Afshin Azimirad

Cesarean section rates have risen significantly in some Middle Eastern countries like Iran, Turkey, and Egypt. Therefore, this review aims to investigate the cultural background for the high cesarean section rates in some Middle Eastern countries to provide the obstetricians and policymakers a better perspective on the crisis. Firstly, the dimensions of the current crisis in the Middle East are discussed. Then, three famous medieval authors are investigated; Ferdowsi (Shahnameh; the birth of Rostam, the Persian superhero, through the cesarean section), Abu Rayhan Biruni (The Remaining Signs of Past Centuries), and Ibn Abi al-Hadid. All these medieval sources try to teach how proud is the one who is born through a cesarean section, and thus a person born vaginally is of a lower rank and therefore less respected. Then, the influencing ancient resources dealing with this subject are reviewed: the birth of Asclepius, the Greek god of medicine, by his father Apollo through a section on the mother’s corpse, and Talmud of the Jews. In ancient times, a birth through the cesarean section was a pure birth, or a gift from gods and restricted to divinities. Hoping to gain a new and comprehensive understanding of this current crisis in the Middle East, the World Health Organization (WHO) guidelines on reducing the prevalence of cesarean section are subsequently introduced. The C-section prevalence has increased significantly in the Middle East; comprehensive national, regional, and international policies are highly demanded.

Although endometriosis is not a newly discovered disease, it has still remained enigmatic. Understanding the pathophysiology of this disease is still one of the challenges of gynecology and reproductive medicine. Therefore, the subject of endometriosis treatment faces many questions to be answered. Even though this is not considered to be a rare disease, testing novel treatments on subjects is definitely contrary to medical ethics. This is where importance of animal studies is emphasized. History of animal studies on endometriosis dates back to the time when the young John Sampson presented his theory of retrograde flow of menstruation to the gynecologic society of his time to explain the mechanism of endometriosis. However, most of the medical society of that time favored metaplasia as the main mechanism over the new theory. In order to prove Sampson's theory, animal models were used to induce endometriosis, and that was the first study of experimental endometriosis. Nowadays, although no one uses animals to evaluate Sampson theory of endometriosis, however, experimental endometriosis is widely used to study many different aspects of the disease from pathogenesis to possible options for treatments. Also, since then, various animals and different techniques have been proposed and so there is a huge body of literature on experimental endometriosis. Contrary to many countries, Iranian medical societies have neglected animal models for endometriosis until recently. This review article aims to go through the prominent articles on the subject and introduce different animals and methods to its readers and have a special look at Iranian literature on experimental endometriosis.

This study aimed to assess the efficacy of thalidomide for treatment of experimental endometriosis. This study was a parallel-group, double-blind, stratified, randomized controlled animal trial with 1:1 allocation ratio. Endometriosis was induced experimentally in 23 mature, nulligravid, female Sprague-Dawley rats, weighing approximately 200 g and aged 2 months. A checkpoint surgery was performed 6 weeks later. Then, the rats were randomly allocated into the thalidomide (22 mg/day p.o.) and control (0.5 mL saline 0.9%/day p.o.) groups of nine. After 6 weeks, they were killed. Before each laparotomy, blood for leukocyte and lymphocyte counts and during them, implants for histopathology and peritoneal fluid for interleukin (IL)-6, tumor necrosis factor-α and vascular endothelial growth factor (VEGF)-A concentrations (by enzyme-linked immunoassay) were collected. Allocation and stratified randomization were done using a computer, based on the obtained histopathology scores of the implants of the checkpoint surgery. The histopathology scores (the main outcome measure) were 2.00 ± 1.55 versus 0.44 ± 1.01 (P = 0.035). The comparisons of after-treatment counts of leukocytes, lymphocytes, VEGF-A and IL-6 between the two groups were statistically significant. The results of this study are in favor of therapeutic implication of thalidomide in experimental endometriosis in rats. This is the first time thalidomide has been evaluated on endometriosis in an animal model.

A 49 year old woman diagnosed as a cervical cancer patient, after receiving appropriate treatment experienced metastasis in her abdominopelvic cavity. After aggressive management, she was well for a while. However, she developed to a poor condition consisting of urologic, gastroenterological, hematologic and neurologic problems just in a short time. In the course of hospital she presented one sided passive bradykinesia, resting tremor, cogwheel rigidity with controlateral suspicious CT scan of brain. She passed away soon after that.

To assess the effects of levamisole on experimental endometriosis in rats through the histopathology of the implants, the blood leukocyte and lymphocyte counts and the concentrations of interleukin-6, vascular endothelial growth factor-A and tumor necrosis factor-alpha in the peritoneal environment at the three healthy, endometriotic and post-treatment milestones. Twenty-two 8-week-old Sprague–Dawley rats with normal estrus cycles were recruited in a prospective, parallel-group, placebo-controlled, double-blind, stratified-randomized animal trial with the equal allocation ratio of 1:1 challenging the efficacy of levamisole. Endometriosis was induced. After 6 weeks, laparotomy was performed to randomly excise one implant for histopathology assessment. Based on the results, they were stratified randomized and allocated (by software) to two groups of nine: levamisole (5 mg/rat/day) or placebo. After 6 weeks, necropsy was done. Two days before each laparotomy, blood samples and during the procedure, peritoneal wash were collected for ELISA. Seven rats showed success in treatment in the levamisole group, while three did in the other group. The histopathology results descriptively revealed a drop in the levamisole group, which was not meaningful statistically (0.66 ± 1.32 vs. 2.00 ± 1.50, p = 0.065). The comparisons of the post-treatment leukocytes and lymphocytes in the groups showed significant differences (11088.88 ± 5869.50 vs. 4677.77 ± 3476.98, p = 0.008, and 8588.88 ± 5721.32 vs. 3511.11 ± 2835.24, p = 0.014, respectively). The results of the cytokines were mostly, but not completely, in favor of the efficacy of levamisole. This study indicates a possible successful role for levamisole in the treatment of experimental endometriosis. Further studies to assess the effects of high dose levamisole on endometriosis are recommended.