Origin-Level Uterine Artery Ligation in Laparoscopic Hysterectomy for Intraligamentary Myoma.

Background and Objectives: Intraligamentary myomas distort broad-ligament anatomy and carry a high risk of bleeding during hysterectomy. We examined whether concomitant origin-level uterine artery ligation was associated with lower estimated blood loss.

In this retrospective single-center cohort, 170 consecutive women underwent total laparoscopic hysterectomy for intraligamentary myoma (2015–2025); 91 received bilateral origin-level ligation. Estimated blood loss was compared with a multivariable regression model adjusted for patient characteristics, myoma diameter, and lateral localization.

Myomas in the ligation group were larger (median 9 vs 7 centimeters) and more often lateral (48% vs 14%), whereas crude mean blood loss was similar. In the regression analysis of mean blood loss, ligation was associated with lower blood loss only after adjustment (adjusted mean ratio 0.84; 95% confidence interval, 0.78 to 0.89), corresponding to an adjusted absolute reduction of 18 milliliters (95% confidence interval, 11 to 25). The postoperative hemoglobin decrease was smaller in the ligation group; operative time, hospital stay, transfusion, and complications did not differ significantly (few events).

In this nonrandomized cohort, origin-level ligation was associated with a modest reduction in adjusted estimated blood loss, without a detectable increase in operative time. Because it was selected intraoperatively for larger, more complex myomas, confounding by indication cannot be excluded; the findings are hypothesis-generating rather than causal.

Broad ligament, Laparoscopic hysterectomy, Leiomyoma, Ligation, Surgical blood loss, Uterine artery

Uterine leiomyomas are the most common benign tumors of the female genital tract. A small but surgically demanding subset extends from the lateral uterine wall between the leaves of the broad ligament as intraligamentary myomas, which account for roughly 6% to 10% of uterine myomas.1 Confined within the broad ligament, these tumors displace the uterine vessels, ureter, and pelvic sidewall structures and distort the anatomic landmarks that normally guide safe pedicle control, making hysterectomy in this setting more difficult and more prone to bleeding than for conventionally located myomas. Ordinarily, most uterine blood flow passes through the uterine arteries; therefore, securing these vessels early is a rational strategy to limit bleeding and improve visualization. Retroperitoneal control of the uterine artery at its origin from the internal iliac artery has been described to reduce blood loss and to facilitate identification of the ureter during both myomectomy and hysterectomy.2–6 Most of the supporting evidence, however, comes from myomectomy series, and the effect on blood loss during hysterectomy has been examined in only a few studies, including a randomized comparison of origin-level versus uterus-level closure.3,7–9 Evidence specific to the intraligamentary myoma—the subgroup in which the artery is most displaced and the ureter most at risk, and in which origin-level control is therefore anatomically most appealing—is particularly scarce. We therefore reviewed a consecutive single-center cohort of women undergoing total laparoscopic hysterectomy for an intraligamentary myoma and examined the factors associated with estimated blood loss, with particular attention to concomitant origin-level uterine artery ligation, while accounting for the greater myoma burden of the patients selected for that technique. We hypothesized that origin-level uterine artery ligation would be associated with lower estimated blood loss.

Study Design and Ethics This was a retrospective cohort study at a single tertiary care center. The study is reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cohort studies.10 Consecutive women who underwent total laparoscopic hysterectomy for an intraligamentary myoma between Jan 2015 and Nov 2025 were identified from the institutional operative database. The study was approved by the institutional ethics committee and conducted in accordance with the Declaration of Helsinki11; because of the retrospective design, the requirement for informed consent was waived. Patients: Inclusion and Exclusion Criteria The source population comprised all total laparoscopic hysterectomies performed at the center during the study period. Cases were excluded if the hysterectomy was performed for—or combined with surgery for—an indication other than an intraligamentary myoma: malignant or suspected malignant indication, abnormal uterine bleeding not attributable to myoma, adenomyosis, endometriosis or chronic pelvic pain, pelvic organ prolapse, benign adnexal or risk-reducing surgery, endometrial hyperplasia without atypia, or other benign indications. Exclusion categories were mutually exclusive, and each excluded case was assigned to a single, hierarchically prioritized reason. The intraligamentary location was confirmed intraoperatively from the operative record, and the diagnosis of leiomyoma was confirmed histologically. In patients with more than 1 myoma, classification was based on the dominant intraligamentary lesion. All eligible patients meeting these criteria were included; the screening and exclusion cascade is shown in Figure 1A. Intraligamentary Myoma Definition and Localization An intraligamentary myoma was defined as a leiomyoma extending from the lateral uterine wall between the leaves of the broad ligament, displacing the adjacent uterine vessels, ureter, or pelvic sidewall. The preoperative diagnosis was based on transvaginal ultrasonography in all patients. Magnetic resonance imaging was additionally performed in 42 patients (24.7%); in our practice, it is requested for myomas larger than 12 cm, for lesions with a suspicious sonographic appearance, when a myoma cannot be distinguished from an adnexal mass, or when its exact site of origin is unclear. The diagnosis was confirmed intraoperatively. Localization was recorded in 4 categories according to the dominant direction of broad-ligament extension—anterior, posterior, lateral, and deep pelvic. In the regression models, lateral localization was modeled as a separate binary covariate, as it captured the sidewall vascular distortion most relevant to blood loss. Selection of the Ligation Approach The decision to perform origin-level uterine artery ligation was made intraoperatively by the operating surgeon, based on the myoma size and localization and the degree of anatomic distortion of the ureter and uterine vessels encountered at surgery; the technique was generally applied to larger and more laterally placed lesions. No protocolized threshold was used, and the choice ultimately reflected intraoperative surgical judgment. Surgical Technique All procedures were performed by surgeons with at least 4 years of advanced laparoscopic experience. In the ligation group, the retroperitoneal space was entered and the origin of the uterine artery from the internal iliac artery was identified; the uterine artery was then isolated and sealed bilaterally at its origin using the LigaSure vessel-sealing device (origin-level uterine artery sealing, hereafter termed ligation for consistency with the existing literature) before the remaining hysterectomy steps. Ureterolysis was not performed routinely; the ureter was formally identified when the origin of the uterine artery could not otherwise be safely exposed. In the standard group, the uterine pedicles were secured at the level of the uterus in the conventional manner using the same vessel-sealing device. Specimens were removed by contained in-bag morcellation or vaginal extraction. Ureteral stents, including lighted stents, and indocyanine green ureteral visualization were not used, as they were not available at our institution during the study period owing to cost and resource limitations; instead, routine cystoscopy was performed at the conclusion of every procedure to confirm bilateral ureteral efflux. Outcomes and Measurements The primary outcome was intraoperative estimated blood loss, determined by the anesthesia team from the suction-canister volume after subtraction of irrigation fluid, together with the anesthetic record and gravimetric assessment of surgical sponges. Operative time was defined as skin-to-skin surgical time, from incision to closure. Secondary outcomes were the postoperative hemoglobin decrease, operative time, hospital stay, blood transfusion, intraoperative organ or vascular injury, conversion to laparotomy, and unplanned 30-day readmission. Postoperative hemoglobin was measured at the 6th postoperative hour, in accordance with our institutional protocol for the early detection of postoperative bleeding; the preto-postoperative hemoglobin difference was documented in the medical record, but the individual preoperative hemoglobin values were not retained in the original analytic dataset and were retrieved from the medical records during the revision. Blood transfusion was not part of routine preoperative preparation and was administered on the basis of the postoperative hemoglobin change and the patient's overall clinical condition. Comorbidity was defined as the presence of diabetes mellitus, hypertension, hypothyroidism, or other chronic systemic disease. Data Sources Baseline, myoma, operative-year, and operating-surgeon data were abstracted from the hospital operative and medical records; the cohort was managed by 8 surgeons. All cases with transfusion, intraoperative injury, conversion, or readmission were individually rereviewed in the electronic medical record to characterize the event. No values were imputed; all included patients had complete data for the analyzed variables. Statistical Analysis Continuous variables are summarized as median (interquartile range) and compared with the Mann–Whitney U test12; categorical variables are summarized as number (percentage) and compared with the Fisher exact test.13 Because estimated blood loss was strictly positive and right-skewed, it was analyzed with a single primary multivariable γ generalized linear model (log link, robust standard errors), with effects expressed as mean ratios (a ratio below 1 indicating lower blood loss). The model included age, body mass index, previous pelvic surgery, comorbidity, largest myoma diameter, and lateral localization; because ligation was used mainly for larger and more laterally placed myomas, these 2 variables were the principal sources of confounding by indication. The adjusted difference was expressed in milliliters as adjusted predicted means, with bootstrap 95% confidence intervals (CIs). Supporting analyses (Table 4) repeated the primary model with propensity-score overlap weighting,14 with additional adjustment for calendar year, operating surgeon, and preoperative hemoglobin, and after exclusion of transfused patients; interactions of ligation with myoma diameter and lateral localization were also examined. Secondary outcomes were analyzed with the same covariates, using linear (hemoglobin decrease) or γ (operative time, hospital stay) models. Table 4. | Analysis | Estimate (95% CI) | P | |---|---|---| | Estimated blood loss, LUA mean ratio | || | Primary adjusted model (Table 3) | 0.84 (0.78–0.89) | <.001 | | Propensity-score overlap weighting | 0.83 (0.75–0.92) | <.001 | | + Calendar year and operating surgeon | 0.84 (0.78–0.90) | <.001 | | + Preoperative hemoglobin | 0.85 (0.80–0.91) | <.001 | | Transfused patients excluded (n = 163) | 0.87 (0.83–0.91) | <.001 | | Hemoglobin decrease, adjusted mean difference, g/dL | || | Primary adjusted model (Table 3) | −0.28 (−0.36 to −0.20) | <.001 | | + Preoperative hemoglobin | −0.26 (−0.35 to −0.18) | <.001 | | Transfused patients excluded (n = 163) | −0.25 (−0.32 to −0.17) | <.001 | Estimated blood loss was analyzed with γ generalized linear models (log link) and hemoglobin decrease with linear regression, all with robust standard errors. Except for the overlap-weighted estimate, all models included the covariates of the primary model. Overlap weights were derived from a propensity score estimated by logistic regression on these covariates (effective sample size 130); calendar year was entered as a linear term and the operating surgeon as fixed effects. Preoperative hemoglobin values were retrieved from the medical records during the revision. CI, confidence interval; LUA, laparoscopic uterine artery ligation. The secondary outcomes were defined by 3 clinical questions: whether ligation reduces bleeding (hemoglobin decrease, transfusion), whether it prolongs surgery (operative time), and whether it affects recovery and safety (hospital stay, intraoperative injury, conversion, and readmission). No formal sample-size calculation was performed; all consecutive eligible patients were included. Descriptive analyses were performed in IBM SPSS Statistics version 27.0 (IBM Corp, Armonk, NY) and regression analyses in Python (statsmodels). A 2-sided P ≤ .05 was considered statistically significant.

Study Population Of 8,852 women who underwent total laparoscopic hysterectomy during the study period, 170 met the criteria for an intraligamentary myoma and formed the study cohort; 79 underwent standard laparoscopic hysterectomy and 91 (53.5%) received concomitant bilateral origin-level uterine artery ligation. The screening process and reasons for exclusion are shown in Figure 1A. The procedures were performed by 8 surgeons (median 22 cases each, range 16–26), whose individual ligation rates ranged from 38.9% to 70.8%. Baseline and Operative Characteristics The 2 groups were similar in age, body mass index, parity, and previous pelvic surgery. The ligation group, however, had substantially larger myomas (median 9 vs 7 cm; standardized mean difference [SMD] 0.73), more frequent lateral localization (48.4% vs 13.9%; SMD 0.80), a higher proportion of deep pelvic lesions (9.9% vs 1.3%), and heavier specimens (median 222 vs 155 g), indicating that ligation had been reserved for the more complex cases (Table 1). Comorbidity was somewhat less frequent in the ligation group (75.8% vs 87.3%; SMD 0.30), a difference for which the multivariable model adjusts and which is unlikely to bias the estimate toward benefit. Table 1. | Characteristic | Standard LH (n = 79) | LUA + LH (n = 91) | SMD | |---|---|---|---| | Age, years | 49 (46–53) | 48 (45–52) | 0.11 | | Body mass index, kg/m² | 25.6 (24.1–26.4) | 25.8 (24.9–26.4) | 0.20 | | Multiparous, n (%) | 77 (97.5) | 86 (94.5) | 0.15 | | Previous pelvic surgery, n (%) | 22 (27.8) | 28 (30.8) | 0.06 | | Comorbidity, n (%) | 69 (87.3) | 69 (75.8) | 0.30 | | Largest myoma diameter, cm | 7 (6–8) | 9 (8–9) | 0.73 | | Myoma localization, n (%) | ||| | Anterior | 46 (58.2) | 11 (12.1) | | | Posterior | 21 (26.6) | 27 (29.7) | | | Lateral | 11 (13.9) | 44 (48.4) | 0.80 | | Deep pelvic | 1 (1.3) | 9 (9.9) | 0.38 | | Removed specimen weight, g | 155 (105–238) | 222 (187–255) | 0.53 | Values are median (interquartile range) unless otherwise indicated. |SMD| > 0.10 indicates potential imbalance. Deep pelvic lesions are shown separately; lateral localization was modeled as a binary covariate in the regression models. LH, laparoscopic hysterectomy; LUA, laparoscopic uterine artery ligation; SMD, standardized mean difference. Primary Outcome: Estimated Blood Loss Median estimated blood loss was modestly lower in the ligation group (88 vs 96 mL; P = .005), but mean blood loss was similar (98.9 vs 102.4 mL), and ligation was not associated with blood loss in the unadjusted model (mean ratio 0.97; 95% CI, 0.88–1.06) (Tables 2 and 3). Table 2. | Outcome | Standard LH (n = 79) | LUA + LH (n = 91) | P | |---|---|---|---| | Estimated blood loss, mL | 96 (88–108) | 88 (82–102) | .005 | | Operative time, minutes | 98 (90–110) | 100 (90–115) | .490 | | Hospital stay, hours | 25 (24–28) | 25 (25–28) | .083 | | Hemoglobin decrease, g/dL | 1.3 (1.1–1.5) | 1.1 (0.9–1.4) | .023 | | Blood transfusion, n (%) | 2 (2.5) | 5 (5.5) | .452 | | Intraoperative organ/vascular injury, n (%) | 1 (1.3) | 2 (2.2) | 1.000 | | Conversion to laparotomy, n (%) | 1 (1.3) | 1 (1.1) | 1.000 | | Unplanned 30-d readmission, n (%) | 6 (7.6) | 3 (3.3) | .306 | Continuous variables compared with the Mann–Whitney U test and categorical variables with the Fisher exact test. Mean ± SD estimated blood loss: standard 102.4 ± 28.5 mL; LUA 98.9 ± 34.2 mL. LH, laparoscopic hysterectomy; LUA, laparoscopic uterine artery ligation. Table 3. | Outcome/Estimate | Estimate (95% CI) | P | |---|---|---| | Estimated blood loss (primary outcome) | || | Unadjusted mean ratio | 0.97 (0.88–1.06) | .47 | | Adjusted mean ratio | 0.84 (0.78–0.89) | <.001 | | Adjusted predicted mean EBL—Standard, mL | 110.6 | | | Adjusted predicted mean EBL—LUA, mL | 92.5 | | | Adjusted absolute difference, mL | −18.1 (−25.3 to −11.1) | | | Secondary outcomes | || | Hemoglobin decrease, adjusted mean difference, g/dL | −0.28 (−0.36 to −0.20) | <.001 | | Operative time, adjusted mean ratio | 0.96 (0.91–1.00) | .071 | | Hospital stay, adjusted mean ratio | 1.07 (0.97–1.18) | .199 | Mean ratios are from γ generalized linear models (log link) and the hemoglobin difference from linear regression, all with robust standard errors; a mean ratio ≤ 1 indicates a lower value in the ligation group. Adjusted estimates are from models including age, body mass index, previous pelvic surgery, comorbidity, largest myoma diameter, and lateral localization; adjusted predicted means are derived from the blood-loss model with bootstrap 95% CIs. CI, confidence interval; EBL, estimated blood loss; LUA, laparoscopic uterine artery ligation. The proportion of cases managed with ligation rose over the study period, from 1 of 9 cases (11.1%) in 2015 to 20 of 25 cases (80.0%) in 2025 (Figure 1B). In the regression analysis of mean blood loss, ligation was associated with lower estimated blood loss only after adjustment for patient characteristics, myoma diameter, and lateral localization (adjusted mean ratio 0.84; 95% CI, 0.78–0.89; P ≤ .001). This corresponded to adjusted mean blood loss of 92.5 vs 110.6 mL, an absolute difference of −18.1 mL (95% CI, −25.3 to −11.1) (Table 3). Supporting analyses, including propensity-score overlap weighting, additional adjustment for calendar year, operating surgeon, and preoperative hemoglobin, and exclusion of transfused patients, gave similar estimates (mean ratios 0.83–0.87) (Table 4), and ligation did not interact with myoma diameter or lateral localization. Secondary Outcomes The adjusted postoperative hemoglobin decrease was smaller in the ligation group (adjusted mean difference −0.28 g/dL; 95% CI, −0.36 to −0.20; P < .001), including after exclusion of transfused patients and after adjustment for preoperative hemoglobin (Table 4). Adjusted operative time (mean ratio 0.96; P = .07) and hospital stay (1.07; P = .20) did not differ materially between groups (Table 3). Safety and Complications Seven patients received a transfusion (2 standard, 5 ligation). All transfusions were given postoperatively, and each patient received 1 U of red blood cells, except 2 patients in the ligation group who received 2 U. Their myomas measured 8–17 cm, preoperative hemoglobin ranged from 10.1 to 10.6 g/dL, within the lowest quartile of the cohort, and 6th-hour postoperative hemoglobin from 7.3 to 8.6 g/dL. Transfusion was prompted by postoperative anemia with a fall in hemoglobin, combined in 4 patients in the ligation group with suspected intraoperative bleeding and in 2 with a low preoperative hemoglobin; no further intervention was required. Three intraoperative injuries occurred, all serosal: 1 bowel serosal injury during resection of a posteriorly located myoma and 2 bladder serosal injuries during anterior dissection, all repaired intraoperatively without full-thickness visceral or ureteral injury and without sequelae. Two procedures were converted to laparotomy—one for limited exposure with a 500-g specimen and one for an anesthesia-related reason—neither for hemorrhage. Nine unplanned 30-day readmissions (6 standard, 3 ligation), for vault hematoma and pain-related presentations, were managed conservatively.

In this consecutive series of 170 women undergoing total laparoscopic hysterectomy for an intraligamentary myoma, concomitant bilateral origin-level ligation of the uterine artery was associated with lower adjusted estimated blood loss. In the regression analysis of mean blood loss, the association emerged only after adjustment—unsurprisingly, since ligation had been reserved for the larger, more laterally placed myomas that bleed more—and corresponded to an absolute difference of approximately 18 mL. The finding was consistent across supporting analyses (Table 4), indicating that neither temporal trends nor operator differences explained it. Because the ligation group comprised the more difficult cases from the outset—larger, more laterally placed myomas with greater anatomic distortion—confounding by indication, rather than a treatment effect, remains the most likely alternative explanation and is the central limitation of this design. Our results are consistent with a growing body of work on uterine artery control during minimally invasive myoma surgery, while extending it to a specific and difficult subgroup. In a randomized trial of total laparoscopic hysterectomy, El-Minawi et al reported that bilateral uterine artery ligation at its origin significantly reduced blood loss compared with conventional hysterectomy (103.7 vs 128.7 mL; P = .007)—a relative reduction of approximately 19%, broadly comparable to the 16% observed here—using the same bilateral origin-level approach, with a modest increase in operative time and no excess major morbidity.9 This pattern is echoed across the total laparoscopic hysterectomy literature. In the largest randomized trial, Uccella et al found that origin-level uterine artery closure reduced intraoperative blood loss and was more reproducible than closure at the uterus level but, as in our cohort, without translation into a measurable clinical benefit; the authors specifically suggested a possible advantage in the presence of pelvic anatomic distortion—the very situation defined by an intraligamentary myoma.8 Smaller prospective series have likewise reported less bleeding and shorter operative times with prior origin-level ligation.7,15,16 In laparoscopic myomectomy, a 2026 systematic review and meta-analysis of 7 comparative studies (857 women) found that temporary uterine artery ligation was associated with lower estimated blood loss (mean difference −84.7 mL; 95% CI, −89.0 to −80.4) and a smaller postoperative hemoglobin decrease, at the cost of a longer operative time (mean difference +16.5 minutes; 95% CI, 3.4 to 29.6); the authors considered it a possible adjunct in selected patients while emphasizing heterogeneity and the need for stratification by ligation technique,17 in keeping with earlier myomectomy series and meta-analyses with heterogeneous effects.4–6,18 In contrast, Lysdal et al found no reduction in blood loss after lateral origin-level uterine artery occlusion in a randomized trial and reported a mean operative time approximately 6 minutes longer, concluding that the technique should not be adopted as a standard procedure; notably, the same group’s earlier systematic review had suggested benefit.19 These divergent results suggest that any benefit may depend on patient selection, anatomical complexity, and the specific occlusion technique—a reading consistent with our own finding of an association confined to an anatomically distorted subgroup. The novelty of the present work lies not in general uterine artery control, which is well described, but in its focus on the intraligamentary myoma managed by hysterectomy, in which distorted anatomy and ureteral displacement make the anatomic rationale for origin-level control strongest. The clinical meaning of the association is best interpreted through the absolute rather than the relative difference. An adjusted difference of roughly 18 mL—smaller than the imprecision inherent in the visual and gravimetric estimation of surgical blood loss—is unlikely to be clinically decisive, and it did not translate into fewer transfusions or a shorter hospital stay.20 Because estimated blood loss was recorded by an unblinded team and is inherently subjective, the postoperative hemoglobin decrease is arguably the more objective hemostatic endpoint, and it is reassuring that it moved in the same direction: the smaller decrease persisted after excluding transfused patients and is not susceptible to the observer bias that limits estimated blood loss. Taken together, the 2 endpoints point consistently, though modestly, in the same direction; the overall picture is one of a modest hemostatic benefit rather than a major clinical advantage. Reassuringly for a retroperitoneal technique whose principal theoretical risk is ureteral injury, no ureteral or full-thickness visceral injury occurred, and neither conversion was for bleeding. The strengths of this study include a consecutive, real-world cohort drawn from a difficult and understudied subgroup and an analysis that accounted for the greater myoma burden of the ligation group, with the effect expressed in clinically interpretable milliliters. Several limitations temper the conclusions. The retrospective, nonrandomized design means the technique was chosen intraoperatively by the operating surgeon on the basis of the anatomic distortion actually encountered at operation. Since this intraoperative judgment of distortion severity was not captured as a structured variable, our adjustment for myoma diameter and lateral localization captures only measurable proxies of surgical difficulty; residual confounding by an unmeasured intraoperative distortion gradient is therefore expected rather than merely possible, and the association should not be read as a treatment effect. Estimated blood loss was recorded by the unblinded surgical and anesthesia team and is inherently subjective. Individual preoperative hemoglobin values were not included in the original analytic dataset because the preto-postoperative difference was recorded directly; on retrieval from the medical records, baseline values were slightly higher in the ligation group (median 11.7 vs 11.3 g/dL; P = .053), and additional adjustment for baseline hemoglobin left the results essentially unchanged (Table 4). The dataset likewise did not capture the total uterine myoma burden, the number of myomas, or the frequency of ureterolysis, all of which may influence bleeding. Historically, the technique and operative team evolved over an 11-year period, and the study was single-center and not powered to assess uncommon complications, limiting inferences about safety and generalizability. The analysis was not preregistered, and the analytic approach was developed during the course of the study. Within these limitations, these findings support further evaluation of bilateral origin-level uterine artery ligation in intraligamentary myoma surgery but do not establish a causal treatment effect or a definitive safety advantage.

In this retrospective single-center cohort of patients undergoing total laparoscopic hysterectomy for intraligamentary myomas, bilateral origin-level uterine artery ligation was associated with lower adjusted estimated blood loss, although the absolute reduction was small (approximately 18 mL). Since the technique was selected intraoperatively for larger, more laterally placed myomas, the association with mean blood loss emerged only after adjustment, and confounding by indication cannot be excluded. The overall picture is one of a modest hemostatic benefit rather than a major clinical advantage: the postoperative hemoglobin decrease was smaller, operative time did not increase, and no ureteral injury or conversion for bleeding occurred, although the study was not powered for uncommon complications. This modest effect concurs with most previous randomized trials of origin-level ligation during total laparoscopic hysterectomy and extends their message to the anatomically distorted intraligamentary myoma, in which prospective studies are warranted. Footnotes Institution where the study was conducted: Department of Obstetrics and Gynecology, University of Health Sciences Tepecik Training and Research Hospital, İzmir, Turkey. Data availability: The deidentified dataset underlying the findings of this study is available from the corresponding author on reasonable request and was made available to the editors and reviewers as part of the peer review process. Institutional review board approval: Ethics approval was obtained from the Tepecik Training and Research Hospital, Ethics Committee (Approval No: 2025/12-09), and the study was performed in line with the principles of the Declaration of Helsinki. Disclosure: none. Conflict of interests: none. Funding sources: none. Contributor Information Uğurcan Dağlı, Department of Obstetrics and Gynecology, University of Health Sciences Tepecik Training and Research Hospital, Izmir, Turkey. (Drs. Dağlı, Kantarcı, Karabulut, Yıldırım, Budak, İleri, and İnan). Sercan Kantarcı, Department of Obstetrics and Gynecology, University of Health Sciences Tepecik Training and Research Hospital, Izmir, Turkey. (Drs. Dağlı, Kantarcı, Karabulut, Yıldırım, Budak, İleri, and İnan). Alaattin Karabulut, Department of Obstetrics and Gynecology, University of Health Sciences Tepecik Training and Research Hospital, Izmir, Turkey. (Drs. Dağlı, Kantarcı, Karabulut, Yıldırım, Budak, İleri, and İnan). Fatih Yıldırım, Department of Obstetrics and Gynecology, University of Health Sciences Tepecik Training and Research Hospital, Izmir, Turkey. (Drs. Dağlı, Kantarcı, Karabulut, Yıldırım, Budak, İleri, and İnan). Anıl Başpınar, Department of Public Health, Hacettepe University, Ankara, Turkey. (Dr. Başpınar). Adnan Budak, Department of Obstetrics and Gynecology, University of Health Sciences Tepecik Training and Research Hospital, Izmir, Turkey. (Drs. Dağlı, Kantarcı, Karabulut, Yıldırım, Budak, İleri, and İnan). Alper İleri, Department of Obstetrics and Gynecology, University of Health Sciences Tepecik Training and Research Hospital, Izmir, Turkey. (Drs. Dağlı, Kantarcı, Karabulut, Yıldırım, Budak, İleri, and İnan). Abdurrahman Hamdi İnan, Department of Obstetrics and Gynecology, University of Health Sciences Tepecik Training and Research Hospital, Izmir, Turkey. (Drs. Dağlı, Kantarcı, Karabulut, Yıldırım, Budak, İleri, and İnan).

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