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Hantoushzadeh S, Poorabdoli M, Parsaei M, Zargarzadeh N, Masoumi M, Khotbesara SE, Tarafdari A. Predicting the Outcomes of In Vitro Fertilization Using Baseline Maternal Serum Inflammatory Markers: A Retrospective Cohort Study. Am J Reprod Immunol 2024; 92:e13900. [PMID: 39049609 DOI: 10.1111/aji.13900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 06/24/2024] [Accepted: 06/27/2024] [Indexed: 07/27/2024] Open
Abstract
PROBLEM Achieving pregnancy through in vitro fertilization (IVF) remains a challenge, with less than one-third of women succeeding. There is a pressing need for reliable predictive tools to assess the likelihood of post-IVF pregnancy. While some serum inflammatory biomarkers have been investigated for their predictive potential, substantial knowledge gaps persist. This study examined the utility of different inflammatory markers in predicting IVF outcomes. METHOD OF STUDY Inflammatory markers including the white blood cell count, neutrophil-to-lymphocyte ratio (NLR), platelet count, mean platelet volume, platelet distribution width, platelet-to-lymphocyte ratio (PLR), C-reactive protein (CRP), erythrocyte sedimentation rate, and vitamin D3 were assessed. Study outcomes were chemical pregnancy (positive serum beta-human chorionic gonadotropin 2 weeks post-embryo transfer), clinical pregnancy (detection of pregnancy sac via transvaginal ultrasonography), and viable pregnancy (detection of fetal heart rate). Univariate and multivariate logistic regression analyses were conducted, with multivariate analysis incorporating age, body mass index, infertility duration, type, and etiology, as well as all studied serum inflammatory markers, embryo count, stage, quality, and endometrial thickness. RESULTS Lower NLR (p < 0.001, odds ratio [OR] = 0.372 [0.247-0.559]) and CRP (p = 0.035, odds ratio = 0.956 [0.916-0.997]) predicted chemical pregnancy in univariate analysis, with NLR maintaining significance in multivariate analysis (p = 0.022, OR = 0.319 [0.120-0.848]). Lower NLR (p < 0.001, OR = 0.309 [0.198-0.482]) and PLR (p = 0.013, OR = 0.994 [0.990-0.999]) predicted clinical pregnancy, with NLR surviving multivariate analysis (p = 0.005, OR = 0.217 [0.075-0.626]). Lower NLR (p < 0.001, OR = 0.320 [0.198-0.516]) also predicted viable pregnancy, maintaining statistical significance in multivariate analysis (p = 0.002, OR = 0.177 [0.058-0.541]). Other studied inflammatory markers did not predict IVF outcomes. CONCLUSIONS NLR emerged as a robust independent predictor of pregnancy attainment after IVF.
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Affiliation(s)
- Sedigheh Hantoushzadeh
- Vali-e-Asr Reproductive Health Research Center, Family Health Research Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Marzie Poorabdoli
- Department of Obstetrics and Gynecology, Family Health Research Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammadamin Parsaei
- Maternal, Fetal & Neonatal Research Center, Family Health Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Nikan Zargarzadeh
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, USA
| | - Masoumeh Masoumi
- Vali-e-Asr Reproductive Health Research Center, Family Health Research Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Saeedeh Eslami Khotbesara
- Vali-e-Asr Reproductive Health Research Center, Family Health Research Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Azadeh Tarafdari
- Department of Obstetrics and Gynecology, Family Health Research Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
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Li X, Luan T, Wei Y, Zhang J, Zhou L, Zhao C, Ling X. Association between the systemic immune-inflammation index and GnRH antagonist protocol IVF outcomes: a cohort study. Reprod Biomed Online 2024; 48:103776. [PMID: 38507919 DOI: 10.1016/j.rbmo.2023.103776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 12/01/2023] [Accepted: 12/14/2023] [Indexed: 03/22/2024]
Abstract
RESEARCH QUESTION What is the relationship between the systemic immune-inflammation index (SII) and IVF outcomes in women undergoing a gonadotrophin-releasing hormone (GnRH) antagonist protocol? DESIGN This retrospective cohort study analysed clinical data and blood samples collected before oocyte retrieval from participants undergoing IVF with the GnRH antagonist protocol. Logistic regression and generalized additive models were used to examine the association between SII quartiles and continuous SII values and IVF outcomes. RESULTS Higher SII values correlated negatively with biochemical pregnancy, clinical pregnancy, live birth and implantation rates, and positively with early pregnancy loss, independent of age, body mass index, anti-Müllerian hormone and stimulation parameters. The most significant adverse outcomes were observed in the highest SII quartile. A non-linear relationship was identified between log-transformed SII and IVF outcomes, with an inflection point at an SII of approximately 6.72, indicating a threshold effect. CONCLUSIONS Elevated SII is associated with poorer IVF outcomes in women after the GnRH antagonist protocol, suggesting its potential as a predictive marker in IVF treatments. Further research is needed to confirm these findings and explore the underlying mechanisms.
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Affiliation(s)
- Xin Li
- Department of Reproductive Medicine, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Ting Luan
- Department of Obstetrics and Gynecology, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Yi Wei
- Department of Reproductive Medicine, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - JuanJuan Zhang
- Department of Reproductive Medicine, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Lin Zhou
- Department of Obstetrics and Gynecology, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China.
| | - Chun Zhao
- Department of Reproductive Medicine, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China.
| | - Xiufeng Ling
- Department of Reproductive Medicine, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China.
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Vexø LE, Stormlund S, Landersoe SK, Jørgensen HL, Humaidan P, Bergh C, Englund ALM, Klajnbard A, Bogstad JW, Freiesleben NLC, Zedeler A, Prætorius L, Andersen AN, Løssl K, Pinborg A, Nielsen HS. Low-grade inflammation is negatively associated with live birth in women undergoing IVF. Reprod Biomed Online 2023; 46:302-311. [PMID: 36446681 DOI: 10.1016/j.rbmo.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/28/2022] [Accepted: 10/08/2022] [Indexed: 11/23/2022]
Abstract
RESEARCH QUESTION Is low-grade inflammation, detected by C-reactive protein (CRP), a marker of IVF outcome addressing both blastocyst quality and pregnancy outcome? DESIGN This sub-study of a multicentre randomized controlled trial included 440 women undergoing IVF treatment with a gonadotrophin-releasing hormone (GnRH) antagonist protocol. Serum CRP was measured on cycle day 2-3 (baseline) and on the day of ovulation triggering. The association between CRP concentrations and reproductive outcomes (number of retrieved oocytes, number of good-quality blastocysts, pregnancy, pregnancy loss and live birth), were analysed, adjusting for relevant confounders. RESULTS A negative association was found between higher baseline CRP concentrations and live birth rate (odds ratio [OR] 0.77, 95% confidence interval [CI] 0.62-0.96, P = 0.02) and higher CRP concentrations at baseline were associated with pregnancy loss among women who conceived (OR 1.37, 95% CI 1.07-1.76, P = 0.01). When testing for a specific cut-off, CRP concentrations above 2.34 (the highest quartile) were more likely to be associated with pregnancy loss (P = 0.02) and a lower chance of live birth (P = 0.04) compared with the lowest quartile. No associations were found between CRP concentrations and pregnancy outcomes on the day of ovulation triggering, and there were no associations between CRP concentrations and the number of good-quality blastocysts. CONCLUSIONS Higher CRP concentrations at cycle day 2-3, before starting ovarian stimulation, are negatively associated with chance of live birth, possibly because of an increased risk of pregnancy loss. No association was found between the number of good-quality blastocysts and CRP concentration. More studies are needed to investigate the impact of low-grade inflammation.
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Affiliation(s)
- Laura Emilie Vexø
- Fertility Department, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Department of Obstetrics and Gynaecology, Fertility Clinic, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark.
| | - Sacha Stormlund
- Department of Obstetrics and Gynaecology, Fertility Clinic, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Selma Kloeve Landersoe
- Fertility Department, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Henrik Løvendahl Jørgensen
- Department of Clinical Biochemistry, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark; Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Peter Humaidan
- Fertility Clinic, Skive Regional Hospital and Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Christina Bergh
- Department of Obstetrics and Gynaecology, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University; Reproductive Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anne Lis Mikkelsen Englund
- Department of Obstetrics and Gynaecology, Fertility Clinic, Region Zealand University Hospital, Koege, Denmark
| | - Anna Klajnbard
- Fertility Clinic, Department of Obstetrics and Gynaecology, Herlev University Hospital, Copenhagen, Denmark
| | - Jeanette Wulff Bogstad
- Fertility Department, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Nina la Cour Freiesleben
- Department of Obstetrics and Gynaecology, Fertility Clinic, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark; Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Anne Zedeler
- Department of Obstetrics and Gynaecology, Fertility Clinic, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Lisbeth Prætorius
- Department of Obstetrics and Gynaecology, Fertility Clinic, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Anders Nyboe Andersen
- Fertility Department, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Kristine Løssl
- Fertility Department, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Anja Pinborg
- Fertility Department, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Department of Obstetrics and Gynaecology, Fertility Clinic, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark; Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Henriette Svarre Nielsen
- Fertility Department, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Department of Obstetrics and Gynaecology, Fertility Clinic, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark; Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Schon SB, Yang K, Schindler R, Jiang L, Neff LM, Seeley RJ, Marsh EE. Obesity-related alterations in protein expression in human follicular fluid from women undergoing in vitro fertilization. F&S SCIENCE 2022; 3:331-339. [PMID: 36096447 DOI: 10.1016/j.xfss.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 09/05/2022] [Accepted: 09/06/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To compare the proteomic composition of follicular fluid from women with normal weight vs. women with obesity but without a history of polycystic ovary syndrome or known ovarian dysfunction undergoing in vitro fertilization. DESIGN Cross-sectional. SETTING Academic medical center. PATIENT(S) Eight women with normal weight and 8 women with obesity undergoing in vitro fertilization and without a history of polycystic ovary syndrome, ovulatory dysfunction, diminished ovarian reserve, or known endometriosis were included in the analysis. INTERVENTION(S) Not applicable. MAIN OUTCOME MEASURE(S) Proteomic assessment using liquid chromatography-mass spectrometry analysis. RESULT(S) The mean age of women with normal weight was similar to that of women with obesity (32.9 vs. 32.6 years, not significant). The mean body mass index of women with normal weight was 21.2 kg/m2 compared with a body mass index of 37.1 kg/m2 in women with obesity. A total of 1,174 proteins were identified with ≥2 peptides present. Twenty-five proteins were found to be significantly altered in the follicular fluid from women with obesity. Of these 25 proteins, 19 were up-regulated and 6 were down-regulated. Notably, C-reactive protein was 11-fold higher in the follicular fluid from women with obesity than in the follicular fluid from women with normal weight. CONCLUSION(S) Obesity is associated with dysregulation at the level of the follicle, including alterations in proteins related to inflammation and metabolism. These include proteins with emerging roles in energy homeostasis and follicular regulation.
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Affiliation(s)
- Samantha B Schon
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - Kun Yang
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - Ronald Schindler
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - Li Jiang
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | | | - Randy J Seeley
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Erica E Marsh
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan.
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Toapanta-Pinta PC, Vasco-Toapanta CS, Herrera-Tasiguano AE, Verdesoto-Jácome CA, Páez-Pástor MJ, Vasco-Morales S. COVID 19 in pregnant women and neonates: Clinical characteristics and laboratory and imaging findings. An overview of systematic reviews. REVISTA DE LA FACULTAD DE MEDICINA 2022. [DOI: 10.15446/revfacmed.v71n1.97588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introduction: SARS-CoV-2 infection in the perinatal period may be associated with an increased risk of morbidity and mortality in both the mother and the neonate.
Objective: To describe the clinical characteristics and, laboratory and imaging findings in pregnant women with COVID-19 and their newborns.
Materials and methods: We searched PubMed, Scopus, Web of Science, and Cochrane databases for systematic reviews published between February 1, 2020, and May 30, 2021, describing clinical characteristics and laboratory and imaging (chest) findings in pregnant women with COVID-19 and their newborns; there were no language restrictions. Data were reanalyzed by means of Bayesian meta-analysis using Markov Chain Monte Carlo methods. The study protocol is registered in PROSPERO under code CRD42020178329.
Results: Six systematic reviews were retrieved (for a total of 617 primary studies). A narrative synthesis of the proportions of signs, symptoms, and imaging and laboratory findings of both mothers and neonates was performed. The Odds ratios (OR) between pregnant women with and without COVID-19 were as follows: fetal well-being involvement: 1.9 (95%CI:1.09-3.63); stillbirth: 1.73 (95%CI:1.01-2.94); preterm birth: 1.77 (95%CI:1.25-2.61); maternal admission to the intensive care unit (ICU): 6.75 (95%CI:1-31.19). Regarding symptomatology, the following OR was obtained for myalgia between pregnant women and non-pregnant women with COVID-19: 0.67 (95% CI:0.51-0.93).
Conclusions: Cough, fever, dyspnea, and myalgia are the most common symptoms in pregnant women with COVID-19; in addition, there is a higher risk of admission to the ICU. Regarding complementary testing, the most frequent alterations are lymphopenia and the evidence of lesions in chest imaging studies. The presence of COVID-19 in pregnant women is associated with premature birth. It seems that SARS-CoV-2 infection in neonates is not serious and the risk of vertical transmission is low, since no data about congenital malformations attributable to the virus were found.
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Gavrizi SZ, Arya S, Peck JD, Knudtson JF, Diamond MP, Wild RA, Hansen KR. High-sensitivity C-reactive protein levels and pregnancy outcomes in women with unexplained infertility after ovarian stimulation with intrauterine insemination in a multicenter trial. F S Rep 2022; 3:57-62. [PMID: 35386508 PMCID: PMC8978106 DOI: 10.1016/j.xfre.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 01/04/2022] [Accepted: 01/06/2022] [Indexed: 11/04/2022] Open
Abstract
Objective To determine if chronic inflammation, assessed by basal high-sensitivity C-reactive protein (hs-CRP) levels, is associated with pregnancy outcomes in women with unexplained infertility undergoing ovarian stimulation with intrauterine insemination. Design Prospective cohort analysis of the Reproductive Medicine Network's Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS) randomized controlled trial. Setting Multicenter university-based randomized controlled trial. Patients A total of 781 couples with unexplained infertility. Interventions Secondary analysis. Main Outcome Measures Adjusted risk ratios of live birth, clinical pregnancy, and pregnancy loss rates by hs-CRP levels. Results Associations between hs-CRP levels and clinical pregnancy rates were not observed after adjustment for baseline body mass index. There were fewer live births among women with higher hs-CRP levels, although confidence intervals crossed 1.0. The risk of pregnancy loss was greater in women with increased hs-CRP levels (1-3 mg/L: risk ratio [RR], 1.67; 95% confidence interval [CI], 1.00-2.79; >3-10 mg/L: RR, 1.84; 95% CI, 1.06-3.20; and >10 mg/L: RR, 2.14; 95% CI, 1.05-4.36 compared to women with hs-CRP <1 mg/L). Conclusions This investigation suggests that chronic inflammation may increase the risk of pregnancy loss but not impact the clinical pregnancy rate in women with unexplained infertility undergoing ovarian stimulation with intrauterine insemination. Associations between inflammation and pregnancy outcomes in women with infertility merit further investigation. Clinical Trial Registration Number clinicaltrials.gov NCT01044862.
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Affiliation(s)
- Sarah Z. Gavrizi
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Sushila Arya
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Jennifer D. Peck
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Jennifer F. Knudtson
- Department of Obstetrics and Gynecology, University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Michael P. Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta, Georgia
| | - Robert A. Wild
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Karl R. Hansen
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
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Ozgu-Erdinc AS, Gozukara I, Kahyaoglu S, Yilmaz S, Yumusak OH, Yilmaz N, Erkaya S, Engin-Ustun Y. Is there any role of interleukin-6 and high sensitive C-reactive protein in predicting IVF/ICSI success? A prospective cohort study. Horm Mol Biol Clin Investig 2021; 43:35-40. [PMID: 34837488 DOI: 10.1515/hmbci-2021-0039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 11/10/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Studies have established a relationship between proinflammatory factors and implantation failure in IVF/ICSI cycles. Likewise, low-grade chronic inflammation is generally blamed for predisposing infertility. In the present study, we aimed to find a relationship between serum IL-6 and hs-CRP levels and IVF/ICSI cycle outcomes. METHODS A total of 129 patients who consented to participate and attended the IVF unit of our department for the treatment of infertility have been enrolled in this prospective cohort study. Serum levels of high sensitive C-reactive protein and interleukin 6 have been detected at the beginning of the IVF/ICSI ovulation induction cycle. Cycle outcomes have been compared between patients with and without clinical pregnancy achievement following ART treatments. IVF/ICSI cycle outcomes of these two groups were also comparable except the number of >14 mm follicles, retrieved oocytes, metaphase II oocytes, and fertilized oocytes (2 pronuclei) which were in favor of the clinical pregnancy group. RESULTS Mean serum hs-CRP levels were 3.08 mg/L (0.12-35.04) and 2.28 mg/L (0.09-22.52) patients with and without clinical pregnancy respectively. Mean serum IL-6 levels were 2 pg/mL (1-10.2) and 2 pg/mL (1-76.9) patients with and without clinical pregnancy respectively. Both tests were found to be statistically insignificant in predicting the success of the ART cycle in terms of implantation, clinical pregnancy, miscarriage, and live birth. CONCLUSIONS In the present study, we have not found any significant effect of hs-CRP and IL-6 levels in the IVF cycle. However, in the light of this and previous studies, large-scale research may prove the exact influence of these markers on IVF success.
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Affiliation(s)
| | - Ilay Gozukara
- University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Serkan Kahyaoglu
- University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Saynur Yilmaz
- University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | | | - Nafiye Yilmaz
- University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Salim Erkaya
- University of Health Sciences, Ankara City Hospital, Ankara, Turkey
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