Monozygotic twin cases of endometriosis with Glanzmann thrombasthenia: a case report and review of literature

BACKGROUND

Glanzmann thrombasthenia (GT) is a rare bleeding disorder with a high prevalence in communities where consanguineous marriages are mainstream. Endometriosis is a chronic inflammatory disease, and its risk increases in women with menstrual periods of longer than six days. The phenotypic expression of endometriosis is determined by the frequency and rate of the menstrual flow, as well as genetic and environmental factors.

RESULT AND CASE PRESENTATION

14-year-old monozygotic twin sisters with GT who developed ovarian endometriosis were referred to Hazrat Rasoul Hospital due to severe dysmenorrhea. In ultrasonic examination, endometrioma cysts were reported in both patients. They both went under endometrioma cystectomy, and the bleeding was managed using antifibrinolytic drugs, followed by recombinant activated coagulation factor VII. Both were discharged after 3 days. In the ultrasound examination performed one year after the surgery, ovaries were normal in the first twin, while the second twin had a 28 × 30 hemorrhagic cyst in the left ovary.

DISCUSSION AND CONCLUSION

Menstrual bleeding and genetic factors are two theories that could be related to GT and endometriosis association, and GT could be considered a risk factor for endometriosis.

Is it possible to reduce the rate of vertical transmission and improve perinatal outcomes by inclusion of remdesivir in treatment regimen of pregnant women with COVID-19?

BACKGROUND

Coronavirus disease 2019 (COVID-19) is currently one of the world's most critical health issues so far. Given the importance of appropriate treatment in pregnancy and the controversies about Remdesivir effectiveness and complications, the present study aimed to evaluate the impact of Remdesivir on maternal, fetal, and perinatal outcomes in pregnant women with COVID-19 diseases.

METHODS

A total of 189 pregnant women with positive polymerase chain reaction (PCR) results for SARS-COV-2, and oxygen saturation [SpO2] of < 95%) were admitted to 12 hospitals affiliated with the Iran University of Medical Sciences from March 1^st, 2020 to June 7^th, 2021, namely the first four COVID-19 Picks in Iran. They were enrolled in this retrospective cohort study by census method and categorized into case and control groups, based on the inclusion of Remdesivir in their treatment protocol. Demographics, clinical outcomes, and pregnancy-related complications of the mothers and the neonates were compared between the two study groups.

RESULTS

A comparison of 54 mothers in the case and 135 in the control group showed no demographic and clinical characteristics difference. Neonates whose mothers did not receive Remdesivir had a higher rate of positive PCR (10.2%), compared to the Remdesivir group (1.9%) with a relative risk of 0.91 reported for Remdesivir (95% CI: 0.85-0.98, P = 0.04); besides, Remdesivir resulted in fewer neonatal intensive care unit admission rates in mild/moderate COVID-19 group (RR = 0.32, 95% CI: 0.105-1.02, P = 0.03). Although neonatal death between the two groups was not statistically significant, from the clinical point seems important; 1(1.9%) in the case vs. 9(7.2%) in the control group. Interestingly LOS (Length of Stay) in the hospital was longer in the case group (median of 7 vs. 3 days; P < 0.0001).

CONCLUSION

The inclusion of Remdesivir in the treatment protocol of pregnant women with COVID-19 may reduce vertical transmission and improve perinatal outcomes, thus being suggested to be considered.

Does laparoscopic treatment of deep endometriosis improve sexual dysfunction

Background

Endometriosis is one of the common gynecological problems during the reproductive years, affecting the quality of life, fertility, and sexual function of women. It is known that sexual dysfunction and quality of life are interrelated. Therefore, this study aimed to evaluate the effect of resection of endometriosis lesions via laparoscopic surgery on the improvement of sexual dysfunction in women with endometriosis.

Methods

This clinical trial was performed on 30 patients with endometriosis. The Female Sexual Function Index, Endometriosis Health Profile-30, and Visual Analog Scale were completed for the patients before laparoscopic surgery and three, six, and 12 months after surgery. The results were examined and compared before and after the intervention using the ANOVA test.

Results

The present results showed that the mean pain score of the patients (dysmenorrhea, dyspareunia, and pelvic pain) was significant after laparoscopic surgery (P<0.005). The female sexual function improved after laparoscopic surgery compared to the preoperative phase, and changes in the domains of psychological stimulation, humidity, and sexual orgasm were significant (P<0.005). Moreover, the female quality of life scores increased in all dimensions compared to the preoperative phase, although these improvements were not statistically significant.

Conclusion

The present results revealed that laparoscopic surgery is an effective treatment, leading to a considerable improvement in female sexual function.

Hyaluronic acid gel application versus ovarian suspension for prevention of ovarian adhesions during laparoscopic surgery on endometrioma: a double-blind randomized clinical trial

Background

This study aimed to compare the effect of ovarian suspension and hyaluronic acid gel to prevent re-adhesions after laparoscopic endometrioma surgery.

Methods

This randomized clinical trial was conducted at Rasoul-e-Akram and Pars Hospitals, Tehran, Iran, 2016-18. Fifty patients with bilateral endometrioma and pelvic adhesions, the candidates of laparoscopic surgery, were included. In each patient, at the end of ovarian cystectomy and adhesiolysis, one of the ovaries was randomly sutured to the abdominal wall, and the HYAcorp Endogel covered the other; the adhesion rate was compared between the groups by ultrasonography, three-month after surgery.

Results

Mean age of patients was 32.6 years. Presurgical variables were similar between right and left ovaries and the study groups (P > 0.05). Postsurgical ultrasonography showed that ovarian soft markers, including < 1/3 ovarian adhesions (minimal adhesions) in 80.5% of ovaries of the Endogel group and 35.5% of the ovarian suspension group (P < 0.001) with higher ovarian mobility in the Endogel group (65% vs. 22%) (P = 0.001). In addition, site-specific tenderness and ovarian fading margin were lower in the Endogel group (P < 0.001).

Trial registration Clinical trial registry number: IRCT2015081723666N1, 12.19.2015, Date of registration: 01/02/2016; https://en.irct.ir/trial/20174?revision=20174. Date and number of IRB: 2015, I.R.IUMS.REC.1394.24703.

Conclusion

Hyaluronic acid gel can be more effective than ovarian suspension in preventing ovarian adhesions after laparoscopic treatment of endometriosis.

The effect of vitamin D supplementation on clinical symptoms and metabolic profiles in patients with endometriosis

BACKGROUND

To our knowledge, data on the effects of vitamin D supplementation on clinical symptoms and metabolic profiles in patients with endometriosis are limited. This study was conducted to determine the effects of vitamin D supplementation on clinical symptoms and metabolic profiles in patients with endometriosis.

METHODS

The current randomized, double-blind, placebo-controlled trial was conducted among 60 patients (aged 18-40 years old) with endometriosis. Participants were randomly allocated into two groups (30 participants each group) to receive either 50,000 IU vitamin D or placebo each 2 weeks for 12 weeks.

RESULTS

Vitamin D supplementation significantly decreased pelvic pain (β - 1.12; 95% CI, -2.1, -0.09; p=.03) and total-/HDL-cholesterol ratio (β - 0.29; 95% CI, -0.57, -0.008; p=.04) compared with the placebo. Moreover, vitamin D intake led to a significant reduction in high-sensitivity C-reactive protein (hs-CRP) (β - 0.64 mg/L; 95% CI, -0.97, -0.30; p<.001) and a significant increase in total antioxidant capacity (TAC) (β 47.54 mmol/L; 95% CI, 19.98, 75.11; p=.001) compared with the placebo.

CONCLUSIONS

Overall, our study demonstrated that vitamin D intake in patients with endometriosis resulted in a significant improvement of pelvic pain, total-/HDL-cholesterol ratio, hs-CRP and TAC levels, but did not affect other clinical symptoms and metabolic profiles.

The Impact of COVID-19 Pandemic on Stress and Anxiety of Non-infected Pregnant Mothers

Background:

The newly emerging COVID-19 has caused severe anxiety around the world and it is infecting more people each day since there is no preventive measure or definite therapy for the diseases. The present study aimed to evaluate its effect on anxiety and stress of pregnant mothers during perinatal care.

Methods:

Three–hundred pregnant mothers without COVID–19 infection who were referred to the hospitals affiliated to Iran University of Medical Sciences for delivery during April 2020, based on negative clinical symptoms and the results of polymerase chain reaction (rt-PCR) for COVID–19, were recruited by census method and asked to complete the Persian version of the perceived stress scale (PSS); participants views about their anxiety level and the role of COVID–19 as the source of their stress and worries were recorded. Women who refused to continue the study were excluded. The frequency of variables and mean scores were calculated using SPSS v. 21.

Results:

Mean age of mothers was 30.20±16.19 years; 31.3% were primigravida and mean gestational age was 38.00±4.14 weeks. Moreover, 16.3% asked for earlier pregnancy termination and 39% requested Cesarean section (C/S). Assessing the mothers’ anxiety revealed a high/very high level of anxiety in 51.3%. The majority felt worried and frustrated because of COVID–19 (86.4%). Social media had a great impact on the level of stress among these mothers (60.3%).

Conclusion:

COVID-19 pandemic is an important source for the increased anxiety and stress among healthy pregnant mothers.

Broad ligament pregnancy in the presence of an intrauterine contraceptive device: A case report

INTRODUCTION

Abdominal pregnancy though scarce is associated with considerable morbidity and mortality. Few cases till now have been diagnosed or managed by laparoscopy.

CASE PRESENTATION

In this study, a case of an abdominal pregnancy in a woman with intrauterine contraceptive device (IUD) in situ and a history of cesarean section is described.

CLINICAL DISCUSSION

Our case was a brief description of a broad ligament pregnancy as a subcategory of abdominal pregnancy .It was located medial to the pelvic sidewall, lateral to the uterus, inferior to the fallopian tube and superior to the pelvic floor.

CONCLUSION

The pregnancy was in the location of the left broad ligament which was diagnosed on laparoscopic evaluation.

Superior hypogastric plexus block as an effective treatment method for endometriosis-related chronic pelvic pain: an open-label pilot clinical trial

We aimed to investigate the effect of superior hypogastric plexus (SHP) block on pain relief and quality of life of patients with refractory endometriosis. Sixteen patients with refractory endometriosis underwent SHP block. The outcome measures included visual analogue scale (VAS) for chronic pelvic pain, VAS for dysmenorrhoea, and VAS for dyspareunia. The short-form endometriosis health profile (EHP-5) was used to measure quality of life. All the outcome measures were evaluated at weeks 0, 1, 4, 12 and 24. The mean baseline VAS scores significantly improved after the SHP block (p < .001 for all). The mean overall EHP-5 score also significantly improved from 54.3 ± 18.2 to 24.6 ± 13.3 (p < .001). The positive effects of SHP were not diminished over time. No serious adverse effect was noticed in any of the patients. Preliminary results suggest that SHP block could be used as an effective method in pain control and improvement of quality of life in refractory endometriosis.IMPACT STATEMENTWhat is already known on this subject? Safety and efficacy of SHP block in the treatment of CPP has been revealed in earlier investigations. However, the efficacy of SHP block for pain management in patients with refractory endometriosis has not been investigated in earlier investigations.What do the results of this study add? SHP block is an effective method for pain control and improvement of quality of life in patients with refractory endometriosis. The positive effects of this treatment did not diminish over 24-weeks follow-up of the study. No serious adverse effect was noticed in any of the patients.What are the implications of these findings for clinical practice and/or further research? Preliminary results suggest that SHP block could be used safely and effectively for controlling pain and improvement of quality of life in patients with refractory endometriosis.

Mineralized Human Amniotic Membrane as a Biomimetic Scaffold for Hard Tissue Engineering Applications

The human amniotic membrane (HAM) has been viewed as a potential regenerative material for a wide variety of injured tissues because of its collagen-rich content. High degradability of HAM limits its wide practical application in bone tissue engineering. In this study, the natural matrix of the decellularized amniotic membrane was developed by the double diffusion method. The results confirmed a reduction of the amniotic membrane's degradability because of the deposition of calcium and phosphate ions during the double diffusion process. Real-time PCR results showed a high expression of osteogenesis-related genes from adipose-derived mesenchymal stem cells (ADMSCs) cultured on the surface of the developed mineralized amniotic membrane (MAM). Further in vivo experiments were conducted using an MAM preseeded with ADMSCs and a critical-size rat calvarial defect model. Histopathological results confirmed that the MAM + cell sample has excellent potential in bone regeneration.

Uterine Isthmus Tourniquet during Abdominal Myomectomy: Support or Hazard? A Randomized Double-Blind Trial

BACKGROUND AND OBJECTIVES

A tourniquet has been suggested as a useful means of reducing massive hemorrhage during myomectomy. However, it is not clear whether the restricted perfusion affects the ovaries. In the present study, we examined the effect of a tourniquet on ovarian reserve and blood loss during myomectomy.

MATERIALS AND METHODS

In a randomized double-blind clinical trial, fertile nonobese patients scheduled for abdominal myomectomy at Rasool-e-Akram Hospital from February 2018 to June 2019 were randomized to a tourniquet (n = 46) or a non-tourniquet group (n = 35). Serum levels of anti-Müllerian hormone (AMH) and follicle-stimulating hormone (FSH) were measured before and 3 months after surgery, blood loss was recorded during surgery, and serum levels of hemoglobin (Hb) were recorded before surgery, 6 h and 3 days after surgery. SPSS version 21 was used for statistical analysis.

RESULTS

Demographic, obstetric, and myoma characteristics were similar in the 2 groups (p > 0.05). The mean baseline values of AMH and FSH did not differ between groups (p > 0.05). After surgery, only FSH was higher in the control group (p = 0.043). Despite the time taken to fasten and open the tourniquet, the mean operating time was shorter in the tourniquet group (p < 0.001). Blood loss was higher in the control group (p = 0.005). The drop in Hb levels at 6 h after surgery was higher in the non-tourniquet group (p = 0.002). Blood loss was significantly associated with the duration of surgery (r = 0.523, p < 0.001).

CONCLUSION

The use of a tourniquet during abdominal myomectomy significantly reduced the mean volume of blood loss compared to the non-tourniquet group, while it did not prolong the duration of surgery, nor reduced the ovarian reserve. A tourniquet is a safe and efficient measure during abdominal myomectomy.

Association of endometrioma with ovarian teratoma and mucinous cystadenoma in a patient diagnosed with endometriosis: A case report

BACKGROUND

Co-occurrence of different tumor types in a same patient’s ovaries diagnosed with endometriosis is a rare phenomenon.

CASE SUMMARY

In this article we present an uncommon association of three distinct ovarian pathologies in a same woman presenting with adnexal mass. A 31-year-old nulliparous woman with a large persistent adnexal mass underwent laparoscopic surgery. Imaging demonstrated a multi-cystic mass with internal echoes. Tumor markers were within normal range. Based on histopathologic assessment, benign mucinous cystadenoma and mature cystic teratoma of the right ovary together with endometrioma of left ovary were revealed.

CONCLUSION

In cases of large adnexal mass, the of existence of more than one tumor type and the involvement of the contralateral ovary is possible. Also, the possibility of concurrent underlying malignancy or diminished ovarian reserve should be kept in mind.

The role of inflammation, oxidative stress, angiogenesis, and apoptosis in the pathophysiology of endometriosis: Basic science and new insights based on gene expression

Endometriosis is a frequent and chronic illness in young women which could be defined by the existence of endometrial stroma and glands outside of the normal site of the lining of the uterus. It has painful symptoms. The advanced stage of endometriosis may lead to gynecological malignancies, such as ovarian cancer, and other complications, including infertility. However, its exact physiopathology is not well known. Recent studies have shown the possible roles of inflammation along with oxidative stress. Additionally, angiogenesis and apoptosis dysregulation contribute to endometriosis pathophysiology. Therapeutic strategies and continuing attempts, to conquer endometriosis should be done regarding molecular signaling pathways. Thus, the present review summarizes current studies and focuses on molecular mechanisms.

Maternal Anthropometric Characteristics and Adverse Pregnancy Outcomes in Iranian Women: A Confirmation Analysis

BACKGROUND

Adverse pregnancy outcome are frequent in developing countries. Pregnancy outcomes are influenced by numerous factors. It seems that maternal anthropometric indices are among the most important factors in this era. The aim of this study was to determine any association between maternal anthropometric characteristics and adverse pregnancy outcomes in Iranian women and provide a predictive model by using factors affecting birth weight (BW) via the pathway analysis.

METHODS

This study was performed in Alborz province between September 2014 and December 2016. In this cross-sectional study, 1006 pregnant women who had the study criteria were selected from 1500 pregnant women. The data were collected in 2 phases: at their first prenatal visit and during the postpartum period. Demographic data, history of previous pregnancy, fundal height (FH), gestational weight gain (GWG), and abdominal circumference (AC) were recorded. Pathway (path) analysis was used to assess effective factors on pregnancy outcomes.

RESULTS

The mean and standard deviation of participant age at delivery was 25.97 ± 5.71 years. Overall, 4.6% of infants were low BW (LBW) and 5.8% had macrosomia. The final model, with a good fit accounting for 22% of BW variance, indicated that AC and FH (both P < 0.001), and pre-pregnancy body mass index (BMI) (P = 0.01) had positive direct effect on BW, while pre-pregnancy BMI and GWG (both P < 0.001) affected BW indirectly through their effect on FH and AC.

CONCLUSION

Based on the path analysis model, FH and AC of neonates with the greatest impact on BW, could be predicted by mother's BMI before pregnancy and weight gain during pregnancy. Therefore, close observation during prenatal care can reduce the risk of abnormal BW.

Comparing the Efficacy of Surgery and Medical Therapy for Pain Management in Endometriosis: A Systematic Review and Meta-analysis

Background: Pain is considered as one of the main symptoms of endometriosis. The treatment for endometriosis remains controversial. Objectives: The aim of this study is to compare the effect of medical or surgical treatments for pain-relief in patients with endometriosis. Study Design: Systematic review and meta-analysis. Setting: Published papers about evaluating pain treatment in endometriosis in PubMed, Scopus, and Google Scholar. Methods: After searching all studies evaluating pain treatment in endometriosis in PubMed, Scopus, and Google Scholar, there were 23 related studies, containing 1,847 patients enrolled in our study. We used a variety of tests: fixed and random effects models, Q Cochrane test and I2 index, Egger and Begg tests, forest and funnel plots, Trim and fill method, and meta-regression in our analysis. Results: There was no statistically significant difference in pain improvement between surgical and medical treatment. Interestingly, pain relief was more prominent longer after treatment. Both clinical trials and cross sectional studies showed higher improvement in pain than cohort studies. High quality studies and lower body mass index (BMI) had a greater effect on pain relief. All studies were heterogeneous, but there was no publication bias. Limitations: There was a higher probability of risk of bias in blinding, random sequence generation, and selective outcome reporting in clinical trial studies entered in our meta-analysis. Conclusions: Our results could not demonstrate the preference of each medical or surgical treatment effect for dysmenorrhea in endometriosis. Additional data is required before a standardized medical protocol can be offered, but we believe this study may encourage clinicians to consider a less invasive alternative for treating their patients’ chronic pelvic pain in the near future. Key words: Endometriosis, pain, meta-analysis, therapy, disease management

Ultrastructural Investigation of Pelvic Peritoneum in Patients With Chronic Pelvic Pain and Subtle Endometriosis in Association With Chromoendoscopy

STUDY OBJECTIVE

To evaluate the pelvic peritoneum under chromoendoscopy by scanning electron microscopy (SEM) as well as light microscopy with hematoxylin and eosin staining and immunohistochemistry (IHC) assays in patients with chronic pelvic pain (CPP) associated with subtle endometriosis.

DESIGN

Case series study (Canadian Task Force classification II).

SETTING

A referral academic community tertiary medical center.

PATIENTS

Three women aged 29 to 37 years were referred to the obstetrics and gynecology clinic of the tertiary university hospital with CPP. They were suspicious for endometriosis, were not responding to medical treatments, and had undergone previous pelvic laparoscopy to determine the stage of endometriosis and preparation of peritoneal samples under the guidance of staining with methylene blue in 0.25% dilution.

INTERVENTIONS

Comparison of stained and unstained pelvic peritoneal samples after the instillation of 0.25% methylene blue into the pelvic cavity.

MEASUREMENTS AND MAIN RESULTS

In 3 patients, laparoscopic examination showed minimal endometriosis. A total of 18 samples (9 stained and 9 unstained) from the 3 patients were prepared for SEM. Ten of the samples (55.6%) showed microstructural peritoneal destruction (7 of 9 stained [77.7%] and 3 of 9 [33.4%] unstained). Eighteen samples (9 stained and 9 unstained) from the 3 patients were also prepared for IHC. Six of these samples (33.3%) were S-100-positive, including 4 of 9 (44.4%) stained samples and 2 of 9 (22.2%) unstained samples.

CONCLUSIONS

In general, in the context of CPP and endometriosis, there is no established relationship between the severity of pain and stage of endometriosis. In the pathophysiology of CPP associated with endometriosis, ultrastructural changes can play a significant role. Under methylene blue staining, some destroyed areas were detected, but the stained areas do not necessarily correlate with increased microstructural peritoneal destruction.

Leiomyosarcoma of the Broad Ligament With Fever Presentation: A Case Report and Review of Literature

Introduction

Leiomyosarcoma is a rare gynecologic malignancy that accounts for less than 1% of gynecological malignancies. Leiomyosarcoma of the broad ligament is an even rarer condition. According to Gardner’s criteria, the diagnosis is made when the mass is completely separated from the uterus and adnexa. So far, 23 cases of primary leiomyosarcoma of the broad ligament have been reported in the literature published in English.

Case Presentation

In September 2014, a 55-year-old, gravida 3, para 3 woman with a BMI of 30 and a chief complaint of fever and dizziness was admitted to the infectious-diseases ward of the Pars general hospital affiliated with Iran University of Medical Sciences in Tehran, Iran. Her symptoms had begun two weeks before. The results of a fever workup and examination for infectious, metabolic, and immunologic problems were all negative. Imaging modalities revealed an endometrial polyp, two calcified myoma in the body of the uterus, and a solid, heterogeneous 70-mm mass in the right para-cervical space, posterior to the broad ligament, and far from the ovary. After surgery, a histologic report revealed leiomyosarcoma.

Conclusions

Although a leiomyosarcoma of the broad ligament is rare, practitioners should consider it when dealing with masses in the region of the broad ligament. If there is any suspicion of malignancy, especially in the presence of fever, it is recommended to avoid morcellation during laparoscopy.

Laparoscopic approach to a large ovarian fibroma: a case report

BACKGROUND

Ovarian fibroma is the most common benign solid tumor of the ovary, which is often difficult to diagnose preoperatively. The choice treatment for ovarian fibroma is surgical removal, but discussions for the operative approach, laparoscopic or open, in the literature seem to be scant.

CASE PRESENTATION

We presented a unique clinical experience of laparoscopic approach to a case of 15 cm unilateral ovarian fibroma in a 24 year old patient, with a successful and complete resection of the tumor beside ovarian tissue preservation in December 2012 in Rasoul-e-Akram hospital, Tehran, Iran.

CONCLUSION

In conclusion, we should not forget the role of laparoscopy as a diagnostic procedure even in suspicious cases of ovarian fibroma with solid tumor, ascites, and pleural effusion.

Assessment of C-reactive Protein and C3 as Inflammatory Markers of Insulin Resistance in Women with Polycystic Ovary Syndrome: A Case-Control Study

BACKGROUND

Polycystic ovary syndrome (PCOS), a common endocrine disorder, is associated with infertility, menstrual dysfunction, hirsutism and frequent miscarriages. Insulin resistance, as a major cause of PCOS, represents a disorder with increase in inflammatory markers and risk of type 2 diabetes. We aimed to investigate whether inflammatory markers, including C-reactive protein and C3 (Complement), are related and altered in polycystic ovary syndrome.

METHODS

A case-control study including forty-two women diagnosed with PCOS, according to Rotterdam criteria, and forty-two healthy controls, matched for body mass index (BMI) and age, was conducted in 2012. C-Reactive protein (CRP) and C3 were assessed as possible determinants of the homeostasis model assessment (HOMA) index. Independent-sample t-test was used to compare the means of the groups in age, BMI, C3, FBS and BS 2hpp (2 hr postprandial glucose) and for CRP, Fasting Insulin and 2 hr Plasma Insulin and HOMA index. Mann-Whitney test and Pearson correlation were used for analyzing the data. The p<0.05 was considered as statistically significant.

RESULTS

Levels of plasma CRP (p=0.039), 2 hr pp (p=0.045), Fasting Insulin (p=0.002), 2 hr Plasma Insulin (p=0.002) and HOMA index (p=0.002) were significantly higher in PCOS patients. But C3 was not significantly higher in cases (p=0.885). There was no significant correlation between C3 and CRP with HOMA index.

CONCLUSION

CRP increased significantly in patients with PCOS and was associated with insulin resistance, the most probable cause of PCOS. However, such an association was not found in C3.