68 research outputs found
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
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
Uterine kisspeptin receptor critically regulates epithelial estrogen receptor α transcriptional activity at the time of embryo implantation in a mouse model
Embryo implantation failure is a major cause of infertility in women of reproductive age and a better understanding of uterine factors that regulate implantation is required for developing effective treatments for female infertility. This study investigated the role of the uterine kisspeptin receptor (KISS1R) in the molecular regulation of implantation in a mouse model. To conduct this study, a conditional uterine knockout (KO) of Kiss1r was created using the Pgr-Cre (progesterone receptor-CRE recombinase) driver. Reproductive profiling revealed that while KO females exhibited normal ovarian function and mated successfully to stud males, they exhibited significantly fewer implantation sites, reduced litter size and increased neonatal mortality demonstrating that uterine KISS1R is required for embryo implantation and a healthy pregnancy. Strikingly, in the uterus of Kiss1r KO mice on day 4 (D4) of pregnancy, the day of embryo implantation, KO females exhibited aberrantly elevated epithelial ERα (estrogen receptor α) transcriptional activity. This led to the temporal misexpression of several epithelial genes [Cftr (Cystic fibrosis transmembrane conductance regulator), Aqp5 (aquaporin 5), Aqp8 (aquaporin 8) and Cldn7 (claudin 7)] that mediate luminal fluid secretion and luminal opening. As a result, on D4 of pregnancy, the lumen remained open disrupting the final acquisition of endometrial receptivity and likely accounting for the reduction in implantation events. Our data clearly show that uterine KISS1R negatively regulates ERα signaling at the time of implantation, in part by inhibiting ERα overexpression and preventing detrimentally high ERα activity. To date, there are no reports on the regulation of ERα by KISS1R; therefore, this study has uncovered an important and powerful regulator of uterine ERα during early pregnancy
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
Ureteric Injury During Transvaginal Ultrasound Guided Oocyte Retrieval
Background: Transvaginal ultrasound guided oocyte retrieval during in vitro fertilization is performed routinely around the world and has reduced the occurrence of intra-abdominal injury considerably over laparoscopic procedures. Despite this, injuries do occur. Case: We report a case of a 37-year-old patient who underwent IVF and encountered a ureteric injury during oocyte retrieval, which was recognized early and treated with ureteral stents with full resolution. During a subsequent IVF cycle, stenting of the ureters allowed better visualization, resulting in an uneventful retrieval and subsequent pregnancy. Conclusion: Ureteric injury can occur during transvaginal ultrasound guided egg retrieval. Prompt recognition is vital to successful treatment. Stenting of the ureters is the most common therapeutic modality and can be used in subsequent retrievals to identify the ureters
Combined transurethral and laparoscopic partial cystectomy for the treatment of bladder endometriosis
We present a case of a 22-year-old nulliparous woman, initially investigated by a urologist after she presented with a history of urinary tract symptoms including catamenial hematuria and suprapubic pain. Ultrasonographic and cystoscopic findings suggested a bladder mass suspicious for endometriosis. Further MRI revealed a 3 X 4 cm mass in the bladder, and the diagnosis of endometriosis was confirmed by the biopsy. Consequently, the patient was offered treatment options including combined laparoscopic and transurethral resection of the bladder lesion for definitive diagnosis and treatment. Using a combination of hydrodissection and CO2 laser energy laparoscopically and monopolar electro-surgery cystoscopically, the lesion was resected uneventfully and the bladder defect was repaired laparoscopically. The patient was discharged on the same day with a Foley catheter, which was removed 10 days later. After 8 weeks follow up period, she remained free of symptoms. Histopathology confirmed endometriosis. We conclude that this combined approach is feasible, safe and effective therapy for intramural bladder endometriosis
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
The Management of Uterine Leiomyomas
Objectives: The aim of this guideline is to provide clinicians with an understanding of the pathophysiology, prevalence, and clinical significance of myomata and the best evidence available on treatment modalities. Options: The areas of clinical practice considered in formulating this guideline were assessment, medical treatments, conservative treatments of myolysis, selective uterine artery occlusion, and surgical alternatives including myomectomy and hysterectomy. The risk-to-benefit ratio must be examined individually by the woman and her health care provider. Outcomes: Implementation of this guideline should optimize the decision-making process of women and their health care providers in proceeding with further investigation or therapy for uterine leiomyomas, having considered the disease process and available treatment options, and reviewed the risks and anticipated benefits. Evidence: Published literature was retrieved through searches of PubMed, CINAHL, and Cochrane Systematic Reviews in February 2013, using appropriate controlled vocabulary (uterine fibroids, myoma, leiomyoma, myomectomy, myolysis, heavy menstrual bleeding, and menorrhagia) and key words (myoma, leiomyoma, fibroid, myomectomy, uterine artery embolization, hysterectomy, heavy menstrual bleeding, menorrhagia). The reference lists of articles identified were also searched for other relevant publications. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits but results were limited to English or French language materials. Searches were updated on a regular basis and incorporated in the guideline to January 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, and national and international medical specialty societies. Benefits, Harms, and Costs: The majority of fibroids are asymptomatic and require no intervention or further investigations. For symptomatic fibroids such as those causing menstrual abnormalities (e.g. heavy, irregular, and prolonged uterine bleeding), iron defficiency anemia, or bulk symptoms (e.g., pelvic pressure/pain, obstructive symptoms), hysterectomy is a definitive solution. However, it is not the preferred solution for women who wish to preserve fertility and/or their uterus. The selected treatment should be directed towards an improvement in symptomatology and quality of life. The cost of the therapy to the health care system and to women with fibroids must be interpreted in the context of the cost of untreated disease conditions and the cost of ongoing or repeat investigative or treatment modalities. Values: The quality of evidence in this document was rated using the criteria described in the Report of the Caadian Task Force on Preventive Health Care (Table 1)
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
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