1
|
Della Corte L, Boccia D, Palumbo M, Mercorio A, Ronsini C, Bifulco G, Giampaolino P. Is There Still a Place for Surgery in Patients with PCOS? A Review. Life (Basel) 2023; 13:1270. [PMID: 37374053 DOI: 10.3390/life13061270] [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: 04/18/2023] [Revised: 05/14/2023] [Accepted: 05/26/2023] [Indexed: 06/29/2023] Open
Abstract
OBJECTIVE The surgical management of polycystic ovary syndrome (PCOS) represents an unclear option compared to medical therapy, and it is necessary to deepen the role of minimally invasive surgery, represented by laparoscopic ovarian drilling (LOD) and transvaginal hydrolaparoscopy (THL), for the treatment of PCOS in infertile women resistant to drug therapy and to establish its success in terms of ovulation and pregnancy rates. METHODS A search was performed in the main electronic databases (MEDLINE, EMBASE, Web of Science, PubMed, and the Cochrane Library) from 1994 to October 2022 in order to evaluate the role of surgery in patients with PCOS resistant to pharmacological treatment. Only original scientific articles in English were included. RESULTS Seventeen studies were analyzed in this review. In all analyzed studies, more than 50% of the population underwent spontaneous ovulation after surgical treatment without great differences between the two surgical techniques (LOD and THL). More than 40% of patients delivered, with a higher rate after LOD, although eight ectopic pregnancies and sixty-three miscarriages were reported. A lower risk of adhesion formation after THL has been reported. No clear data regarding the effect of surgery on the regularization of the menstrual cycle has been described. A reduction in LH and AMH serum levels as well as the LH/FSH ratio compared to preoperative levels for both surgical techniques has been described. CONCLUSIONS Despite the scarcity and heterogeneity of data, surgical therapy could be considered an effective and safe approach in the management of PCOS patients with resistance to pharmacological treatment who desire to become pregnant.
Collapse
Affiliation(s)
- Luigi Della Corte
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples "Federico II", 80131 Naples, Italy
| | - Dominga Boccia
- Department of Public Health, School of Medicine, University of Naples "Federico II", 80131 Naples, Italy
| | - Mario Palumbo
- Department of Public Health, School of Medicine, University of Naples "Federico II", 80131 Naples, Italy
| | - Antonio Mercorio
- Department of Public Health, School of Medicine, University of Naples "Federico II", 80131 Naples, Italy
| | - Carlo Ronsini
- Department of Woman, Child and General and Specialized Surgery, School of Medicine, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy
| | - Giuseppe Bifulco
- Department of Public Health, School of Medicine, University of Naples "Federico II", 80131 Naples, Italy
| | - Pierluigi Giampaolino
- Department of Public Health, School of Medicine, University of Naples "Federico II", 80131 Naples, Italy
| |
Collapse
|
2
|
Burnik Papler T, Stimpfel M, Kovacik B, Bokal EV. Poor Ovarian Response to Gonadotrophins in PCOS Women after Laparoscopic Ovarian Drilling. Medicina (B Aires) 2022; 58:medicina58020147. [PMID: 35208471 PMCID: PMC8879148 DOI: 10.3390/medicina58020147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 01/13/2022] [Accepted: 01/16/2022] [Indexed: 11/16/2022] Open
Abstract
Background and Objectives: Polycystic ovary syndrome (PCOS) is a major cause of anovulatory infertility, and ovulation induction is the first-line treatment. If this fails, laparoscopic ovarian drilling (LOD) is used to induce mono-ovulations. There have been implications, that LOD can cause destruction of ovarian tissue and therefore premature ovarian failure. Furthermore, unexpected poor ovarian response (POR) to gonadotrophins can occur in PCOS women after LOD. There have been reports about FSH receptor polymorphisms found in women with PCOS that are related to higher serum FSH levels and POR to gonadotrophins. Materials and Methods: In the present study, we retrospectively analyzed data of 144 infertile PCOS women that had LOD performed before IVF. Results: Thirty of included patients (20.8%) had POR (≤3 oocytes) to ovarian stimulation with gonadotrophins. Women with POR had significantly higher median levels of basal serum FSH (7.2 (interquartile range (IQR), 6.0–9.2) compared to women with normal ovarian response (6.0 (IQR, 5.0–7.4); p = 0.006). Furthermore, women with POR used a significantly higher median cumulative dose of gonadotrophins (1875 IU (IQR, 1312.5–2400) for ovarian stimulation compared to women with normal ovarian response (1600 IU (IQR, 1200–1800); p = 0.018). Conclusion: Infertile PCOS women who experience POR after LOD have significantly higher serum FSH levels compared to women with normal ovarian response after LOD. As these levels are still within the normal range, we speculate that LOD is not the cause of POR. We presume that women with PCOS and POR after LOD could have FSH-R genotypes associated with POR and higher serum FSH levels.
Collapse
Affiliation(s)
- Tanja Burnik Papler
- Department of Human Reproduction, Division of Obstetrics and Gynecology, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia or (M.S.); (E.V.B.)
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
- Correspondence:
| | - Martin Stimpfel
- Department of Human Reproduction, Division of Obstetrics and Gynecology, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia or (M.S.); (E.V.B.)
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Brina Kovacik
- Obstetrics and Gynecology Hospital Kranj, 4000 Kranj, Slovenia;
| | - Eda Vrtacnik Bokal
- Department of Human Reproduction, Division of Obstetrics and Gynecology, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia or (M.S.); (E.V.B.)
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| |
Collapse
|
3
|
Wang Q, Wang H, Li P, Li X, Wang Z, Yan L, Shi Y. Association of Polycystic Ovary Syndrome Phenotypes With Adverse Pregnancy Outcomes After In-Vitro Fertilization/Intracytoplasmic Sperm Injection. Front Endocrinol (Lausanne) 2022; 13:889029. [PMID: 35721747 PMCID: PMC9203834 DOI: 10.3389/fendo.2022.889029] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 04/28/2022] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE This study aims to evaluate the association between polycystic ovary syndrome (PCOS) phenotypes and adverse perinatal outcomes, comparing the characteristics, ovarian response, and assisted reproductive outcomes in patients with various PCOS phenotypes after in-vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI). METHODS This study comprised 6,732 patients who underwent the first cycle of IVF/ICSI treatment in our outpatient department from January 2017 to July 2018. Propensity score matching (PSM) was used in PCOS and non-PCOS groups to balance the influence of intergroup confounding factors. After the PSM procedure, 1,186 patients were included in the two groups, and the PCOS patients were further divided into four PCOS phenotype groups based on the Rotterdam criteria. RESULTS Patients with various PCOS phenotypes had similar rates of biochemical pregnancy, clinical pregnancy, and live birth (all P-values > 0.05). The overall incidence of adverse pregnancy outcomes (including ectopic pregnancy, miscarriage, preterm birth) was significantly higher in PCOS phenotype A and D groups than in the control group (44% and 46.4% vs. 28.7%, P = 0.027). The rates of hypertensive disorder of pregnancy (HDP) were significantly higher in PCOS phenotype A and C groups than in the control group (9.3% and 12.5% vs. 3.1%, P = 0.037). After adjustment for potential confounders, the differences in adverse pregnancy outcomes persisted (P = 0.025). CONCLUSIONS The overall incidence of adverse pregnancy outcomes is higher in women with PCOS phenotypes A and D than in women with non-PCOS.
Collapse
Affiliation(s)
- Qiumin Wang
- Center for Reproductive Medicine, Shandong University, Jinan, China
- Shandong Provincial Clinical Medicine Research Center for Reproductive Health, Shandong University, Jinan, China
| | - Honghong Wang
- Center for Reproductive Medicine, Shandong University, Jinan, China
- Shandong Provincial Clinical Medicine Research Center for Reproductive Health, Shandong University, Jinan, China
- Children’s Hospital of Shanxi and Women Health Center of Shanxi, Taiyuan, China
| | - Ping Li
- Women and Children’s Hospital, School of Medicine, Xiamen University, Xiamen, China
| | - Xiufang Li
- Center for Reproductive Medicine, Shandong University, Jinan, China
- Shandong Provincial Clinical Medicine Research Center for Reproductive Health, Shandong University, Jinan, China
| | - Ze Wang
- Center for Reproductive Medicine, Shandong University, Jinan, China
- Shandong Provincial Clinical Medicine Research Center for Reproductive Health, Shandong University, Jinan, China
| | - Lei Yan
- Center for Reproductive Medicine, Shandong University, Jinan, China
- Shandong Provincial Clinical Medicine Research Center for Reproductive Health, Shandong University, Jinan, China
- *Correspondence: Lei Yan, ; Yuhua Shi,
| | - Yuhua Shi
- Shandong Provincial Clinical Medicine Research Center for Reproductive Health, Shandong University, Jinan, China
- Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- *Correspondence: Lei Yan, ; Yuhua Shi,
| |
Collapse
|
4
|
Collée J, Mawet M, Tebache L, Nisolle M, Brichant G. Polycystic ovarian syndrome and infertility: overview and insights of the putative treatments. Gynecol Endocrinol 2021; 37:869-874. [PMID: 34338572 DOI: 10.1080/09513590.2021.1958310] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Infertility concerns 15% of the couples. Management of female infertility requires a complete history of the patient followed by a physical, gynecological and endocrine examination. Infertility etiology will be investigated thanks to different tests including ovarian function and reserve assessment, search for uterine abnormalities and evaluation of tubal permeability. Polycystic ovarian syndrome (PCOS) is a predominant cause of infertility and a common gyne-endocrine disorder affecting 7 to 15% of women in reproductive age. Behavioral, medical and surgical treatments have been evaluated in order to improve the fertility of women with PCOS. Lifestyle modifications (stop smoking, physical exercise and weight loss when necessary) are of the utmost importance. Clomiphene citrate remains the first line of medical treatment of infertility in women with PCOS in absence of other male or female causes of infertility. Use of metformin solely for infertility is not recommended in absence of metabolic anomaly and new treatment as myoinositol is emerging. Surgical techniques aiming to enhance ovulation and pregnancy rate are an option when medical treatment failed. Ovarian drilling by laparoscopy or by transvaginal hydrolaparoscopy is taking a larger place in the treatment of infertility. In vitro maturation and fertilization remain the third-line of treatment in PCOS.
Collapse
Affiliation(s)
- Julie Collée
- Department of Obstetrics and Gynecology, Hospital CHR Liège, University of Liège, Liège, Belgium
| | - Marie Mawet
- Department of Obstetrics and Gynecology, Hospital CHR Liège, University of Liège, Liège, Belgium
| | - Linda Tebache
- Department of Obstetrics and Gynecology, Hospital CHR Liège, University of Liège, Liège, Belgium
| | - Michelle Nisolle
- Department of Obstetrics and Gynecology, Hospital CHR Liège, University of Liège, Liège, Belgium
| | - Géraldine Brichant
- Department of Obstetrics and Gynecology, Hospital CHR Liège, University of Liège, Liège, Belgium
| |
Collapse
|
5
|
Giampaolino P, Foreste V, Di Filippo C, Gallo A, Mercorio A, Serafino P, Improda FP, Verrazzo P, Zara G, Buonfantino C, Borgo M, Riemma G, Angelis CD, Zizolfi B, Bifulco G, Della Corte L. Microbiome and PCOS: State-of-Art and Future Aspects. Int J Mol Sci 2021; 22:2048. [PMID: 33669557 PMCID: PMC7922491 DOI: 10.3390/ijms22042048] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/14/2021] [Accepted: 02/15/2021] [Indexed: 12/11/2022] Open
Abstract
Polycystic ovary syndrome (PCOS) is a complex and heterogeneous endocrine disease. The hypothesis that alterations in the microbiome are involved in the genesis of PCOS has been postulated. Aim of this review is to summarize the available literature data about the relationship between microbiome and PCOS. A search on PubMed and Medline databases was performed from inception to November 20Most of evidence has focused on the connection of intestinal bacteria with sex hormones and insulin-resistance: while in the first case, a relationship with hyperandrogenism has been described, although it is still unclear, in the second one, chronic low-grade inflammation by activating the immune system, with increased production of proinflammatory cytokines which interfere with insulin receptor function, causing IR (Insulin Resistance)/hyperinsulinemia has been described, as well as the role of gastrointestinal hormones like Ghrelin and peptide YY (PYY), bile acids, interleukin-22 and Bacteroides vulgatus have been highlighted. The lower genital tract microbiome would be affected by changes in PCOS patients too. The therapeutic opportunities include probiotic, prebiotics and synbiotics, as well as fecal microbiota transplantation and the use of IL-22, to date only in animal models, as a possible future drug. Current evidence has shown the involvement of the gut microbiome in PCOS, seen how humanized mice receiving a fecal transplant from women with PCOS develop ovarian dysfunction, immune changes and insulin resistance and how it is capable of disrupting the secondary bile acid biosynthesis. A future therapeutic approach for PCOS may involve the human administration of IL-22 and bile acid glycodeoxycholic acid.
Collapse
Affiliation(s)
- Pierluigi Giampaolino
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (P.G.); (A.G.); (F.P.I.); (P.V.); (C.B.); (M.B.); (C.D.A.); (B.Z.)
| | - Virginia Foreste
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, 80131 Naples, Italy; (V.F.); (C.D.F.); (A.M.); (P.S.); (G.Z.); (G.B.)
| | - Claudia Di Filippo
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, 80131 Naples, Italy; (V.F.); (C.D.F.); (A.M.); (P.S.); (G.Z.); (G.B.)
| | - Alessandra Gallo
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (P.G.); (A.G.); (F.P.I.); (P.V.); (C.B.); (M.B.); (C.D.A.); (B.Z.)
| | - Antonio Mercorio
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, 80131 Naples, Italy; (V.F.); (C.D.F.); (A.M.); (P.S.); (G.Z.); (G.B.)
| | - Paolo Serafino
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, 80131 Naples, Italy; (V.F.); (C.D.F.); (A.M.); (P.S.); (G.Z.); (G.B.)
| | - Francesco Paolo Improda
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (P.G.); (A.G.); (F.P.I.); (P.V.); (C.B.); (M.B.); (C.D.A.); (B.Z.)
| | - Paolo Verrazzo
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (P.G.); (A.G.); (F.P.I.); (P.V.); (C.B.); (M.B.); (C.D.A.); (B.Z.)
| | - Giuseppe Zara
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, 80131 Naples, Italy; (V.F.); (C.D.F.); (A.M.); (P.S.); (G.Z.); (G.B.)
| | - Cira Buonfantino
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (P.G.); (A.G.); (F.P.I.); (P.V.); (C.B.); (M.B.); (C.D.A.); (B.Z.)
| | - Maria Borgo
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (P.G.); (A.G.); (F.P.I.); (P.V.); (C.B.); (M.B.); (C.D.A.); (B.Z.)
| | - Gaetano Riemma
- Obstetrics and Gynecology Unit, Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy;
| | - Chiara De Angelis
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (P.G.); (A.G.); (F.P.I.); (P.V.); (C.B.); (M.B.); (C.D.A.); (B.Z.)
| | - Brunella Zizolfi
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy; (P.G.); (A.G.); (F.P.I.); (P.V.); (C.B.); (M.B.); (C.D.A.); (B.Z.)
| | - Giuseppe Bifulco
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, 80131 Naples, Italy; (V.F.); (C.D.F.); (A.M.); (P.S.); (G.Z.); (G.B.)
| | - Luigi Della Corte
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, 80131 Naples, Italy; (V.F.); (C.D.F.); (A.M.); (P.S.); (G.Z.); (G.B.)
| |
Collapse
|
6
|
Jiang B, Xue M, Xu D, Song Y, Zhu S. Upregulation of microRNA-204 improves insulin resistance of polycystic ovarian syndrome via inhibition of HMGB1 and the inactivation of the TLR4/NF-κB pathway. Cell Cycle 2020; 19:697-710. [PMID: 32089069 PMCID: PMC7145337 DOI: 10.1080/15384101.2020.1724601] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 12/02/2019] [Accepted: 12/29/2019] [Indexed: 12/21/2022] Open
Abstract
There is growing evidence of the position of microRNAs (miRs) in polycystic ovarian syndrome (PCOS), thus our objective was to discuss the impact of miR-204 on insulin resistance (IR) in PCOS by targeting highmobility group box protein 1(HMGB1)-mediated toll-like receptor 4(TLR4)/nuclear factor-kappa B (NF-κB) pathway.PCOS-IR patients and PCOS non-insulin resistance (PCOS-NIR) patients were included. The levels of serum sex hormones and related insulin were measured, the expression of miR-204, HMGB1, TLR4 and NF-κB p65 was detected, the diagnostic efficacy of miR-204 in PCOS-IR was analyzed, and the correlation between the expression of miR-204 in PCOS-IR and fasting blood glucose (FPG), fasting insulin (FINS), homeostasis model of assessment for insulin resistance index (HOMA-IR) was analyzed. Both in vitro and in vivo experiments were performed to elucidate the capabilities of miR-204 and HMGB1 in proliferation and apoptosis of PCOS-IR granulosa cells.MiR-204 was lowly expressed as well as HMGB1, TLR4 and NF-κB p65 were highly expressed in PCOS-IR patients. Follicule-stimulating hormone was downregulated, while luteinizing hormone, estrogen, progesterone, FPG, FINS and HOMA-IR were elevated in PCOS-IR. Upregulation of miR-204 and downregulation of HMGB1 could repress TLR4/NF-κB pathway activation, degraded insulin release and testosterone (T) leveland ascended ovarian coefficient, boosted cell proliferation and restrained apoptosis of granulosa cells. Overexpression of HMGB1 reverses the effect of upregulation of miR-204 on IR of PCOS.Our study presents that high expression of miR-204 or inhibition of HMGB1 can improve IR of PCOS via the inactivation of TLR4/NF-κB pathway.
Collapse
Affiliation(s)
- Bin Jiang
- Department of Gynaecology, The Third Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Min Xue
- Department of Gynaecology, The Third Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Dabao Xu
- Department of Gynaecology, The Third Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Yujia Song
- Department of Gynaecology, The Third Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Shujuan Zhu
- Department of Gynaecology, The Third Xiangya Hospital of Central South University, Changsha, Hunan, China
| |
Collapse
|
7
|
Abu Hashim H, Foda O, El Rakhawy M. Unilateral or bilateral laparoscopic ovarian drilling in polycystic ovary syndrome: a meta-analysis of randomized trials. Arch Gynecol Obstet 2018; 297:859-870. [PMID: 29374790 DOI: 10.1007/s00404-018-4680-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 01/17/2018] [Indexed: 12/26/2022]
Abstract
PURPOSE This systematic review and meta-analysis aimed to compare the effectiveness of unilateral vs. bilateral laparoscopic ovarian drilling (ULOD vs. BLOD) for improving fertility outcomes in infertile women with clomiphene-resistant polycystic ovary syndrome (PCOS) as well as its effect on ovarian reserve. METHODS Searches were conducted on PubMed, ScienceDirect, ClinicalTrials.gov, and CENTRAL databases from January 1984 to January 2017. Only randomized trials comparing ULOD with BLOD were included. The PRISMA Statement was followed. Main outcomes were ovulation and clinical pregnancy rates per woman randomized. Secondary outcomes were; live birth and miscarriage rates as well as postoperative serum anti-mullerian hormone (AMH) concentration and antral follicle count (AFC). Quality assessment was performed by the Cochrane Collaboration risk of bias tool. RESULTS Eight eligible trials (484 women) were analyzed. No significant difference was found in rates of ovulation (OR 0.73; 95% CI 0.47-1.11), clinical pregnancy (OR 0.56; 95% CI 0.22-1.41), live birth (OR 0.77; 95% CI 0.28-2.10), or miscarriage (OR 0.90; 95% CI 0.33-2.84) when ULOD was compared with BLOD. The reduction in AMH was comparable between the two procedures (MD 0.64 ng/ml; 95% CI - 0.08 to 1.36). A significantly higher AFC at 6-month follow-up was found with dose-adjusted ULOD (MD 2.20; 95% CI 1.01-3.39). CONCLUSIONS After carefully weighing up the well-known benefits of BLOD against a potential risk to ovarian reserve, clinicians could be advised to offer the fixed-dose ULOD to their infertile patients with clomiphene-resistant PCOS. This is concordant with the "primum non nocere" principal if LOD will be envisaged.
Collapse
Affiliation(s)
- Hatem Abu Hashim
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mansoura University, Mansoura, Egypt.
| | - Osama Foda
- Endocrinology Unit, Department of Internal Medicine, Mansoura University, Mansoura, Egypt
| | - Mohamed El Rakhawy
- Department of Diagnostic Radiology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| |
Collapse
|