pregnancy after ovarian torsion

2009 Dec. 92(6):1983-7. Conservative management of ovarian torsion in pre-pubertal girl 3. Smorgick N, Pansky M, Feingold M, Herman A, Halperin R, Maymon R. The clinical characteristics and sonographic findings of maternal ovarian torsion in pregnancy. Ovarian cyst torsion in reproductive age group-changing trends in management 4. Treatment options limited to surgery, either by laparoscopy approach or laparotomy. Would you like email updates of new search results? Pregnant patients are reported to have a 1% increased risk of ovarian tor-sion compared to nonpregnant patients. However, the outcomes of pregnancy varied: 12 (60%) term deliveries, three (15%) preterm deliveries at over 31 gestational weeks, one missed abortion and four elective abortions in the first trimester. Lee JH, Roh HJ, Ahn JW, Kim JS, Choi JY, Lee SJ, Lee SH. Ovarian torsion is a condition that occurs when an ovary twists around the ligaments that hold it in place. Delayed diagnosis and treatment can cause ovarian necrosis and fetal loss. Ovarian torsion is most common in the first trimester of pregnancy, but can happen well into the third trimester, and torsion early in pregnancy seems to increase the risk for recurrence at a later gestational age (1). • There is a high rate of cyst recurrence after the procedure (33–40%) • Offered only to simple benign cysts • If it’s a malignant cyst then it may increase the stage of cancer, but it is uncertain if this worsens the prognosis. Although rare, ovarian torsion is a serious but treatable risk of in vitro fertilization (IVF). Laparoscopic Adnexal Detorsion in a 20-Week Pregnant Patient: A Case Report and Literature Review. Taiwan J Obstet Gynecol. Ovarian torsion (OT) is when an ovary twists on its attachment to other structures, such that blood flow is decreased. Most patients in the first trimester (75%) and a minority in the second and third trimesters (37.5%) received management via laparoscopy. With ovarian torsion, the blood supply to the ovary can be blocked and permanently hurt the ovary. Adnexal torsion during pregnancy is a gynecological emergency. Patients undergoing laparoscopy treatment had smaller ovarian masses and a shorter postoperative hospital stay than those receiving laparotomy. Epub 2015 Dec 14. HHS Recurrence of ovarian torsion occurs more frequently in pregnant patients, and in particular in enlarged multicystic ovaries. The ovulation stimulation was the standard long protocol as described in previous reports . She also presented with one of the most recognized risk factors for ovarian torsion: ovarian hyperstimulation syndrome with consequent cystic increase in ovarian volume (being the other main risk factors for ovarian torsion the hypermobility of the ovary, the presence of adnexal masses and pregnancy ). Ethical issues. Like most great pretenders, ovarian torsion mimics other, more common medical emergencies, such as ruptured ovarian cysts, ectopic pregnancy and even appendicitis.A relatively rare condition, it has been detected in women of all ages and even a fetus, according to a study published in Ultrasound in Obstetrics & Gynecology and presented at the 26th World Congress on Ultrasound in …  |  It can also cause an infection (peritonitis) in the abdominal cavity. Other symptoms may include nausea. Approximately 20% of the cases occur during pregnancy 1. The difficulty for the clinician lies in differentiating between ovarian torsion and other etiologies such as ectopic pregnancy, appendicitis, ovarian cysts, pelvic inflammatory disease (PID), urinary tract infection (UTI), nephrolithiasis, and endometriosis. Published by Elsevier Inc. All rights reserved. Maternal ovarian torsion in pregnancy is a rare complication. Twenty pregnant women were identified with surgically proven OT, 10 in the first trimester, eight in the second, and two in the third. Pregnancy after treatment for infertility is a risk factor for adnexal torsion. A retrospective study was conducted at a tertiary center between January 2008 and January 2018. VTE after ovarian torsion-detorsion in pregnancy is an infrequent event and is more likely to occur in the first and second trimester. Clinical characteristics, treatment and outcomes of adnexal torsion in pregnant women: a retrospective study. Heterotopic pregnancy is also a rare entity and cause pain abdomen but without the classical symptom of bleeding per vaginum. Accordingly, adnexectomy was performed more often in group 1 (P=0.002). Maternal adnexal torsion in pregnancy, with a reported incidence of 1–10 per 10,000 spontaneous pregnancies, is very uncommon. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. Maternal adnexal torsion in pregnancy is associated with significant risk of recurrence. Clinical, surgical and pathologic findings of adnexal torsion in pregnant and nonpregnant women. Recurrence of ovarian torsion occurs more frequently in pregnant patients, and in particular in enlarged multicystic ovaries. Ovarian Torsion in Pregnancy (4 Posts) Add message | Report. The most common clinical presentation is acute onset of severe, colicky unilateral pelvic pain that is usually unremitting but can wax and wane in cases of incomplete, intermittent torsion. Study objective: Although the etiology of the disease is not fully understood, predisposing factors include increased ovarian size, free mobility, and long pedicle. Epub 2017 Sep 7. Management of a Ruptured Ovarian Cyst. J Clin Med. This condition is usually associated with reduced venous return from the ovary as a result of stromal edema, internal hemorrhage, hyperstimulation, or a mass. Case Report . It is a rare condition in the pregnancy and it is tipically detected in the right side. Because pregnant women are usually … 2010 Jun;202(6):536.e1-6. We report a very rare case of bilateral ovarian torsion complicating SOHSS in a singleton pregnancy, which was successfully managed by laparoscopic detorsion. Ovarian torsion associated with infertility treatment often occurs mainly with ovarian hyperstimulation syndrome (OHSS) after OPU, but if it seems to be caused by ovarian swelling just before OPU. Ovarian torsion, a major complication of OHSS, is estimated to occur in 12-25% of pregnant women. Surgeons always try to save the ovary after torsion, when possible, because a woman’s ability to have children decreases after an ovary and/or fallopian tube is removed. Ovarian torsion, also sometimes termed adnexal torsion or tubo-ovarian torsion, refers to rotation of the ovary and portion of the fallopian tube on the supplying vascular pedicle.. When the patient is pregnant this can also lead to fetal mortality and potential loss of fertility for the patient. doi: 10.1097/MD.0000000000020627. Hasson J, Tsafrir Z, Azem F, Bar-On S, Almog B, Mashiach R, Seidman D, Lessing JB, Grisaru D. Am J Obstet Gynecol. Morice P, Louis-Sylvestre C, Chapron C, Dubuisson JB. NLM If an ovary is lost to necrosis, conception and pregnancy are still possible. 2016 Apr;25(4):391-6. doi: 10.1089/jwh.2015.5490. Ovarian torsion in the third trimester of pregnancy leading to a midline laparotomy and caesarean section for the delivery of a preterm baby is an uncommon event. This study assessed the clinical characteristics, treatment and outcomes of adnexal torsion in pregnant women. Diagnosis of ovarian torsion in pregnancy can be made with clinical presentations in conjunction with ultrasound with color Doppler. [Adnexal torsion: a report of 135 cases]. The treatment of ovarian tumors before attempting pregnancy decreases the risk of a corpus luteum cyst or OHSS. Harkins G. Ovarian torsion treated with untwisting: second look 36 hours after untwisting. Oophorectomy is commonly performed for adnexal torsion with a possible negative impact on fertility in women of reproductive age. Torsion occurs due to two main reasons 2: 1. hypermobility of the ovary: <50% 2. adnexal mass: ~50-80% 2.1. most lesions are dermoid cysts or paraovarian cysts 2.2. large cystic ovaries undergoing ovarian hyperstimulation are at particular risk 2.3. masses between 5-10 cm are at most risk 13 In patients undergoing ovulation induction with gonadotropins, the incidence of ovarian torsion is as high as 6%, and 16% for those who have ovarian hyperstimulation syndrome. This site needs JavaScript to work properly. Rarely, a cyst may be malignant (cancer) (see FAQ096 Ovarian Cancer). Adnexal torsion during pregnancy is a gynecological emergency. Ovarian torsion during pregnancy is a rare condition, more common in the third trimester, and exceptional during the first trimester(1). Acta Obstet Gynecol Scand. 2021 Jan 11. doi: 10.1007/s00404-020-05864-0. Detorsion only or detorsion plus ancillary procedures via laparoscopy is recommended to treat pregnant women suffering from OT, owing to the advantages of a shorter hospital stay and favorable surgical and pregnancy outcomes. Harkins G. Ovarian torsion treated with untwisting: second look 36 hours after untwisting. Ovarian torsion can sometimes be difficult to diagnose in pregnancy. When the torsion occurs in the right ovary, the symptoms may be confused with the appendix. AbstractObjectiveMaternal ovarian torsion in pregnancy is a rare complication. The patient was discharged 48 hours after the operation with a good general condition Feng JL, Zheng J, Lei T, Xu YJ, Pang H, Xie HN. Ovarian torsion occurs more on right side, presumably because the sigmoid colon limits the mobility of the left ovary. During this minimally invasive procedure, a small incision is made at the abdomen. 2. The diagnosis of ovarian torsion is difficult and occasionally remains a diagnostic dilemma. It is possible to perform volume reduction before OPU and also possible to become pregnant by embryo transfer afterward. Maternal ovarian torsion in pregnancy is a rare complication. Successful pregnancy complicated by early and late adnexal torsion after in vitro fertilization. 2003. Bouguizane S, Bibi H, Farhat Y, Dhifallah S, Darraji F, Hidar S, Lassoued L, Chaieb A, Khairi H. J Gynecol Obstet Biol Reprod (Paris). This study was conducted to review the clinical manifestations, and to compare the outcome between laparoscopy and laparotomy in women undergoing surgery for ovarian torsion (OT) during pregnancy. A quick and confident diagnosis is … Fertil Steril 2009. I'm currently about 5 and a bit weeks pregnant. 2018 Feb;25(1):51-59. doi: 10.1007/s10140-017-1549-8. Djavadian D, Braendle W, Jaenicke F. Laparoscopic oophoropexy for the treatment of recurrent torsion of the adnexa in pregnancy: case report and review. This twisting can cut off blood flow to the ovary and fallopian tube. larged ovaries are prone to torsion. Please enable it to take advantage of the complete set of features! Introduction Ovarian torsion refers to the complete or partial rotation of the ovary on its ligamentous supports, which often leads to an impedance of its blood supply [1].Adnexal torsion during pregnancy is very rare and the incidence is reported to be in the range of 0,01-0,05 per hundred [2].It occurs in all three trimesters, but is most common in the first trimester. Thirteen (65%) cases were suspected before operation to be adnexal torsion. The clinical presentation is often nonspecific with few distinctive physical findings, commonly resulting in delay in diagnosis and surgical management. 2007 Mar;87(3):697.e9-12. 2009 Sep-Oct;16(5):551-3. doi: 10.1016/j.jmig.2009.05.003. Ovarian torsion doesn’t affect fertility in any way. Ovarian rupture and torsion . A gestational age eight-week pregnant woman who received in vitro fertilization (IVF) came to the clinic and was suspected of adnexal torsion. Pregnancy after treatment for infertility is a risk factor for adnexal torsion. Distinctive pattern of left-right asymmetry of ovarian benign teratomas in Chinese population: a 12-year-long cross-sectional study. Mashiach S, Bider D, Moran O, et al. In the first trimester, women may have corpus luteum cysts that cause the ovary to … The laparoscope transmits images onto a screen, which guides the surgeon in addressing the torsion. Recurrence of ovarian torsion occurs more frequently in pregnant patients, and in particular in enlarged multicystic ovaries. The diagnosis depends mainly on the clinical manifestation, D-dimer level and imaging tests such as compression ultrasonography and computed tomography pulmonary angiogram. Adnexal torsion in the third trimester of pregnancy: a case report and diagnostic value of MR imaging. If a disease such as ovarian tumor is found during the work-up, attempts to become pregnant can be delayed until the disease has been treated. Would you like email updates of new search results?  |  While classically the pain is sudden in onset, this is not always the case. trimester after ovarian hyper stimulation.2 Increased frequency during pregnancy is due to greater laxity of the tissues adjoining the ovaries and tubes as well as to enlargement of the ovary in early pregnancy secondary to corpus luteum cyst. Online ahead of print. Open torsion, right salpingectomy and cystectomy were performed. They can occur during the childbearing years or after menopause.Most ovarian cysts are benign (not cancer) and go away on their own without treatment. The ovary and fallopian tube are typically involved. Ovarian torsion (OT) during pregnancy is a rare condition that can cause maternal and fetal morbidity. Sixty-four pregnant women and 198 nonpregnant women with episodes of adnexal torsion. J Gynecol Obstet Biol Reprod (Paris). The increased use of assisted reproductive technologies has led to an increase in the risk of adnexal torsion, particularly in pregnant women or women with ovarian hyperstimulation syndrome (OHSS). Epub 2006 Dec 4. Laparoscopic Detorsion of Twisted Ovary in a Nulliparous Woman with a Recurrent, Bilateral Mature Cystic Teratoma 5. In our patient, right sided ovarian torsion was suspected as appendicitis. Role of surgery . Epub 2014 Dec 11. This can cut off blood supply to the ovary. This article provides an overview of the symptomatology, ultrasound diagnosis and classification, as well as treatment options for ovarian torsion. Interventions: Conclusion: Treatment is traditionally surgical removal of the ovary or adnexum, however, there is increasing evidence for conservative surgery, such as de‐torsion and oophoropexy, particularly in younger women. BMC Pregnancy Childbirth. Similar But Different: A Comparison of Adnexal Torsion in Pediatric, Adolescent, and Pregnant and Reproductive-Age Women. NIH To review the literature on the available surgical options. Characteristics and surgical invervention of ovarian torsion in pregnant compared with nonpregnant women. Comparison of adnexal torsion between pregnant and nonpregnant women. Adnexal torsion • incidence of ovarian torsion in pregnancy … At 30 weeks gestation, the patient delivered healthy infants by cesarean section because of severe preeclampsia. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. Medicine (Baltimore). On Thursday afternoon I started suffering from intense pain in my left side around my pelvis area, the pain was awful and I was in agony! Ovarian torsion is most common in the first trimester of pregnancy, but can happen well into the third trimester, and torsion early in pregnancy seems to increase the risk for recurrence at a later gestational age . Setting: It can be intermittent or sustained and results in venous, arterial and lymphatic stasis. Traditionally adnexal torsion presenting as acute abdomen is managed by laparotomy. Symptoms typically include pelvic pain on one side. 1991 Nov;173(5):363-6. 2020 Jun 12;99(24):e20627. Bai W, Xu X, Xie H, Sun C, Che K, Liu M, Liu J, Shi Y, Ma H. BMC Med Imaging. Women who were pregnant after IVM were younger (28.6 ± 3.4 years vs 29.3 ± 3.6 years, P = 0.005) and had ... such as ovarian hyperstimulation syndrome or ovarian torsion. NIH After adjustment for such covariates as age, pregnancy was found to be associated with a lower rate of AT (adjusted odds ratio 0.314, 95% confidence interval [CI] 0.237–0.416, P value <0.01) and ovarian hyperstimulation syndrome was associated with a higher rate of AT (adjusted odds ratio 20.091, 95% CI 3.607–111.908, P value <0.01). Pregnancy is a risk factor for torsion (odds ratio: 18:1) but remains an uncommon event (0.167%). Ovarian torsion is an acute abdomen requiring prompt intervention.  |  She had no complications or recurrence of ovarian torsion during this pregnancy. COVID-19 is an emerging, rapidly evolving situation. Measurements and main results: Pregnant women can experience ovarian torsion as well as those who are not pregnant. eCollection 2019. Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. 2020 Aug 24;20(1):483. doi: 10.1186/s12884-020-03173-7. Thirty six episodes of adnexal torsion in the pregnant group (56%) developed after treatment for infertility, compared with only 14 such episodes (7%) in the nonpregnant group (p < .001). Ovarian torsion is a disorder with a very high patient morbidity. The left side is thought to barely have space because of the sigmoid colon. Fertil Steril. Since it has been described as a severe complication after controlled ovarian hyper-stimulation for in vitro fertilization (IVF), it is more common in IVF pregnancies. As the woman is likely to present with nonspecific symptoms of lower abdominal pain, nausea, and vomiting, ovarian torsion can often be misdiagnosed as appendicitis or preterm labour. Aziz D, Davis V, Allen L, Langer JC. The increased use of assisted reproductive technologies has led to an increase in the risk of adnexal torsion, particularly in pregnant women or women with ovarian hyperstimulation syndrome (OHSS). Halimeh R, Tomassian S, El Hage M, Metri N, Bersaoui M, Daou R, Anastasiadis E. Case Rep Obstet Gynecol. Ovarian torsion in the third trimester of pregnancy leading to a midline laparotomy and caesarean section for the delivery of a preterm baby is an uncommon event. Ovarian torsion in IVF twin pregnancy. Using the International Classification of Disease, Ninth Revision, and Clinical Modification, we reviewed the clinical records of patients with OT during pregnancy between 1997 and 2008 at a university hospital. Because success rates after IVM are correlated to the number of antral follicles, IVM has typically been offered to patients with polycystic ovary syndrome (PCOS) (Guzman et al., 2013). Ovarian torsion seldom occurs during pregnancy. We report a very rare case of bilateral ovarian torsion complicating SOHSS in a singleton pregnancy, which was successfully managed by laparoscopic detorsion. Figure 1 (A) Power Doppler on presentation of patient to the emergency department shows no vascular flow to left ovary. 2020 Jul 13;9(7):2209. doi: 10.3390/jcm9072209. A repeated episode of torsion occurred more frequently in the pregnant group (14% vs 4%; p = .03). Conclusion: abdominal pain, emergency laparotomy was performed, which revealed ruptured ectopic pregnancy and ovarian torsion with active bleeding and a 7×6 cm cyst in the same side with two rounds of torsion. An ovarian rupture is a medical emergency. Since it has been described as a severe complication after controlled ovarian hyper-stimulation for in vitro fertilization (IVF), it is more common in IVF pregnancies. Tissue preservation was achieved more frequently in pregnant than in nonpregnant patients (95% vs 77%; p < .001), and the duration of surgery was 15 minutes shorter in the pregnant women (p < .001). 2019 Nov 11;2019:1093626. doi: 10.1155/2019/1093626. Ovarian torsion. Eighty-two pregnant women with surgically … The diagnosis depends mainly on the clinical manifestation, D-dimer level and imaging tests such as compression ultrasonography and computed tomography pulmonary angiogram. Clipboard, Search History, and several other advanced features are temporarily unavailable. Ovarian torsion usually occurs on just one side and can cause sudden, intense pain and vomiting. The larger the cyst, the more likely that ovarian torsion will occur. Both hemorrhagic and ischemic necrosis were present. Here, we report two cases of ovarian torsion after IVF and discuss the optimal management of this … None of these patients had significant complications during or after surgery. Ovarian torsion associated with infertility treatment often occurs mainly with ovarian hyperstimulation syndrome (OHSS) after OPU, but if it seems to be caused by ovarian swelling just before OPU. To compare the clinical manifestation, management, and outcome of adnexal torsion in pregnant and nonpregnant women. In our patient, right sided ovarian torsion was suspected as appendicitis. Fertility and Sterility 1496.e10. VTE after ovarian torsion-detorsion in pregnancy is an infrequent event and is more likely to occur in the first and second trimester. Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. Tertiary care university hospital. However, when torsion occurs during pregnancy, symptoms are … Comparison of ovarian torsion between pregnant and non-pregnant women at reproductive ages: sonographic and pathological findings. The patient had a benign convalescence and was dis-charged on the third postoperative day. Adnexal torsion during pregnancy is a rare condition. The diagnosis of OT during pregnancy is often missed due to nonspecific clinical features and uncommon objective findings.  |  Objective: An ovarian cysts is a sac or pouch filled with fluid or other tissue that forms in or on an ovary.Ovarian cysts are very common. Copyright © 2011. Delayed diagnosis and treatment can cause ovarian necrosis and fetal loss. Ovarian torsion has a bimodal age distribution occurring mainly in young women (15-30 years) and post-menopausal women. 2015 Mar;94(3):236-44. doi: 10.1111/aogs.12542. Surgery to treat proved adnexal torsion. 2008 Dec;34(6):1020-5. doi: 10.1111/j.1447-0756.2008.00806.x. However, the outcomes of pregnancy varied: 12 (60%) term deliveries, three (15%) preterm deliveries at over 31 gestational weeks, one missed abortion and four elective abortions in the first trimester. Adnexal torsion during pregnancy: report of four cases and review of the literature. They may want to monitor the cyst throughout your pregnancy. The incidence of the disease increases after ovarian stimulation for the treatment of fertility. It is possible to perform volume reduction before OPU and also possible to become pregnant by embryo transfer afterward. Hyttel TE, Bak GS, Larsen SB, Løkkegaard EC. This site needs JavaScript to work properly. An ovarian cyst is a fluid-filled sac in or on the surface of an ovary. Please enable it to take advantage of the complete set of features! Keywords: ovarian cyst torsion, pregnancy, corpus luteum cyst. BMC Pregnancy Childbirth. The majority of ovarian torsion cases affect women of reproductive age, but girls can have the condition as well. COVID-19 is an emerging, rapidly evolving situation. J Minim Invasive Gynecol 2007; 14:270. Maternal adnexal torsion in pregnancy, with a reported incidence of 1–10 per 10,000 spontaneous pregnancies, is very uncommon. abdominal pain, emergency laparotomy was performed, which revealed ruptured ectopic pregnancy and ovarian torsion with active bleeding and a 7×6 cm cyst in the same side with two rounds of torsion. Laparoscopy for adnexal torsion in pregnant women. I. The symptoms are nonspecific, and can be confused with other acute abdominal conditions such as appendicitis, ureteral or renal colic, cholecystitis and bowel obstruction. It can cause internal bleeding. 2020 Jan;10(1):137-147. doi: 10.21037/qims.2019.11.06. Ovarian Torsion Blood flow to the ovary is reduced or cut off when the weight of a cyst causes the ovary to turn over on itself one or more times (called ovarian torsion). Clinical characteristics, treatment and outcomes of adnexal torsion in pregnant women: a retrospective study. Case Reports Case 1. The Diagnostic Accuracy of Magnetic Resonance Imaging for Maternal Acute Adnexal Torsion during Pregnancy: Single-Institution Clinical Performance Review. J Obstet Gynaecol Res. 2. The incidence of ovarian torsion after IVF treatment is rare, ranging from 0.08 to 0.13% [9]. Contact us to talk with a fertility expert and determine an effective plan of action if you are experiencing symptoms of this complication. (B) Color-flow Doppler after aspiration of ovarian cysts and body … Adnexal torsion of hyperstimulated ovaries in pregnancies after gonadotropin therapy. 1. andlaparoscopichypothesis.Therightovarywascompletely necrotic. If this happens, surgery is necessary to restore blood flow. Here, we report our experience managing ovarian torsion in early pregnancy after IVF treatment. To understand the clinical presentation and ultrasound characteristics associated with ovarian torsion.  |  This study assessed the clinical characteristics, treatment and outcomes of adnexal torsion in pregnant women. A laparoscope (an instrument with a small lighted camera at the end) is inserted. ( 3 ):236-44. doi: 10.1007/s10140-017-1549-8 of left-right asymmetry of ovarian torsion, Wang Y, Sarig-Meth T Maymon. Mobility, and pregnant and pregnancy after ovarian torsion women Reproductive-Age women although rare, ranging from 0.08 to 0.13 % 9! 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Patient under … AbstractObjectiveMaternal ovarian torsion is a risk factor for adnexal torsion ages: sonographic and findings. And outcomes of adnexal torsion 2008 Dec ; 50 ( 4 ):409-10.:., Trichot C, Morcelet MC, Prevot S, Bider D, Papakonstantinou K Kontoravdis! Factors include increased ovarian size, free mobility, and pregnant and non-pregnant women at reproductive:., commonly resulting in delay in diagnosis and treatment can cause ovarian necrosis fetal! Third postoperative day by laparoscopy approach or laparotomy a 12-year-long cross-sectional study |... % ), Lipitz S, Bider D, mashiach S, Bider,. Classification, as well or OHSS between pregnant and nonpregnant women TE pregnancy after ovarian torsion Bak,! Shows no vascular flow to the ovary and fallopian tube for the treatment of fertility for the patient …... 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