Reproductive outcomes from ten years of elective oocyte cryopreservation

Research question: To assess the relationship between the number of oocytes retrieved during elective oocyte cryopreservation (EOC) cycles with various clinical, biochemical, and radiological markers, including age, body mass index (BMI), baseline anti-Müllerian hormone (AMH), antral follicle count (AFC), Oestradiol level (E2) and total number of follicles ≥ 12 mm on the day of trigger. To also report the reproductive outcomes from women who underwent EOC. Methods: A retrospective cohort of 373 women embarking on EOC and autologous oocyte thaw cycles between 2008 and 2018 from a single London clinic in the United Kingdom. Results: 483 stimulation cycles were undertaken amongst 373 women. The median (range) age at cryopreservation was 38 (26–47) years old. The median numbers of oocytes retrieved per cycle was 8 (0–37) and the median total oocytes cryopreserved per woman was 8 (0–45). BMI, E2 level and number of follicles ≥ 12 mm at trigger were all significant predictors of oocyte yield. Multivariate analysis confirmed there was no significant relationship between AFC or AMH, whilst on univariate analysis statistical significance was proven. Thirty six women returned to use their cryopreserved oocytes, of which there were 41 autologous oocyte thaw cycles undertaken. There were 12 successful livebirths achieved by 11 women. The overall livebirth rate was 26.8% per cycle. No livebirths were achieved in women who underwent EOC ≥ 40 years old, and 82% of all livebirths were achieved in women who had done so between 36 and 39 years old. Conclusion: Clinical, biochemical and radiological markers can predict oocyte yield in EOC cycles. Reproductive outcomes are more favourable when cryopreservation is performed before the age of 36, with lower success rates of livebirth observed in women aged 40 years and above

Fertility sparing surgery and borderline ovarian tumours

o determine the oncological outcomes following fertility-sparing surgery (FSS) for the management of Borderline Ovarian Tumours (BOTs). A retrospective analysis of participants diagnosed with BOTs between January 2004 and December 2020 at the West London Gynaecological Oncology Centre was conducted. A total of 172 women were diagnosed; 52.3% (90/172) underwent FSS and 47.7% (82/172) non-FSS. The overall recurrence rate of disease was 16.9% (29/172), of which 79.3% (23/29) presented as the recurrence of serous or sero-mucinous BOTs and 20.7% (6/29) as low-grade serous carcinoma (LGSC). In the FSS group, the recurrence rate of BOTs was 25.6% (23/90) presenting a median 44.0 (interquartile range (IQR) 41.5) months, of which there were no episodes of recurrence presenting as LGSC reported. In the non-FSS group, all recurrences of disease presented as LGSC, with a rate of 7.7% (6/78), following a median of 47.5 months (IQR 47.8). A significant difference between the type of surgery performed (FSS v Non-FSS) and the association with recurrence of BOT was observed (Pearson Chi-Square: p = 0.000; x = 20.613). Twelve women underwent ultrasound-guided ovarian wedge resection (UGOWR) as a novel method of FSS. Recurrence of BOT was not significantly associated with the type of FSS performed (Pearson Chi- Square: x = 3.166, p = 0.379). Non-FSS is associated with negative oncological outcomes compared to FSS, as evidenced by the higher rate of recurrence of LGSC. This may be attributed to the indefinite long-term follow up with ultrasound surveillance all FSS women undergo, enabling earlier detection and treatment of recurrences

Implications for the future of obstetrics and gynaecology following the COVID-19 pandemic: a commentary.

In March 2020, the World Health Organization (WHO) declared COVID-19 a global pandemic. At the time of writing, more than 261,184 cases of COVID-19 have been confirmed in the UK resulting in over 36,914 directly attributable deaths.1 The National Health Service (NHS) has been confronted with the unprecedented task of dealing with the enormity of the resultant morbidity and mortality. In addition, the workforce has been depleted as a direct consequence of the disease, in most cases temporarily, but in some tragic cases permanently

Age-related fertility decline: is there a role for elective ovarian tissue cryopreservation?

Age-related fertility decline (ARFD) is a prevalent concern amongst western cultures due to the increasing age of first-time motherhood. Elective oocyte and embryo cryopreservation remain the most established methods of fertility preservation, providing women the opportunity of reproductive autonomy to preserve their fertility and extend their childbearing years to prevent involuntary childlessness. Whilst ovarian cortex cryopreservation has been used to preserve reproductive potential in women for medical reasons, such as in pre- or peripubertal girls undergoing gonadotoxic chemotherapy, it has not yet been considered in the context of ARFD. As artificial reproductive technology (ART) and surgical methods of fertility preservation continue to evolve, it is a judicious time to review current evidence and consider alternative options for women wishing to delay their fertility. This article critically appraises elective oocyte cryopreservation as an option for women who use it to mitigate the risk of ARFD and introduces the prospect of elective ovarian cortex cryopreservation as an alternative

Provision of obstetrics and gynaecology services during the COVID-19 pandemic:a survey of junior doctors in the UK National Health Service

Objective: The COVID-19 pandemic is disrupting health services worldwide. We aimed to evaluate the provision of obstetrics and gynaecology services in the UK during the acute-phase of the COVID-19 pandemic. Design: Interview-based national survey. Setting: Women’s healthcare units in the National Health Service. Population: Junior doctors in obstetrics and gynaecology. Methods: Participants were interviewed by members of the UKARCOG trainees’ collaborative between 28th March and 7th of April 2020. We used a quantitative analysis for closed-ended questions and a thematic framework analysis for open comments. Results: We received responses from 148/155 units (95%), majority of the participants were in years 3-7 of training (121/148, 82%). Most completed specific training drills for managing obstetric and gynaecological emergencies in women with COVID-19 (89/148, 60.1%) and two-persons donning and doffing of Personal Protective Equipment (PPE) (96/148, 64.9%). The majority of surveyed units implemented COVID-19 specific protocols (130/148, 87.8%), offered adequate PPE (135/148, 91.2%) and operated dedicated COVID-19 emergency theatres (105/148, 70.8%). Most units reduced face-to-face antenatal clinics (117/148, 79.1%), and suspended elective gynaecology services (131/148, 88.5%). The two-week referral pathway for oncology gynaecology was not affected in half of the units (76/148, 51.4%), while half reported a planned reduction in oncology operating (82/148, 55.4%). Conclusion: The provision of obstetrics and gynaecology services in the UK during the acute phase of the COVID-19 pandemic seems to be in line with current guidelines, but strategic planning is needed to restore routine gynaecology services and ensure safe access to maternity care on the longterm

An audit of the infection prevention and control program at Port Shepstone Regional Hospital.

Masters Degree. University of KwaZulu-Natal, Durban.BACKGROUND Infectious diseases are the leading cause of death in South Africa. The treatment of these diseases and their complications consume huge amounts of already limited healthcare resources. Antibiotic resistance is growing global concern and the strategy to contain it has 3 main components; Infection Prevention and Control (IPC) programs, microbiological resistance testing and antibiotic stewardship programs (ASP). South Africa has recently embarked on a journey to upgrade and develop its own Antimicrobial Program which encompass these 3 components. Emphases have been placed on developing antibiotic stewardship programs and recent literature reflects this. At the 400 bed Port Shepstone Regional Hospital (PSH), in contrast, the most developed of these components is the IPC program. We aim to describe the core component of PSH’s antimicrobial program and compare its IPC program with that of an established program. OBJECTIVE To use the CDC’s Infection Control Assessment Tool for Acute Care Hospitals (USA) to evaluate the infection control program at PSH and report on the Core Elements of the hospital’s Antibiotic Stewardship Program METHOD A prospective descriptive study with a quantitative component was conducted at PSH between February to March 2018. The first part of the study determined which of the CDCs 17 core components of an infection control program were operative at PSH. The assessed components were leadership commitment, pharmacy services, laboratory services, a dedicated specialist team, infection control policy, guidelines for antibiotic use, antibiotic rotation, personal protective equipment policies, protocols for prevention of catheter-related UTI, protocols for central line use, protocols for injection safely, protocols for prevention of ventilator-associated events, protocols for surgical site infection, services for environmental cleaning , infrastructure for isolation of contagious patients, policies for clostridium difficile infection, and policies for tracking of infective patients between institutions. In the second part, in each of the 11 adult long-stay wards, responders (nurses) were identified for completion of 5 selected elements of the CDC tool. The tool elicited if responders knew which policies were in place, their knowledge of the protocol, the level of education and training and the ongoing auditing practices. These areas were Handwashing (15 questions), Personal protection equipment (19Q), Catheter-associated Urinary Tract Infections (38Q), Injection safety (16 Q) and surgical site infection (31Q) After collection, the data was entered into an excel workbook. A positive answer received a score of 1 while a negative or unknown received a 0. Overall performance was graded arbitrarily into excellent (>80%), good (60 to 80%) and poor (<60%) RESULTS Part 1 The infection control program at PSH has 10 of the 17 components that were considered important. It has leadership commitment, pharmacy services, laboratory services, infection control policy, guidelines for antibiotic use, personal protection equipment, a protocol for prevention of catheter- related UTI, protocols for injection safely, protocols for surgical site infection, and services for environmental cleaning PSH does not have a dedicated specialist team, infrastructure for isolation of contagious patients, policies for the prevention of central line-associated bloodstream infection, policies for clostridium difficile infection, antibiotic rotation, a protocol for prevention of ventilator-associated events, or tracking of infective patients between institutions. Part 2: Comparison of 11 wards in 5 components Handwashing: The score per ward ranged from 11 to 15 (68% to 100%). The questions where respondents performed poorly were because of poor initial education and poor auditing skills or systems. Personal protective equipment: The score ranged from 16-19 (84% to 100%). The worst scoring questions were because PSH did not have a respiratory protection program. Catheter-associated Urinary tract infections (CAUTI) – The scores ranged from 20 to 34 (52% to 89%). PSH does not have a system in place for a CAUTI database. There is no ongoing collection of data and thus no dissemination of information back to the wards. Injection Safety: The score ranged from 10 to 14 (62% to 87%) Poor performance was due to lack of any protocol to identify tampering and on-going education. The Surgical Site Infections: Lowest score being 0 and highest 31 (0% - 85%). Non -surgical wards did not know the process so could not answer questions at all. The surgical wards were poor in the auditing process. OVERALL PERFORMANCE. The total possible score was 119. The highest scoring ward was the gynaecology ward 110 (95%). The lowest was in the psychiatric ward, which scored 64 (53%). 8 wards had excellent performance (>80% [total score>95]): High care, ICU, Post-natal, Gynaecology, Labour ward, Surgical male, Surgical female, Orthopaedic. 2 Wards had a Good performance (60%-80% [71-95]): Medical Male, Medical Female One ward performed poorly <60% [71]): Psychiatry The best overall performance was in handwashing. The worst performance was surgical site infections. Poor auditing practices were identified. Wards with a surgical focus performed the best. This is probably related to the fact that the staff working in surgical wards has to have additional familiarity with protocols and processes related to wound care. Units with no surgical expertise (medicine and psychiatry) do not usually have surgical patients under their care so do not have much-specialised knowledge. The psychiatric ward additionally usually does not often deal with patients that have any infectious diseases, so the staff is understandably less knowledgeable. CONCLUSION The South African literature is scanty and tends to favour Antibiotic Stewardship Programs above Infection Prevention and Control programs. Core strategies and coordination of audits and research are in the early stages. This audit is timely in the assessment of an IPC program in a provincial hospital in the public sector. The results of the audit performed at PSH are encouraging and the strengthening of the entire IPC program should be possible. To achieve the proper application of the IPC program more emphasis needs to be placed on constantly auditing existing practice and giving feedback to staff

Chronic tubal ectopic pregnancy following clinically successful methotrexate treatment for an acute ectopic: a review of the literature

Chronic tubal ectopic pregnancy following clinically successful methotrexate treatment for an acute ectopic: a review of the literatur