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Objectives: To compare success rates and complications in women undergoing laparoscopic versus open surgical management of tubo-ovarian abscess. We further examined whether early laparoscopic intervention has any impact on pregnancy rates in a subgroup of infertile patients following frozen-thawed embryo transfer. Material and methods: Hospital records of 48 patients diagnosed with TOA between January 2015 and December 2020, who underwent surgical intervention or received only medical treatment were analyzed. All patients were hospitalized, and parenteral antibiotics were commenced on admission initially. Laparoscopic or open surgery was performed within 48 hours course of intravenous antibiotherapy (early intervention) or later according to the clinical findings and antibiotherapy response. Results: Of 48 patients with TOA, 18 (37.5%) underwent laparoscopic and 30 (62.5%)underwent open surgical intervention. The median postoperative hospital stay was shorter (4.5 days vs 7.5 days, respectively; p = 0.035), and postoperative opioid analgesic requirement was lesser in the laparoscopy group compared to open surgery group (22% vs 53%, respectively; p = 0.034). Intra-and post-operative complication rates were similar between the groups. Of these 48 patients, seven were diagnosed to have TOA following oocyte retrieval, and four of these conceived with frozen thawed embryo transfer all of whom underwent laparoscopic surgery within 48 hours of diagnosis. Conclusions:Minimal invasive surgery should be preferred even in the presence of severely adhesive and inflammatory TOA in order to improve postoperative outcomes. Moreover, early laparoscopic intervention may be considered in infertile patients with an aim to optimize pregnancy rates in a subsequent frozen-thawed embryo transfer.

Objective: Progestins are used as an alternative to gonadotropin releasing hormone (GnRH) antagonists to suppress premature luteinizing hormone (LH) surge and a flexible protocol has been defined recently. The aim of this study was to compare the efficacy of flexible protocols with dydrogesterone and GnRH antagonist in suppressing LH surge. Material and Methods: This retrospective, case-control study, was conducted in an infertility unit of a tertiary university hospital. A daily dose of 40 mg dydrogesterone was compared with GnRH antagonist (GnRHant) in controlled ovarian hyperstimulation cycles between July 2018 and July 2019. Dydrogesterone was started when the leading follicle was 12 mm or serum estradiol was over 300 pg/mL. A subgroup analysis of poor responder patients was also performed. Results: In total there were 105 subjects aged between 23 and 41 years, 52 in the dydrogesterone group and 53 in the GnRHant group. Duration of pituitary suppression was longer in dydrogesterone group. Premature ovulation was observed in 11.5% (6/52) and 0% in the dydrogesterone and GnRHant groups, respectively. However, collected oocyte counts and metaphase II oocyte counts were found to be similar between the groups. The six patients with premature ovulation were in poor responder subgroup. Conclusion: Dydrogesterone can be used as an alternative to antagonist regimen in patients where embryo transfer is not planned in the same cycle. However, flexible regimen may not be appropriate in patients with diminished ovarian reserve, as advanced follicular maturation and delayed suppressive effect of oral progesterone may cause premature ovulation. Randomized controlled trials in particular patient groups are required to determine the most effective minimum dose and time of application to ensure treatment success.

In the present case series our aim is to present seven patients with extremely decreased ovarian reserve and oligomenorrhea, conceived with in vitro fertilization following a very short ovarian stimulation of incidentally detected big antral follicles. The study included women pursuing in vitro fertilization due to premature ovarian failure risk. When an incidental growing antral follicle was detected under ultrasound, immediate ovarian stimulation was initiated if the blood estradiol, luteinizing hormone and progesterone levels were correlated. Serum anti-Mullerian hormone measurements of all patients were consistent with extremely diminished ovarian reserve (ranged between 0.01 and 0.09ng/ml) and FSH levels varied between 13-104IU/l. The mean stimulation length ranged between 2-4 days. A total of 8 oocytes were retrieved; 6 MII, 1 GV and 1 degenerated. All 6 MII oocytes were fertilized with intracytoplasmic sperm injection. Two patients conceived after fresh embryo transfer, whereas the one conceived following frozen thawed embryo transfer. The ongoing pregnancy rate was 50% per transfer, and two of them resulted in a healthy live birth. In conclusion, close monitoring of oligoamenorrheic infertile patients who are at high risk of imminent ovarian failure using ultrasound and blood hormone levels is very important. Albeit low, the possibility of having a healthy pregnancy following “a very short ovarian stimulation” in such a specific patient group is emphasized.

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