Impact of class III obesity on outcomes and complications of transvaginal ultrasound-guided oocyte pickup

Objective: To assess the impact of class III obesity on outcomes and complications of transvaginal ultrasound-guided oocyte pickup (OPU). Design: Retrospective cohort study. Setting: Hospital-based fertility clinic. Patient(s): All women undergoing OPU procedures during autologous in vitro fertilization (IVF) and oocyte banking cycles, grouped by patient body mass index (BMI: \u3c25, 25–29.9, 30–34.9, 35–39.9, ≥40 kg/m2). Intervention(s): Transvaginal OPU under conscious sedation. Main Outcome Measure(s): Sedation and procedure-related parameters and complications. Result(s): A total of 2,141 OPU procedures in 1,579 patients were analyzed, including 121 OPU procedures in 94 patients with BMI ≥40 kg/m2. There was a statistically significant increase in total fentanyl and midazolam doses and procedure duration as BMI increased. Compared with patients with BMI \u3c25 kg/m2, those with BMI ≥40 kg/m2 were more likely to require additional sedation during the procedure (adjusted odds ratio [aOR] 1.99; 95% confidence interval [CI], 1.14–3.49). The rate of difficult access was 28.9% for procedures with BMI ≥40 kg/m2 compared with 5.2% with BMI \u3c25 kg/m2 (aOR 7.57; 95% CI, 4.66–12.29). The OPU was incomplete due to inaccessible follicles through a transvaginal approach in 18.2% of procedures with BMI ≥40 kg/m2 compared with 1.3% with BMI \u3c25 kg/m2 (aOR 16.94; 95% CI, 8.24–34.84). The rates of sedation and procedure-related complications were low, and none occurred in patients with BMI ≥40 kg/m2. Conclusion(s): There was no increased risk of complications for women with class III obesity undergoing OPU with conscious sedation. However, the operator was more likely to encounter difficult access and to incompletely aspirate follicles through a transvaginal approach

Expression and localization of NRF2/Keap1 signalling pathway genes in mouse preimplantation embryos exposed to free fatty acids.

Obese women experience greater incidence of infertility, with reproductive tracts exposing preimplantation embryos to elevated free fatty acids (FFA) such as palmitic acid (PA) and oleic acid (OA). PA treatment impairs mouse preimplantation development in vitro, while OA co-treatment rescues blastocyst development of PA treated embryos. In the present study, we investigated the effects of PA and OA treatment on NRF2/Keap1 localization, and relative antioxidant enzyme (Glutathione peroxidase; Gpx1, Catalase; Cat, Superoxide dismutase; Sod1 and γ-Glutamylcysteine ligase catalytic unit; Gclc) mRNA levels, during in vitro mouse preimplantation embryo development. Female mice were superovulated, mated, and embryos cultured in the presence of bovine Serum albumin (BSA) control or PA, or OA, alone (each at 100 μM) or PA + OA combined (each at 100 μM) treatment. NRF2 displayed nuclear localization at all developmental stages, whereas Keap1 primarily displayed cytoplasmic localization throughout control mouse preimplantation development in vitro. Relative transcript levels of Nrf2, Keap1, and downstream antioxidants significantly increased throughout control mouse preimplantation development in vitro. PA treatment significantly decreased blastocyst development and the levels of nuclear NRF2, while OA and PA + OA treatments did not. PA and OA treatments did not impact relative mRNA levels of Nrf2, Keap1, Gpx1, Cat, Sod1 or Gclc. Our outcomes demonstrate that cultured mouse embryos display nuclear NRF2, but that PA treatment reduces nuclear NRF2 and thus likely impacts NRF2/KEAP1 stress response mechanisms. Further studies should investigate whether free fatty acid effects on NRF2/KEAP1 contribute to the reduced fertility displayed by obese patients

Fertility and pregnancy outcomes following uterine artery embolization (UAE) for uterine arteriovenous malformation (AVM)

A 19-year-old patient presented with intractable uterine bleeding, 11 weeks post-abortion. A pelvic ultrasound with Doppler and color imaging suggested a uterine arteriovenous malformation. Failing conservative therapies, the patient consented to uterine artery embolization (UAE). Two months later, she conceived and had an uneventful normal vaginal delivery at term. Since this is an extremely rare condition, allowing limited clinical exposure and experience, there may be an underlying reluctance by general practitioners to treat these cases with uterine artery embolization for fear of compromising future fertility and pregnancies. However, data from the 20 pregnancies embolized for uterine AVM cited in the present report and data from embolization for uterine fibroids indicate that such fears may be unfounded since pregnancy rates and outcomes may not be compromised after UAE. © 2009 Springer-Verlag

Postablation endometrial carcinoma

Background: Many women have undergone both resectoscopic and nonresectoscopic (or global) endometrial ablation (EA) during the past 20 years. These women are now approaching their sixth and seventh decades of life, a time frame in which endometrial carcinoma (EC) is most frequently diagnosed. Database: In several reports, surgeons have expressed concern that endometrial ablation may leave a sequestered island of EC that may escape detection, possibly delaying its diagnosis or causing it to appear at an advanced stage. Others suggest that EA artifact does not hinder the evaluation and treatment planning in the presence of EC. Data bases used are from Medline and PubMed. Discussion: We introduce 6 new cases of postablation endometrial carcinoma (PAEC), 4 of which occurred after the introduction of global endometrial ablation (GEA) techniques. In addition, we examine several key questions regarding the impact of EA on the subsequent development of EC, including the manner in which PAEC presents, the efficacy of traditional diagnostic modalities, the ablation-to-cancer interval, and the stage of PAEC at the time of diagnosis. Finally, we explore the use of reoperative hysteroscopic surgery (RHS) as a diagnostic modality and address the possible role ultrasound surveillance as a screening method for women at risk of EC

Long-term clinical outcomes of repeat hysteroscopic endometrial ablation after failed hysteroscopic endometrial ablation

The study aims to describe patient characteristics, uterine cavity shape and histopathology, complications, and long-term clinical outcomes of women who failed hysteroscopic rollerball or loop endometrial ablation (HEA) and subsequently consented to repeat hysteroscopic endometrial ablation (RHEA), and is a retrospective cohort study (Canadian Task Force classification II-2). The study was conducted in the university-affiliated teaching hospital. Patients included women who failed primary hysteroscopic endometrial ablation (PHEA, n = 183) and subsequently underwent RHEA by the senior author (GAV) from 1993 through 2007 with a minimum follow-up of 5 years. RHEA was performed under general anesthesia using 26 F (~9 mm) resectoscope, monopolar loop electrode in 136 (74.3 %), 3–5 mm rollerball in 41 (22.4 %) or combination in 6 (3.3 %) women. Patient characteristics, uterine cavity, and clinical outcomes of women who failed PHEA and subsequently consented to RHEA were evaluated by retrospective chart review and patient follow-up including office visits and/or telephone interview. The corresponding median age (range) for PHEA and RHEA was 40 (26–70) and 43 (29–76) years. Indications for PHEA included abnormal uterine bleeding (AUB, 52.7 %), AUB and dysmenorrhea (25.8 %), dysmenorrhea (18.8 %), and others (2.7 %). Indications for RHEA included persistent AUB (53 %), AUB and uterine/pelvic pain (26.2 %), uterine/pelvic pain only (19.1 %), postmenopausal bleeding (1.1 %), and thickened endometrium (0.5 %). Complications of RHEA (n = 7, 3.8 %) included false passage (3), uterine perforation (2), and bleeding (2). One patient with excessive bleeding required immediate hysterectomy. At a median follow-up of 9 years (5–19), 69 % of women avoided hysterectomy. Repeat hysteroscopic endometrial ablation is a feasible, safe, and long-term effective alternative to hysterectomy for abnormal uterine bleeding from benign causes when performed by experienced surgeons

Impact of the COVID-19 Pandemic on Access to Fertility Care: A Retrospective Study at a University-Affiliated Fertility Practice

Objective: To elucidate the impact of the COVID-19 pandemic on access to fertility services. Methods: A retrospective quality improvement study was conducted at a university-affiliated fertility practice in southwestern Ontario. Annual procedural volumes for intrauterine and donor inseminations (IUI/DI), in vitro fertilization and intracytoplasmic sperm injections (IVF/ICSI), and frozen embryo transfers (FET) during the COVID-19–affected year were compared with mean annual volumes from the 2 preceding years. In addition, volumes for the same procedures were compared between the first quarter of 2021 and mean first quarter volumes from 2018 to 2019. Piecewise linear regressions were conducted to evaluate whether any changes in monthly procedural volume were attributable to the COVID-19 pandemic. Results: In 2020, our fertility practice attained the mean annual volumes of 89.7% for IUI/DI, 69.0% for IVF/ICSI, and 60.6% for FET. In contrast, in 2021, we performed mean first quarter volumes of 130.1% for IUI/DI, 164.3% for IVF/ICSI, and 126.8% for FET. The slopes of the pre- and post–COVID-19 segments of the piecewise linear regressions were significantly different for IUI/DI (P \u3c 0.001) and IVF/ICSI (P = 0.001), but not for FET (P = 0.133). Conclusion: The COVID-19 pandemic resulted in decreased annual volumes of medically assisted reproductive procedures at a university-affiliated fertility practice in southwestern Ontario. Impact on monthly procedural volume was confirmed for IUI/DI and IVF/ICSI by linear regression. Local adaptations helped compensate and exceed expected volumes in 2021. As a result, the COVID-19 pandemic resulted in a short-lived limitation in access to fertility care

Corrigendum to ‘Guideline No. 412: Laparoscopic Entry for Gynaecological Surgery’ [Journal of Obstetrics and Gynaecology Canada 43 (2021) 376−389](S1701216320310343)(10.1016/j.jogc.2020.12.012)

The authors regret that the print version of this article contained the incorrect reference 51. Reference 51 should have been: Bernante P, Foletto M, Toniato A. Creation of pneumoperitoneum using a bladed optical trocar in morbidly obese patients: technique and results. Obes Surg. 2008 Aug;18(8):1043-6. doi: 10.1007/s11695-008-9497-8. The online version of the article has now been corrected The authors would like to apologize for any confusion this caused. DOI of original article: https://doi.org/10.1016/j.jogc.2021.03.00

Fertility and pregnancy outcomes following resectoscopic septum division with and without intrauterine balloon stenting: A randomized pilot study

BackgrounD AND OBJECTIVES: Although uterine stenting is performed routinely following hysteroscopic metroplasty, we were unable to find any evidence documenting its value with regards to septum reformation and/or obstetrical performance. To evaluate the benefits of intrauterine Foley catheter/balloon splinting after resectoscopic septum division on septum reformation, fertility, and pregnancy outcomes. Design AND SETTING: Prospective, randomized controlled pilot study (Canadian Task Force Classification I) conducted in university affiliated teaching hospital. Patients AND METHODS: Twenty-eight women with infertility and/or adverse pregnancy outcomes diagnosed with intrauterine septum were randomized into having a No. 14 pediatric Foley catheter/balloon for 5 days (n=13) vs. no balloon (n=15) following resectoscopic septum division. None of the patients received preoperative endometrial thinning, antibiotic prophylaxis or adjuvant postoperative hormone therapy. All uterine septa were divided under general anaesthesia using a 26 F (9 mm) resectoscope with a monopolar electrical knife using glycine irrigant solution (1.5%) and 120 watts of power of low voltage (cut) waveform. Results: The median age (range) was 29 years (23-38) and 32 years (22-40), respectively (P=.59). The groups were comparable by age, past obstetrical performance and comorbidities including endometriosis stage I-IV in 3 and 4 women, in the catheter/balloon and balloon group, respectively, and one in each group of polycystic ovarian syndrome and Crohn disease and one case of tubal obstruction in the balloon group. There were no intra- or postoperative complications. At 3 months, a hysterosalpingogram was done in 10 (77%) and 13 (87%) women, respectively, the results of which were normal. At 12-18 months, 1 woman in the balloon and 3 in the control group were not trying to conceive and 1 in each group had not conceived. Of the remaining women, 11 (92%) in each group had conceived and pregnancy outcomes included spontaneous abortion 3 (25%) and 4 (33.3%), ectopic pregnancy 0 and 1, second trimester loss 1 (8.3%) and 0 and term pregnancy 8 (66.6%) in both groups. Conception through assisted reproductive technology occurred in 2 and 1 woman, respectively. Conclusions: Following resectoscopic septum division with monopolar knife electrode, splinting the uterine cavity with Foley catheter provided no advantage in septum reformation, clinical pregnancy rate, and pregnancy outcomes

In vitro fertilization cycles stimulated with follitropin delta result in similar embryo development and quality when compared with cycles stimulated with follitropin alfa or follitropin beta

Objective: To study the impact of follitropin delta for ovarian stimulation on embryo development and quality compared with that of follitropin alfa or beta in in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) cycles. Design: Retrospective cohort study Setting: University-affiliated, hospital-based fertility clinic Patient(s): A total of 403 IVF/ICSI cycles were conducted from September 1, 2018 to December 31, 2019. Cycles were grouped on the basis of stimulation with follitropin delta vs. follitropin alfa or beta. Intervention(s): None. Main Outcome Measure(s): Embryo parameters and clinical pregnancy and implantation rates. Result(s): Ovarian stimulation using follitropin delta resulted in no statistically significant difference in day 3 embryo quality between the control group and follitropin delta group (median 0.50 vs. 0.54 for good quality embryos and median 0.25 vs. 0.20 for intermediate quality embryos). Although on initial analysis there was a lower proportion of good quality blastocysts in the follitropin delta group than in the control group (0.11 vs. 0.22), this difference was no longer present when day 3 after fertilization vitrification and transfer cycles were excluded (0.26 vs. 0.33 follitropin delta vs. control). The clinical pregnancy rates and clinical implantation rates were similar in both groups in fresh transfer cycles. Conclusion(s): Stimulation with follitropin delta in IVF/ICSI cycles resulted in similar embryo development and pregnancy rates compared with those of stimulation with follitropin alfa or beta

Uterine aquaporin expression is dynamically regulated by estradiol and progesterone and ovarian stimulation disrupts embryo implantation without affecting luminal closure

The study investigated the effect of normal and supraphysiological (resulting from gonadotropin-dependent ovarian stimulation) levels of estradiol (E2) and progesterone (P4) on mouse uterine aquaporin gene/protein (Aqp/AQP) expression on Day 1 (D1) and D4 of pregnancy. The study also examined the effect of ovarian stimulation on uterine luminal closure and uterine receptivity on D4 of pregnancy and embryo implantation on D5 and D7 of pregnancy. These analyses revealed that the expression of Aqp3, Aqp4, Aqp5 and Aqp8 is induced by E2 while the expression of Aqp1 and Aqp11 is induced by P4. Additionally, P4 inhibits E2 induction of Aqp3 and Aqp4 expression while E2 inhibits Aqp1 and Aqp11 expression. Aqp9, however, is constitutively expressed. Ovarian stimulation disrupts Aqp3, Aqp5 and Aqp8 expression on D4 and AQP1, AQP3 and AQP5 spatial expression on both D1 and D4, strikingly so in the myometrium. Interestingly, while ovarian stimulation has no overt effect on luminal closure and uterine receptivity, it reduces implantation events, likely through a disruption in myometrial activity and embryo development. The wider implication of this study is that ovarian stimulation, which results in supraphysiological levels of E2 and P4 and changes (depending on the degree of stimulation) in the E2:P4 ratio, triggers abnormal expression of uterine AQP during pregnancy, and this is associated with implantation failure. These findings lead us to recognize that abnormal expression would also occur under any pathological state (such as endometriosis) that is associated with changes in the normal E2:P4 ratio. Thus, infertility among these patients might in part be linked to abnormal uterine AQP expression