kNN), and Support Vector Machines (SVM) were used in the analysis. According to the results (using 80 measurements for training and 14 measurements for the test set), it was found that kNN-weighted gave the best classification model with sensitivity and specificity values of 80.5% and 89.7%, respectively. Testing the model with unseen data yielded a sensitivity value of 100% and a specificity value of 100%. To the best of our knowledge, this is the first study in which Raman spectroscopy was used in combination with PCA and classification algorithms as a non-invasive method applied on blood sera for the diagnosis of endometriosis.
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http://dx.doi.org/10.1038/s41598-019-56308-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6930314PMC
December 2019

How can we manage patients over forty with endometriosis?

Minerva Med 2020 Feb 11;111(1):62-67. Epub 2019 Dec 11.

Private practitioner, Izmir, Turkey.

Peri/postmenopausal endometriosis is not as rare as once we thought. Accumulated data revealed that around 1/3-1/4 of women with surgically-diagnosed endometriosis after the age of 40. The uneasiness of the issue of malignant transformation or malignancy in such women created a challenge for us. Here the management strategy for women with endometriosis after the age of 40 is discussed in the light of scientific evidence.
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http://dx.doi.org/10.23736/S0026-4806.19.06377-8DOI Listing
February 2020

Endometriomas with low-risk malignancy potential in ultrasonography with high human epididymis protein 4 and risk of ovarian malignancy algorithm: a cases series.

Gynecol Endocrinol 2020 Feb 20;36(2):117-121. Epub 2019 Aug 20.

Department of Obstetrics and Gynecology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey.

Endometriosis is an estrogen-dependent disease that affects 5 to 15% of women of reproductive age. Data from large-cohort and case-control studies indicate an increased risk for ovarian cancers in women with endometrioma. Recently, as an ovarian cancer biomarker, human epididymal secretory protein E4 (HE4) has been increasingly investigated in the differentiating of endometrioma from ovary malignancy and in confirming the benign structure of the endometrioma. This case series study describes women who underwent surgery due to increased serum HE4 levels and higher Risk of Ovarian Malignancy Algorithm (ROMA) index, in whom the final pathology was reported as benign, although, ultrasonography and magnetic resonance imaging (MRI) findings showed features of "typical" endometrioma.
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http://dx.doi.org/10.1080/09513590.2019.1653842DOI Listing
February 2020

Clinical and Genetic Investigation of Premature Ovarian Insufficiency Cases from Turkey.

J Gynecol Obstet Hum Reprod 2019 Dec 23;48(10):817-823. Epub 2019 Apr 23.

Istanbul University, Istanbul Medical Faculty, Department of Medical Genetics, Turkey. Electronic address:

Objective: Premature ovarian insufficiency is a lack of ovarian functions in patients younger than 40 years old. Genetic causes leading to accelerated follicle depletion may result in premature ovarian insufficiency. We aimed to determine genetic etiology of nonsyndromic premature ovarian insufficiency cases from Turkey.

Materials And Methods: We analyzed 86 nonsyndromic premature ovarian insufficiency cases and 26 matched control female participants. Participants have been investigated in cytogenetic analysis followed by FMR1 repeat size expansions and search of variants for nine premature ovarian insufficiency-associated genes.

Results: Four cases had a structural cytogenetic abnormality. Two cases revealed with premutation size FMR1 triplet repeat expansion. Four cases carried variants in which two were very rare in FSHR and PDPK1, and three were novel in NR5A1, PDPK1, and POF1B genes. Six novel variants have been identified in NOBOX, NR5A1, POF1B, and PDPK1 in control population assigned to be benign alterations.

Conclusion: Mosaicism of sex chromosomes was responsible in 4.6% and FMR1 premutation in 2.4% of premature ovarian insufficiency cases, while the association of premature ovarian insufficiency-related genes was found very subtle. Novel variants in NR5A1, PDPK1, and POF1B may necessitate further evaluation for their association with premature ovarian insufficiency via functional studies.
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http://dx.doi.org/10.1016/j.jogoh.2019.04.007DOI Listing
December 2019

The Role of Serum Caspase 3 Levels in Prediction of Endometriosis Severity.

Gynecol Obstet Invest 2018 2;83(6):576-585. Epub 2018 Aug 2.

Department of Obstetrics and Gynecology, University of Health Sciences, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey.

Background/aims: To identify the role of serum caspase 3, Annexin A2 (ANXA2), and Soluble Fas Ligand (sFasL) levels in the prediction of endometriosis severity.

Methods: The study was performed on 90 women who were candidates for laparoscopic surgery due to endometrioma or any other benign ovarian cysts detected by ultrasound examination, pelvic pain, or infertility. The control group comprised 29  patients. The second group comprised 29 patients with stage I-II endometriosis and the third group comprised 30 patients with stage III-IV endometriosis.

Results: Significant differences were detected between the control and stage III-IV endometriosis groups and between stage I-II and stage III-IV endometriosis groups in terms of caspase-3 levels (both, p < 0.001), ANXA2 levels (p = 0.007 and p = 0.002), and sFasL levels (p = 0.022 and p = 0.044). After receiver operating characteristic analysis, the area under curve was 93% (95% CI 57-82) at 10.7 ng/mL cut-off level for caspase-3 with 90% sensitivity and 87% specificity.

Conclusion: Serum caspase-3 level may be a reliable predictor of endometriosis severity.
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http://dx.doi.org/10.1159/000489494DOI Listing
January 2019

Concomitant endometriosis in malignant and borderline ovarian tumours.

J Obstet Gynaecol 2018 Nov 8;38(8):1104-1109. Epub 2018 Jun 8.

a Department of Obstetrics and Gynecology, Cerrahpasa Medical School , İstanbul University , İstanbul , Turkey.

The aim of the study was to reveal the prevalence of concomitant endometriosis in malignant and borderline ovarian tumours. A retrospective analysis was performed of 530 patients with malignant ovarian tumours and 131 with borderline ovarian tumours, who underwent surgery in our hospital between 1995 and 2011. Forty-eight (7.3%) of 661 patients with malignant and borderline ovarian tumours were associated with endometriosis. Of the 48 endometriosis cases, 73% of those were atypical. Infertility was noted in 38% of patients with endometriosis-associated ovarian tumours. The most frequently endometriosis-associated subtypes were endometrioid (33%) and clear cell (18%) histologies. Of endometriosis-associated endometrioid and clear cell ovarian tumours, 70% were early stage and 60% were premenopausal. The prevalence of concomitant endometriosis in borderline tumours (12%) was found to be significantly higher than that found in the malignant ones (6%; p = .02). Of 32 endometriosis-associated malignant ovarian tumours, 69% were FIGO stages I and II. In conclusion, ovarian endometriosis is seen with both malignant and borderline ovarian tumours, the association being significant with borderline tumours. Fortunately, the endometriosis-associated malignant ovarian tumours are mostly early stage. Impact statement What is already known on this subject? Epidemiologic data suggest that endometriosis has malignant potential. However, a subgroup of women with endometriosis at a high risk for ovarian cancer is yet to be clarified. Currently, endometriosis and ovarian cancer association does not seem to have a clinical implication. What do the results of this study add? The findings of this study revealed that nearly 75% of endometriosis-associated ovarian tumours were of atypical endometriosis. Half of endometriosis-associated ovarian tumour cases were of endometrioid/clear cell histology and 70% were early-stage. Endometriosis was significantly associated with borderline ovarian tumours and the endometriosis-associated malignant ovarian tumours were mostly early stage. What are the implications of these findings for clinical practice and/or further research? Additional studies need to be conducted to develop screening approaches for malignant transformation or an association in women with endometriosis. Till that time, a change of current clinical practices cannot be justified. However, counselling and treating women with endometriosis who are at high risk for cancer coexistence or conversion is encouraged.
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http://dx.doi.org/10.1080/01443615.2018.1441815DOI Listing
November 2018

Letter from original author re. Does telomerase activity have an effect on infertility in patients with endometriosis? Methodological issues.

Eur J Obstet Gynecol Reprod Biol 2017 09 12;216:259-260. Epub 2017 Jul 12.

Department of Obstetrics and Gynecology, Istanbul University, Cerrahpasa Medical Faculty, Istanbul, 34098, Turkey.

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http://dx.doi.org/10.1016/j.ejogrb.2017.07.009DOI Listing
September 2017

Does telomerase activity have an effect on infertility in patients with endometriosis?

Eur J Obstet Gynecol Reprod Biol 2017 Jun 18;213:116-122. Epub 2017 Apr 18.

Department of Obstetrics and Gynecology, Istanbul University, Cerrahpasa Medical Faculty, Istanbul, Turkey.

Objective: This study aimed to investigate the role of telomerase activity in the development of endometriosis-related infertility by evaluation of the serum telomerase in eutopic and ectopic endometrial tissue.

Study Design: Eutopic endometrium, cystic wall/ovarian cortex, and venous blood were assessed in forty-seven patients. The following groups of patients were identified: females with endometriosis requiring surgical intervention and healthy control females. Patients with histopathologically confirmed endometriosis were further subdivided in the infertile (n=14) and fertile (n=17) groups. Patients who underwent hysterectomy and oophorectomy for benign gynecological conditions were enrolled in the healthy control group (n=16). Telomerase activity was evaluated with three-group, endometriosis-based and fertility-based designs. Analyses were performed regardless the menstrual cycle phase (Phase G), in proliferative (Phase P) (n=22) and secretory phases (Phase S) (n=25). Telomeric Repeat Amplification Protocol PCR was applied for telomerase activity assessment. All statistical analyses were performed with STATA 14.2, GraphPad Prisma 7.01.

Results: In analyses of the eutopic endometrium, with three-group design, a significant difference was not found in Phase G and P (p=0.58 and p=0.33, respectively). However, a statistical difference was shown in Phase S (p=0.008). A significant difference was not established in Phase G, P and S of endometriosis-based design (p=0.35, p=1.0, p=0.13, respectively). No difference was detected in Phase G and P of fertility-based design (p=0.66 and p=0.14, respectively), whereas in secretory phase difference was approved (p=0,049). Telomerase activity was not established in ectopic endometrium and in serum assessment.

Conclusions: Telomerase activity is useless as a biomarker in peripheric blood analysis. The absence of activity in cystic wall approves the high differentiation of endometriosis tissue, what is the possible reason of low malignancy risk. The high rate of telomerase activity in the eutopic endometrium of the infertile group may be considered as a cause of endometriosis-related infertility.
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http://dx.doi.org/10.1016/j.ejogrb.2017.04.027DOI Listing
June 2017

Iodine status of pregnant women in a metropolitan city which proved to be an iodine-sufficient area. Is mandatory salt iodisation enough for pregnant women?

Gynecol Endocrinol 2016 22;32(3):188-92. Epub 2015 Oct 22.

c Department of Endocrinology and Metabolism , Ankara University School of Medicine , Ankara , Turkey .

The objective of this study was to assess the iodine status of pregnant women in a metropolitan city which was stated as iodine sufficient area after salt iodination program. This multicenter, cross-sectional study was carried out on 3543 pregnant women. Age, gestational weeks, smoking, consumption of iodized salt, dietary salt restriction, history of stillbirth, abortus and congenital malformations were questioned. Spot urine samples were analyzed for urine iodine concentration (UIC). The outcomes were: (a) median UIC in three trimesters of pregnancy and (b) frequency of ID among pregnant women. The median UIC was 73 µg/L. The median UIC was 77 µg/L (1-324), 73 µg/L (1-600) and 70 µg/L (1-1650) in three trimesters of pregnancy, respectively (p: 0.14). UIC <50 µg/L was observed in 36.6% (n: 1295) and UIC<150 µg/L was observed in 90.7% (n: 3214) of pregnant women. Only 1% (n: 34) of the pregnant women had UIC levels higher than 500 µg/L. This study showed that more than 90% of the pregnant women in this iodine-sufficient city are facing some degree of iodine deficiency during their pregnancy. A salt iodization program might be satisfactory for the non-pregnant population, but it seems to be insufficient for the pregnant population.
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http://dx.doi.org/10.3109/09513590.2015.1101443DOI Listing
December 2016

Progestin therapy in endometriosis.

Womens Health (Lond) 2015 Aug 21;11(5):643-52. Epub 2015 Sep 21.

Reproductive Endocrinology & Infertility Division, Cerrahpaşa School of Medicine, Obstetrics & Gynecology Department, İstanbul University, Cerrahpaşa PTT PK:31 34301 Fatih/İstanbul, Turkey.

Progestins are synthetic compounds that mimic the effects of progesteron. For over 50 years, oral progestins have been demonstrated to be effective in the treatment of endometriosis. They were reported to reduce or eliminate pain symptoms in approximately 90% of the patients. Progestins are available in many forms, including oral preparations, injections, subdermal implants and intrauterine systems. Continuous progestin use is an effective therapy for the treatment of painful symptoms associated with endometriosis but there had been no evidence of progestin use being superior to other types of treatment in endometriosis-related pain symptoms.
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http://dx.doi.org/10.2217/whe.15.42DOI Listing
August 2015

Endometriosis and ovarian reserve.

Womens Health (Lond) 2015 Aug 7;11(5):671-5. Epub 2015 Sep 7.

Endometriosis is characterized by development of the endometrial tissue outside the uterus like ovary, pelvic peritoneum, pelvic organs, and affects 6-10% of reproductive-aged women. The prevalence of endometrioma is 17-44% of women with endometriosis. Since endometriosis is mainly a disease for the women at their reproductive ages, it is important to consider ovarian reserve when managing the cases with ovarian endometriosis. There has been a long debate whether the endometrioma per se decreases the ovarian reserve and/or surgery for endometrioma - either by laparoscopy or by laparotomy - decreases it. Although the dispute for these questions is not totally settled down, in this article, we would like to give some clues for the answers in view of the literature.
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http://dx.doi.org/10.2217/whe.15.53DOI Listing
August 2015

Foreword.

Womens Health (Lond) 2015 Aug 7;11(5):575. Epub 2015 Sep 7.

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http://dx.doi.org/10.2217/whe.15.61DOI Listing
August 2015

Surgical treatment before assisted reproductive technologies.

Semin Reprod Med 2014 Jul 11;32(4):253-61. Epub 2014 Jun 11.

Department of Obstetrics and Gynecology, Cerrahpaşa Medical Faculty, Istanbul University School of Medicine, Istanbul, Turkey.

Advances in technology have transformed surgery from a major approach into an art of science capable of treating many diseases and conditions in a less risky way. This advance let physicians perform surgery commonly in their practice. Today, surgery in reproductive medicine has become so customary that evidence has not been questioned commonly. Therefore, this review will help reproductive endocrinologists to read the most recent evidence for surgery to improve in vitro fertilization outcome. This will also help them to inform their patients with the most recent evidence.
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http://dx.doi.org/10.1055/s-0034-1375177DOI Listing
July 2014

Time-lapse embryo imaging technology: does it improve the clinical results?

Curr Opin Obstet Gynecol 2014 Jun;26(3):138-44

aBahceci Fulya IVF Centre bDivision of Reproductive Endocrinology, Department of Obstetrics and Gyneocology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey.

Purpose Of Review: The purpose of the review is to summarize recent developments in time-lapse technologies and early embryo morphokinetics and to discuss their impact on current clinical outcomes.

Recent Findings: Contemporary embryo culture and selection methodologies that are based on classical morphology are clearly limited in providing the most suitable embryo for a successful pregnancy. Noninvasive observation of embryo development by capturing the images with a time-lapse device has recently been proposed to be a better method of embryo viability assessment. Such methodologies have been shown to increase the quality and the quantity of information on the viability without disturbing the culture conditions.

Summary: Commercial availability of different time-lapse devices for human embryos facilitated the use of morphokinetics as an additional tool in human embryo selection. The application of such technologies has already shown positive results on clinical outcome by increasing our scope of traditional embryo selection, leading to higher implantation and clinical pregnancy rates. Additional benefit can come from the less-disturbed incubation environment that is created by all-in-one incubators. Such devices can also be very important research tools in order to observe and analyze the effect of different patient-specific or clinical conditions on embryo development parameters that are not available through classical embryo scoring.
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http://dx.doi.org/10.1097/GCO.0000000000000072DOI Listing
June 2014

Serum YKL-40 levels are altered in endometriosis.

Gynecol Endocrinol 2014 May 17;30(5):381-4. Epub 2014 Feb 17.

Department of Obstetrics & Gynecology .

Endometriosis is traditionally defined as the presence of endometrial glands and stroma in ectopic locations, especially the pelvic peritoneum, ovaries and rectovaginal septum. YKL-40, a new biomarker of inflammation, is secreted by activated macrophages and neutrophils in different tissues with inflammation. Serum concentrations of YKL-40 are elevated in patients with diseases characterized by inflammation. We aimed to investigate the possible association between serum YKL-40 levels and endometriosis. A total number of 88 women were recruited for this case-control study. About 53 patients with surgically proven endometriosis were included, while 35 patients without endometriosis comprised the control group. Patients were classified as having minimal, mild, moderate and severe disease in accordance with the severity. Two new groups were formed by combining patients with minimal and mild disease (Stage 1-2) and with moderate and severe disease (Stage 3-4). Serum YKL-40 levels were statistically higher in the endometriotic group compared to control group (p:0.001). YKL-40 levels were significantly higher in Stage 3-4 group compared to Stage 1-2 group (p values 0.001) as well. Correlation analysis revealed a positive correlation between serum YKL-40 levels and the stage of the disease. YKL-40 may be utilized as a marker for determining the severity of endometriosis.
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http://dx.doi.org/10.3109/09513590.2014.887671DOI Listing
May 2014

Anti-Müllerian hormone and polycystic ovary syndrome: assessment of the clinical pregnancy rates in in vitro fertilization patients.

Gynecol Endocrinol 2013 May 6;29(5):440-3. Epub 2013 Mar 6.

Cerrahpasa School of Medicine, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and IVF unit, Istanbul University, Istanbul, Turkey.

Objective: The purpose of this study is to investigate the role of serum anti-Müllerian hormone (AMH), follicle-stimulating hormone (FSH) and antral follicle count (AFC) for the prediction of clinical pregnancy rates (CPR) in women with polycystic ovary syndrome (PCOS) undergoing IVF treatment.

Design: Prospective cohort study.

Setting: University hospital.

Patients: One hundred and fifty consecutive women with PCOS.

Interventions: All women underwent controlled ovarian stimulation with long agonist protocol followed by IVF procedure. Outcomes of pregnant and non-pregnant groups were compared.

Main Outcome Measure: CPR; AMH, FSH and AFC means and percentiles.

Results: Fifty-one (34%) clinical pregnancies were observed in 150 women. Mean AMH was 6.7 ± 2.8 and 7.1 ± 4.3 ng/mL in pregnant and non-pregnant women, respectively (p = 0.594). The CPR were 27.8%, 35.0% and 37.8% in <25%, 25%-75% and >75% AMH percentiles, respectively (p = 0.656). There were also no significant difference in mean FSH and AFC between pregnant and non-pregnant women (p = 0.484 and p = 0.165, respectively).

Conclusion: AMH, FSH and AFC are not predictive for CPR in women with PCOS undergoing IVF treatment. Mean AMH values were not significantly different between pregnant and non-pregnant women. Although CRP increased in parallel with the raise in AMH percentiles, this remained insignificant.
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http://dx.doi.org/10.3109/09513590.2013.769519DOI Listing
May 2013

Evaluation of subgroups of the human sperm hypoosmotic swelling test in normozoospermic male cases with recurrent fertilization failure: a prospective case-controlled study.

Arch Gynecol Obstet 2013 Apr 18;287(4):797-801. Epub 2012 Nov 18.

Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, IVF-ET Unit, Cerrahpaşa School of Medicine, Istanbul University, Istanbul, Turkey.

Purpose: To compare subgroups of the human sperm hypoosmotic swelling test subgroups in both recurrent fertilization negative infertile cases with normal semen analysis and fertilization positive controls.

Methods: This was a prospective case-controlled study performed with normospermic 33 previously fertile male (secondary infertility) and 41 infertile men who had undergone two or three unsuccessful in vitro fertilization attempts. HOS test was investigated in 4 subgroups including HOS 1, HOS 2, HOS 3, and HOS 4 according to the degree of sperm tail swelling and compared between the two groups.

Results: Four subgroups were compared and statistical significance was demonstrated in HOS 1, HOS 3 and HOS 4 tests (p < 0.001) in fertile and infertile men. Highest HOS 1 and lowest HOS 4 grades were determined in Group A. However, no statistical significance was determined between two groups in HOS 2 test which was minimal swelling in sperm tails.

Conclusions: HOS 1, HOS 3 and HOS 4 subgroups of HOS test are reliable and useful methods providing important information regarding the sperm function. A high HOS test 1 grade plus a low HOS test 4 grade should suggest a fertility problem, despite a normal semen analysis. HOS test subgroups provide additional information in normospermic cases with unexplained infertility.
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http://dx.doi.org/10.1007/s00404-012-2634-6DOI Listing
April 2013

Female obesity and assisted reproductive technologies.

Semin Reprod Med 2012 Dec 16;30(6):507-16. Epub 2012 Oct 16.

IVF Unit, Department of Obstetrics and Gynecology, Fırat University Medical School, Elazig, Turkey.

Obesity has grown to epidemic proportions, and currently nearly half of the reproductive-age women are overweight or obese. Risks, success rates, and economic aspects of infertility treatments in obese women have been extensively investigated. Unfavorable ovarian stimulation characteristics like increased gonadotropin consumption, fewer selected follicles, and lower number of retrieved oocytes have been observed in obese women undergoing assisted reproductive technologies (ART). There seems to be a strong association between increased body mass index and lower pregnancy and live-birth rates and increased miscarriage rate. Coexisting factors like age and polycystic ovary syndrome status have also been blamed for these adverse effects. The mechanisms underlying those adverse outcomes, whether ovarian or endometrial, still remain to be fully elucidated. Moreover, maternal, perinatal, and neonatal complications have also been reported to be higher in obese pregnant women. Hence in some countries strict restrictions exist for access to elective fertility treatment in obese women. However, it is controversial if these policies are socially and ethically acceptable. Furthermore, because weight reduction is not an easy task, it may lead to the decreased probability of conception due to the advancing reproductive age for many obese women. Thus weight reduction should be encouraged and patients counseled accordingly, but whether restriction for fertility treatment is implemented in obese women remains a matter of debate. There remains much to be known regarding the association between obesity and ART.
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http://dx.doi.org/10.1055/s-0032-1328879DOI Listing
December 2012

Serum anti-müllerian hormone, follicle stimulating hormone and antral follicle count measurement cannot predict pregnancy rates in IVF/ICSI cycles.

J Assist Reprod Genet 2012 Jul 11;29(7):589-95. Epub 2012 Apr 11.

Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, Istanbul University, Cerrahpasa School of Medicine, Istanbul, Turkey.

Purpose: To investigate whether serum anti-müllerian hormone (AMH), follicle stimulating hormone (FSH), or antral follicle count (AFC) are predictive for clinical pregnancy in in vitro fertilization (IVF) patients.

Methods: Serum AMH, inhibin B, FSH, luteinizing hormone (LH), estradiol (E2), prolactin, and thyroid stimulating hormone (TSH) levels and AFC of 189 women under 40 years of age were investigated. Pregnant and non-pregnant women were compared.

Results: Forty-seven (24.8 %) clinical pregnancies were observed in 189 women. There was no significant difference in terms of mean age, duration of infertility, body mass index, AMH, LH, FSH, E2, TSH, Inhibin B, AFC and total oocyte number between women who did and who did not become pregnant. Additionally, there was no significant difference in clinical pregnancy rates between the quartiles of AMH, FSH and AFC. (P values were 0.668, 0.071, and 0.252, respectively.)

Conclusion: Serum AMH and FSH, and AFC cannot predict clinical pregnancy in IVF patients under 40; the pregnancy rate tends to increase as AMH increases, although this remains non-significant.
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http://dx.doi.org/10.1007/s10815-012-9754-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3401265PMC
July 2012

Is the measurement of anti-Müllerian hormone essential?

Curr Opin Obstet Gynecol 2012 Jun;24(3):151-7

Department of Obstetrics & Gynecology, Bagcilar Education and Research Hospital, Istanbul, Turkey.

Purpose Of Review: Over the past decade, a large number of studies examining the multiple roles of anti-Müllerian hormone (AMH) have been published. The purpose of this article is to focus on the clinical usefulness of AMH in the fields of current gynecological clinical practice.

Recent Findings: AMH has entered clinical practice in terms of poor ovarian response definition. It prevents folliculogenesis by reducing follicle sensitivity to follicle-stimulating hormone (FSH), and leads to anovulation when secreted in excess amounts in polycystic ovary syndrome (PCOS). Better results might be obtained in the assisted reproductive technique cycle in the presence of high AMH levels even though FSH is increased in women diagnosed with diminished ovarian reserve. In a more recently published study it has been reported that AMH can also predict the outcome of pregnancy in assisted reproduction.

Summary: AMH levels accurately reflect the ovarian follicular reserve and might, therefore, be considered as a sensitive marker of ovarian aging and ovarian reserve. Evaluation of the level of AMH has clinical value in predicting the success of in-vitro fertilization (IVF). Hyper-response/ovarian hyperstimulation syndrome (OHSS) might be anticipated as about 3.5 ng/ml or above. The cycle stability and operator independency make AMH a most appealing single marker of ovarian reserve. Use of AMH to paint tailored stimulation protocol could result in a reduced risk of OHSS, optimized treatment burden and maintained pregnancy rates. Cost-effectiveness of the use of AMH as a single test before initiating an IVF program should be determined.
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http://dx.doi.org/10.1097/GCO.0b013e3283527dcfDOI Listing
June 2012

Has fertility declined in recent decades?

Curr Opin Obstet Gynecol 2012 Jun;24(3):119-26

Division of Reproductive Endocrinology and Infertility, Department of Obstetrics & Gynecology, Marmara University School of Medicine, Istanbul, Turkey.

Purpose Of Review: Over the last decade, a number of studies have been published on whether fertility has declined. The purpose of this article is to review the trends in fertility rates and assess how biological, behavioural, social and environmental factors affect fertility rates.

Recent Findings: The average total fertility rate (TFR) in Europe is down to 1.5 children per woman, and the perceived ideal family size is also declining. Factors impacting on lower fertility include the instability of modern partnerships and value changes. Fertility depends on natural fecundity but also on a number of behavioural determinants, such as culture, society, economic conditions, living standards and other similar background determinants on individual reproductive behaviour.

Summary: Increasing use of infertility treatment and a decline in demographic fertility in some countries have raised concern whether human fecundity is declining or has declined over time. The downward trend in fecundity articulated on numerous occasions over the last decade, seems unsubstantiated as the forecasting agencies such as the United Nations and Eurostat are likely to be right in their medium variant assumption that TFR levels in most countries will rise to 1.5 or above in the decades ahead.
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http://dx.doi.org/10.1097/GCO.0b013e32835213f1DOI Listing
June 2012
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