Incidence and Clinical Implications of Placenta Accreta Spectrum after Treatment for Asherman Syndrome.

STUDY OBJECTIVE: To investigate the incidence, predictors, and clinical implications of placenta accreta spectrum (PAS) in pregnancies after hysteroscopic treatment for Asherman syndrome (AS). DESIGN: This is a retrospective cohort study, conducted through a telephone survey and chart review. SETTING: Minimally invasive gynecologic surgery center in an academic community hospital. PATIENTS: Database of 355 patients hysteroscopically treated for AS over 4 years. We identified patients who achieved pregnancy past the first trimester and evaluated the incidence and predictors for PAS as well as associated clinical implications. INTERVENTIONS: Telephone survey. MEASUREMENTS AND MAIN RESULTS: We identified 97 patients meeting the inclusion criteria. Among these patients, 23 (23.7%) patients had PAS. History of cesarean delivery was the only variable statistically significantly associated with having PAS (adjusted odds ratio 4.03, 95% confidence interval 1.31-12.39). PAS was diagnosed antenatally in 3 patients (14.3%), with patients having placenta previa more likely to be diagnosed (p <.01). Nine patients (39.13%) with PAS required cesarean hysterectomy, which is 9.3% of those with a pregnancy that progressed past the first trimester. Factors associated with cesarean hysterectomy were the etiology of AS (dilation and evacuation after the second trimester pregnancy or postpartum instrumentation, p <.01), invasive placenta (increta or percreta, p <.05), and history of morbidly adherent placenta in previous pregnancies (p <.05). Two patients with PAS (9.5%) had uterine rupture, and another 2 (9.5%) experienced uterine inversion. CONCLUSION: There is a high incidence of PAS and associated morbidity in pregnancies after hysteroscopic treatment for AS. There is a low rate of antenatal diagnosis as well as a lack of reliable clinical predictors, which both stress the importance of clinical awareness, careful counseling, and delivery planning.

Impact of Race and Ethnicity on Perioperative Outcomes During Hysterectomy for Endometriosis.

STUDY OBJECTIVE: To assess whether complications incurred during hysterectomy for the treatment of endometriosis differ among racial-ethnic groups. DESIGN: Retrospective cohort study. SETTING: American College of Surgeons National Surgical Quality Improvement Program database from 2014 to 2019. This database is a robust, comprehensive, multi-institutional database with nearly 700 participating hospitals. PATIENTS: Patients with a diagnosis of endometriosis or with an endometriosis-associated symptom as the primary indication for surgery and surgical intraoperative documentation of endometriosis. INTERVENTIONS: Compare perioperative complications based on patient race and ethnicity. MEASUREMENTS AND MAIN RESULTS: A total of 5639 patients underwent hysterectomy for endometriosis; of these, 4368 were White patients (77.5%), 528 Black patients (9.4%), 491 Hispanic patients (8.7%), 252 Asian patients (4.5%). There was no association between location of endometriosis and patient race and ethnicity. However, White patients had highest rate, and Asian patients had the lowest rate of laparoscopic hysterectomy, 85.3% vs 69.8%, respectively (p <.01). In addition, there were differences in concomitant procedures performed at time of hysterectomy based on race and ethnicity, with White patients having the highest rates of adnexal/peritoneal surgery at 12.5% (p <.01) compared with patients of the other racial and ethnic groups. Asian patients had the highest rate of ureteral surgery at 6.8% (p <.01) and highest rate of intestinal surgery at 16.3% (p <.01) compared with patients of other racial and ethnic groups. There was no association of rates of concomitant bladder surgery, appendectomy, or rectal surgery with patient race and ethnicity. Black patients had the highest rate of minor complications at 13.5% (p <.01) and the highest rate of major complications at 6.6% (p <.01) compared with patients of other racial and ethnic groups. After multivariable analysis, Black patients still had increased odds of having a major complication compared with patients of other racial and ethnic groups even after controlling for patient characteristics and perioperative factors such as endometriosis lesion location, surgical approach, and concomitant procedures (odds ratio 1.64; 95% confidence interval, 1.10-2.45). CONCLUSION: Endometriosis lesion location did not differ with patient race and ethnicity. However, patient race and ethnicity did have an impact on the surgical approach and the concomitant surgical procedures performed at time of hysterectomy. Black patients had the highest odds of major complications.

A Systematic Review of Adenomyosis: It Is Time to Reassess What We Thought We Knew about the Disease.

OBJECTIVE: To summarize and update our current knowledge regarding adenomyosis diagnosis, prevalence, and symptoms. DATA SOURCES: Systematic review of PubMed between January 1972 and April 2020. Search strategy included: "adenomyosis [MeSH Terms] AND (endometriosis[MeSH Term OR prevalence study [MeSH Terms] OR dysmenorrhea[text word] OR prevalence[Text Word] OR young adults [Text Word] OR adolesce* [Text Word] OR symptoms[Text Word] OR imaging diagnosis [Text Word] OR pathology[Text Word]. METHODS OF STUDY SELECTION: Articles published in English that addressed adenomyosis and discussed prevalence, diagnosis, and symptoms were included. The included articles described pathology diagnosis, imaging, biopsy diagnosis, prevalence and age of onset, symptoms, and concomitant endometriosis. TABULATION, INTEGRATION, AND RESULTS: Sixteen articles were included in the qualitative analysis. The studies are heterogeneous when diagnosing adenomyosis with differing criteria, protocols, and patient populations. The prevalence estimates range from 20% to 88.8% in women who are symptomatic (average 30%-35%), with most diagnosed between the ages of 32 years and 38 years. The correlation between imaging and pathology continues to evolve. As imaging advances, newer studies report that younger women who are symptomatic are being diagnosed with adenomyosis on the basis of both magnetic resonance imaging and/or transvaginal ultrasound. High rates of concomitant endometriosis create challenges when discerning the etiology of pelvic pain. Symptoms that are historically attributed to endometriosis may actually be caused by adenomyosis. CONCLUSION: Adenomyosis remains a challenge to identify, assess, and research because of the lack of standardized diagnostic criteria, especially in women who wish to retain their uterus. As noninvasive diagnostics such as imaging and myometrial biopsies continue to improve, younger women with variable symptoms will likely create criteria for diagnosis with adenomyosis. The priority should be to create standardized histopathologic and imaging diagnoses to gain a deeper understanding of adenomyosis.

Effects of Asherman Syndrome on Maternal and Neonatal Morbidity with Evaluation by Conception Method.

STUDY OBJECTIVE: Create a comprehensive summary of maternal and neonatal morbidities from patients previously treated for Asherman syndrome and evaluate for differences in perinatal outcomes based on conception method. DESIGN: Retrospective cohort. SETTING: Community teaching hospital affiliated with a large academic medical center. PATIENTS: Total of 43 singleton births identified from 40 patients previously treated at our institution for Asherman syndrome. INTERVENTIONS: Review of fertility and obstetric data to summarize the maternal and neonatal outcomes in singleton births from patients with Asherman syndrome who had been treated with hysteroscopic adhesiolysis. MEASUREMENTS AND MAIN RESULTS: Primary outcomes of maternal morbidity (i.e., hypertensive disease, gestational diabetes, ruptured membranes, postpartum hemorrhage, morbidly adherent placenta [MAP]) and secondary outcomes of neonatal morbidity (i.e., gestational age at birth, method of delivery, weight, length, 1- and 5-minute Apgar score oxygen requirement, anatomic malformations, length of neonatal admission) were evaluated. We identified 40 patients who completed successful treatment of Asherman syndrome and went on to carry a singleton gestation within our institution: 20 (50%) with mild disease, 18 (45%) with moderate disease, and 2 (5%) with severe disease under the March classification system. In total, 43 singleton births were examined, with 27 of 43 (62.8%) conceived without in vitro fertilization (IVF) (group A: non-IVF conception) and 16 of 43 (37.2%) conceived through IVF (group B: IVF conception). The overall rate of preterm birth in Asherman pregnancies was 11.6%, with no difference between the 2 conception groups. We documented 9.3% cases with intrauterine growth restriction, with no difference based on conception groups. The rate of MAP in patients with Asherman syndrome was 14.0%, and the rate of postpartum hemorrhage was 32.6%, with no differences between the conception groups. Newborn anatomic malformations of any cause were documented in 18.6% of all singleton births, with no difference between the conception groups. CONCLUSION: Our series indicates a higher incidence of intrauterine growth restriction, MAP, postpartum hemorrhage, and newborn anatomic malformations in Asherman syndrome pregnancies than that reported in pregnancies within the general population. However, we found no significant differences in the maternal and neonatal outcomes of patients with Asherman syndrome who conceived with or without IVF after being treated with hysteroscopic adhesiolysis.

Concomitant Adenomyosis among Patients with Asherman Syndrome.

STUDY OBJECTIVE: To characterize obstetric outcomes for concomitant Asherman syndrome and adenomyosis. DESIGN: A retrospective cohort study. SETTING: A community teaching hospital affiliated with a large academic medical center. PATIENTS: A total of 227 patients with Asherman syndrome with available hysteroscopy and pelvic ultrasound reports. INTERVENTIONS: Telephone survey to assess and compare the obstetric outcomes of patients with Asherman syndrome with concomitant adenomyosis (Group A) vs patients with Asherman syndrome without concomitant adenomyosis (Group B). MEASUREMENTS AND MAIN RESULTS: A telephone survey and confirmatory chart review were conducted to obtain information on patients' demographics, gynecologic and obstetric history, past medical and surgical history, and Asherman syndrome management. Adenomyosis was a common sonographic finding, detected in 39 patients with Asherman syndrome (17.2%). In this cohort, 77 patients attempted pregnancy and produced 87 pregnancies. Age (odds ratio [OR] 0.67; 95% confidence intervals [CI], 0.52-0.86) was negatively associated with a pregnancy outcome. Age (OR 0.83; 95% CI, 0.73-0.95) and severe Asherman disease (OR 0.06; 95% CI, <0.01-0.99) were negatively associated with a live birth outcome. Adenomyosis was not an independent predictor of pregnancy rate, miscarriage rate, or live birth rate among patients with Asherman syndrome. CONCLUSION: Adenomyosis is relatively common in patients with Asherman syndrome. Adenomyosis does not seem to add any distinct detriment to fertility among patients with Asherman syndrome.

Novel Technology to Capture Objective Data from Patients' Recovery from Laparoscopic Endometriosis Surgery.

STUDY OBJECTIVE: To assess the feasibility of a noncontact radio sensor as an objective measurement tool to study postoperative recovery from endometriosis surgery. DESIGN: Prospective cohort pilot study. SETTING: Center for minimally invasive gynecologic surgery at an academically affiliated community hospital in conjunction with in-home monitoring. PATIENTS: Patients aged above 18 years who sleep independently and were scheduled to have laparoscopy for the diagnosis and treatment of suspected endometriosis. INTERVENTIONS: A wireless, noncontact sensor, Emerald, was installed in the subjects' home and used to capture physiologic signals without body contact. The device captured objective data about the patients' movement and sleep in their home for 5 weeks before surgery and approximately 5 weeks postoperatively. The subjects were concurrently asked to complete a daily pain assessment using a numeric rating scale and a free text survey about their daily symptoms. MEASUREMENTS AND MAIN RESULTS: Three women aged 23 years to 39 years and with mild to moderate endometriosis participated in the study. Emerald-derived sleep and wake times were contextualized and corroborated by select participant comments from retrospective surveys. In addition, self-reported pain levels and 1 sleep variable, sleep onset to deep sleep time, showed a significant (p <.01), positive correlation with next-day-pain scores in all 3 subjects: r = 0.45, 0.50, and 0.55. In other words, the longer it took the subject to go from sleep onset to deep sleep, the higher their pain score the following day. CONCLUSION: A patient's experience with pain is challenging to meaningfully quantify. This study highlights Emerald's unique ability to capture objective data in both preoperative functioning and postoperative recovery in an endometriosis population. The utility of this uniquely objective data for the clinician-patient relationship is just beginning to be explored.

Endometrial thickness measurements among Asherman syndrome patients prior to embryo transfer.

STUDY QUESTION: Is there an association between endometrial thickness (EMT) measurement and clinical pregnancy rate among Asherman syndrome (AS) patients utilizing IVF and embryo transfer (ET)? SUMMARY ANSWER: EMT measurements may not be associated with successful clinical pregnancy among AS patients undergoing IVF. WHAT IS KNOWN ALREADY: Clinical pregnancy rate after IVF is significantly lower in patients with a thin endometrium, defined as a maximum EMT of <7 mm. However, AS patients often have a thin EMT measurement due to intrauterine scarring, with a paucity of data and no guidance on what EMT cutoff is appropriate when planning an ET among these patients. STUDY DESIGN, SIZE, DURATION: This is a retrospective cohort study of 45 AS patients treated at a specialized advanced hysteroscopic clinic from 1 January 2015, to 1 March 2019. PARTICIPANTS/MATERIALS, SETTING, METHODS: Review of EMT measurements prior to a total of 90 ETs, among 45 AS patients. The impact of the maximum EMT measurement prior to ET on clinical pregnancy rate was analyzed. MAIN RESULTS AND THE ROLE OF CHANCE: A total of 25/45 (55.6%) AS patients ultimately went on to have ≥1 clinical pregnancy following a mean ± SD of 2.00 ± 1.26 ET attempts. There was a total of 90 ETs among the 45 AS patients, with 29/90 (32.2%) ETs resulting in a clinical pregnancy. Younger patient age (P = 0.05) and oocyte donation (P = 0.01) were the only variables identified to be significant predictors for a positive clinical pregnancy outcome on bivariate analysis. The mean EMT measurement prior to all ETs among AS patients was 7.5 ± 1.6 mm. EMT measurement prior to ET did not predict a positive clinical pregnancy on either bivariate (P = 0.84) or multivariable analysis (odds ratio 0.91, P = 0.60). 31.8% of EMT measurements measured <7.0 mm. In this small cohort, no difference in the clinical pregnancy rate was detected when comparing ETs with EMT measurements of <7.0 mm versus ≥7.0 mm (P = 0.83). The mean EMT measurement decreased with increasing AS disease severity; 8.0 ± 1.6 mm for mild disease, 7.0 ± 1.4 mm for moderate disease and 5.4 ± 0.1 mm for severe disease. LIMITATIONS, REASONS FOR CAUTION: Our small sample size limits our ability to draw any definitive conclusions. In addition, patients utilized various infertility clinics. This limits our ability to evaluate the consistency of EMT measurements and the IVF care that was received. WIDER IMPLICATIONS OF THE FINDINGS: EMT measurement cutoff values should be used with caution if canceling a scheduled ET in AS patients. STUDY FUNDING/COMPETING INTEREST(S): This study was not funded. K.I. reports personal fees from Karl Stroz and personal fees from Medtronics outside the submitted work. The other authors have no conflicts of interest. TRIAL REGISTRATION NUMBER: N/A.

Diagnosing endometriosis before laparoscopy: radiologic tools to evaluate the disease.

PURPOSE OF REVIEW: The current gold standard for diagnosing endometriosis is laparoscopy with tissue biopsy. This review presents new evidence regarding advanced imaging for more optimal clinical assessment and preoperative evaluation for endometriosis. RECENT FINDINGS: A systematic approach to the imaging evaluation of endometriosis using transvaginal ultrasound and magnetic resonance imaging has been proposed by expert groups and societies. Evidence suggests that new imaging techniques improve the accuracy of clinical diagnosis and facilitate improved preoperative mapping of endometriotic lesions. SUMMARY: The clinical diagnosis of endometriosis, including new structured imaging protocols and techniques, is paramount in an initial evaluation. If surgery is indicated, clinical examination and imaging should provide sufficient information to anticipate the extent of surgery, properly counsel the patient, and when appropriate, refer to a minimally invasive gynecologic surgery specialist or assemble a multidisciplinary team.

Opioid use after laparoscopic hysterectomy: prescriptions, patient use, and a predictive calculator.

BACKGROUND: In the setting of America's opioid epidemic, judicious postoperative opioid prescribing is important. Gynecologists lack standard guidelines about postoperative opioid prescriptions. OBJECTIVES: The objectives of the study were to describe opioid prescribing practices by a group of minimally invasive gynecologic surgeons, to measure postoperative opioid use after minimally invasive hysterectomy, and to identify preoperative factors that could predict whether a patient will be a low or high postoperative opioid user. STUDY DESIGN: This was a prospective survey-based study including 125 women undergoing laparoscopic hysterectomy for benign indications at 2 community teaching hospitals. Patients were preoperatively surveyed about demographics, past medical history, and current and expected pain scores and were screened for anxiety, depression, and pain catastrophizing. At 1 and 2 weeks after surgery, patients were surveyed about their pain and pain medication use. RESULTS: Ninety-eight percent of patients were prescribed an opioid for acute postoperative pain. The median opioid prescription was for 150 morphine milligram equivalents, equivalent to 20 tablets of oxycodone 5 mg, while median patient postoperative use was 37.5 morphine milligram equivalents, equivalent to 5 tablets of oxycodone 5 mg. Ninety percent of patients had leftover opioids at 2 weeks after surgery, and most leftover opioids were stored in an unsecure location. Preoperative factors that were most strongly correlated with postoperative opioid use included a history of chronic pelvic pain or endometriosis, preoperative opioid use, anxiety, depression, pain catastrophizing, preoperative pain score, anticipated postoperative pain score, and anticipated postoperative pain medication needs. A predictive calculator was developed based on these factors to help identify patients who are likely to be a high opioid user (defined as taking greater than 112.5 morphine milligram equivalents) or a low opioid user (defined as taking 37.5 morphine milligram equivalents or less). CONCLUSION: On average, surgeons prescribed 4 times the amount of opioids than was needed for patients undergoing laparoscopic hysterectomy for acute postoperative pain control. Individualizing patients' opioid prescriptions based on preoperative risk factors could help reduce excess prescription opioids.

Organoid co-culture model of the human endometrium in a fully synthetic extracellular matrix enables the study of epithelial-stromal crosstalk.

BACKGROUND: The human endometrium undergoes recurring cycles of growth, differentiation, and breakdown in response to sex hormones. Dysregulation of epithelial-stromal communication during hormone-mediated signaling may be linked to myriad gynecological disorders for which treatments remain inadequate. Here, we describe a completely defined, synthetic extracellular matrix that enables co-culture of human endometrial epithelial and stromal cells in a manner that captures healthy and disease states across a simulated menstrual cycle. METHODS: We parsed cycle-dependent endometrial integrin expression and matrix composition to define candidate cell-matrix interaction cues for inclusion in a polyethylene glycol (PEG)-based hydrogel crosslinked with matrix metalloproteinase-labile peptides. We semi-empirically screened a parameter space of biophysical and molecular features representative of the endometrium to define compositions suitable for hormone-driven expansion and differentiation of epithelial organoids, stromal cells, and co-cultures of the two cell types. FINDINGS: Each cell type exhibited characteristic morphological and molecular responses to hormone changes when co-encapsulated in hydrogels tuned to a stiffness regime similar to the native tissue and functionalized with a collagen-derived adhesion peptide (GFOGER) and a fibronectin-derived peptide (PHSRN-K-RGD). Analysis of cell-cell crosstalk during interleukin 1B (IL1B)-induced inflammation revealed dysregulation of epithelial proliferation mediated by stromal cells. CONCLUSIONS: Altogether, we demonstrate the development of a fully synthetic matrix to sustain the dynamic changes of the endometrial microenvironment and support its applications to understand menstrual health and endometriotic diseases. FUNDING: This work was supported by The John and Karine Begg Foundation, the Manton Foundation, and NIH U01 (EB029132).

Incidental Bladder Cancer at the Time of Routine Cystoscopy following Laparoscopic Hysterectomy.

Three patients with abnormal uterine bleeding underwent uncomplicated minimally invasive total hysterectomy with routine cystoscopy. At time of cystoscopy, the patients had unexpected findings of bladder masses and postoperatively were expeditiously referred to urology. Final pathology for all revealed low-grade urologic carcinoma. The patients were treated with transurethral excision and are currently in surveillance without concern for recurrence. All three patients were asymptomatic at time of diagnosis. If the masses were not identified at the time of hysterectomy with cystoscopy, it is unclear when the patients may have developed symptoms to warrant a workup and likely would have experienced progression of the malignancy during that time. We hope this case series showcases that abnormal bladder masses are easily identifiable by the benign gynecologist at time of cystoscopy and illustrates another benefit of routine cystoscopy at time of hysterectomy.

Intraoperative Factors Associated with More Postoperative Opioid Use after Laparoscopic Hysterectomy.

BACKGROUND AND OBJECTIVES: To identify intraoperative factors during laparoscopic hysterectomy associated with postoperative opioid use and increased pain scores during the acute postoperative period. METHODS: This is a prospective survey-based cohort study at two teaching hospitals in the Boston metropolitan area. A total of 125 patients undergoing laparoscopic hysterectomy were enrolled. Surveys were administered by telephone at one-week postoperatively and in-person at their two-week postoperative visit to elicit opioid consumption converted to morphine milligram equivalents (MMEs) and pain scores. RESULTS: The median total opioid consumption was 37.5 MME (range 0-960 MMEs). Intraoperative factors associated with increased total MME consumption were lower uterine weight and resection of endometriosis at the time of surgery. Patients with uteri less than 250 grams used twice as much opioid compared to participants with uteri greater than 250 grams (median of 49.8 MME (interquartile range [IQR] 7.5-120.5) vs. 22.5 MME (IQR 7.5-61.0). The median opioid consumption by patients with resection or ablation of endometriosis was three times that of those who did not undergo surgical treatment of endometriosis (97.0 MME (IQR 53.1-281.3) vs. 30.0 MMEs (IQR 7.5-81.3 MME)). Maximum pain scores and reported pain score at one and two-week interviews were also significantly higher in patients with these characteristics. CONCLUSION: Several easily identified intraoperative factors may be correlated with opioid requirements during the acute postoperative period. This can allow surgeons to set expectations and dispense patient-specific opioid prescriptions. Individualizing prescriptions may lower the amount of excess circulating opioids and help combat the opioid epidemic.

Factors associated with burnout among minimally invasive gynecologic surgery fellows.

BACKGROUND: While burnout has been identified in half of practicing physicians, no validated questionnaires have assessed burnout among minimally invasive gynecologic surgery fellows. OBJECTIVE: This study aimed to assess factors associated with burnout among minimally invasive gynecologic surgery fellows. STUDY DESIGN: Cross-sectional online survey including the validated Copenhagen Burnout Inventory: 100 minimally invasive gynecologic surgery fellows in the United States were invited, including the classes of 2021 and 2022. Of the 100 fellows invited, 60 fellows completed the Copenhagen Burnout Inventory survey. Descriptive statistics were used to report the demographic variables, the mean Copenhagen Burnout Inventory score, and the responses to the survey questions. Logistic and linear regression models were created to assess relationships between fellow characteristics and Copenhagen Burnout Inventory scores. RESULTS: Of the 60 fellows with complete Copenhagen Burnout Inventory survey data, 73% were female, 50% were first-year, and 50% were second-year fellows. The mean Copenhagen Burnout Inventory score was 39.2 (standard deviation, 14.4), indicating moderate burnout, and 21.7% of fellows had scores >50, indicating high burnout. Personal and work-related burnout were highest, with Copenhagen Burnout Inventory scores of 47.9 (standard deviation, 16.8) and 45.1 (standard deviation, 17.6), respectively. Patient-related burnout scores were the lowest at 23.5 (standard deviation, 16.5).Factors associated with overall burnout included career choice dissatisfaction (beta, 5.6; 95% confidence interval, 0.9-10.3; P=.02) and absence of a positive and respectful work environment (beta, 5.9; 95% confidence interval, 1.0-10.9; P=.02). Fellows who were somewhat satisfied with their career choice scored 11.2 points higher than those who were highly satisfied. Fellows whose work environment was almost never positive and respectful scored 17.8 points higher than those whose work environment was always positive and respectful. Female fellows were significantly less likely to have a low Copenhagen Burnout Inventory score than male fellows (odds ratio, 0.05; 95% confidence interval, 0.004-0.3; P=.004).Only one-third of fellows reported regular individual wellness behaviors: mindfulness (23%), exercise (35%), 7 to 8 hours of sleep (37%), and recreation (27%); however, these factors were not associated with lower burnout scores. CONCLUSION: Fellows had moderate to high personal and work-related burnout, whereas patient-related burnout was low. Factors associated with burnout were negative work culture, lack of control over work schedule, and decreased career satisfaction. Individual wellness behaviors were not associated with burnout, highlighting the need to look beyond individual behavior in the fight against physician burnout.

Patient-reported menstrual and obstetric outcomes following hysteroscopic adhesiolysis for Asherman syndrome.

OBJECTIVE: Review the menstrual and obstetric outcomes among Asherman syndrome patients when stratified by disease severity. DESIGN: Retrospective cohort study. SETTING: A community teaching hospital affiliated with a large academic medical center. PATIENTS: A total of 355 Asherman syndrome patients stratified by March classification who underwent hysteroscopic adhesiolysis. INTERVENTIONS: Telephone survey, analyzed with multivariable analysis. MAIN OUTCOME MEASURES: Return of menstruation. Pregnancy, miscarriage, and live birth rate. RESULTS: A total of 355 patients underwent hysteroscopic adhesiolysis. Of these, 150 (42.3%) patients completed the telephone survey with a mean follow-up of 2.21 years. Additionally, 40.7% had mild, 52.7% had moderate, and 6.6% had severe disease. Furthermore, 25.3% of patients reported amenorrhea at presentation, with mild disease patients having the highest rate of returning menstruation (93.8%) following treatment. The cumulative pregnancy rate was 81.9%, and the cumulative live birth rate was 51.2%, with no statistical differences identified by the classification group. CONCLUSION: Asherman syndrome disease severity predicted returning menstruation but not pregnancy or live birth rate.

Symptoms of Adenomyosis and Overlapping Diseases.

To summarize and update our current knowledge regarding adenomyosis diagnosis, prevalence, and symptoms. Systematic review of PubMed between January 1972 and April 2020. Search strategy included: "adenomyosis [MeSH Terms] AND (endometriosis[MeSH Term OR prevalence study [MeSH Terms] OR dysmenorrhea[Text Word] OR prevalence[Text Word] OR young adults [Text Word] OR adolesce* [Text Word] OR symptoms[Text Word] OR imaging diagnosis [Text Word] OR pathology[Text Word]. Articles published in English that addressed adenomyosis and discussed prevalence, diagnosis, and symptoms were included. Included articles described: pathology diagnosis, imaging, biopsy diagnosis, prevalence and age of onset, symptoms, and concomitant endometriosis. Sixteen articles were included in the qualitative analysis. The studies are heterogeneous when diagnosing adenomyosis with differing criteria, protocols, and patient populations. Prevalence estimates range from 20% to 88.8% in symptomatic women (average 30-35%) with most diagnosed between 32-38 years old. The correlation between imaging and pathology continues to evolve. As imaging advances, newer studies report younger symptomatic women are being diagnosed with adenomyosis based on both magnetic resonance imaging (MRI) and/or transvaginal ultrasound (TVUS). High rates of concomitant endometriosis create challenges when discerning the etiology of pelvic pain. Symptoms that are historically attributed to endometriosis may actually be caused by adenomyosis. Adenomyosis remains a challenge to identify, assess and research because of the lack of standardized diagnostic criteria, especially in women who wish to retain their uterus. As noninvasive diagnostics such as imaging and myometrial biopsies continue to improve, younger women with variable symptoms will likely create criteria for diagnosis with adenomyosis. The priority should be to create standardized histopathological and imaging diagnoses to gain deeper understandings of adenomyosis.

Physiomimetic Models of Adenomyosis.

Adenomyosis remains an enigmatic disease in the clinical and research communities. The high prevalence, diversity of morphological and symptomatic presentations, array of potential etiological explanations, and variable response to existing interventions suggest that different subgroups of patients with distinguishable mechanistic drivers of disease may exist. These factors, combined with the weak links to genetic predisposition, make the entire spectrum of the human condition challenging to model in animals. Here, after an overview of current approaches, a vision for applying physiomimetic modeling to adenomyosis is presented. Physiomimetics combines a system's biology analysis of patient populations to generate hypotheses about mechanistic bases for stratification with in vitro patient avatars to test these hypotheses. A substantial foundation for three-dimensional (3D) tissue engineering of adenomyosis lesions exists in several disparate areas: epithelial organoid technology; synthetic biomaterials matrices for epithelial-stromal coculture; smooth muscle 3D tissue engineering; and microvascular tissue engineering. These approaches can potentially be combined with microfluidic platform technologies to model the lesion microenvironment and can potentially be coupled to other microorgan systems to examine systemic effects. In vitro patient-derived models are constructed to answer specific questions leading to target identification and validation in a manner that informs preclinical research and ultimately clinical trial design.

Minimally invasive specialists and rates of laparoscopic hysterectomy.

BACKGROUND AND OBJECTIVE: Despite the prevalence of hysterectomy for treatment of benign gynecologic conditions, providers nationwide have been slow to adopt minimally-invasive surgical techniques. Our objective is to investigate the impact of a department for minimally invasive gynecologic surgery (MIGS) on the rate of laparoscopic hysterectomy at an academic community hospital without robotic technology. METHODS: This retrospective observational study included all patients who underwent hysterectomy for benign indications from January 1, 2004, through December 31, 2012. The primary outcome was route of hysterectomy: open, laparoscopic, or vaginal. Secondary outcomes of interest included length of stay and factors associated with an open procedure. RESULTS: In 2004, only 24 (8%) of the 292 hysterectomies performed for benign conditions at Newton-Wellesley Hospital (NWH) were laparoscopic. The rate increased to more than 50% (189/365) by 2008, and, in 2012, 72% (316/439) of hysterectomies were performed via a traditional laparoscopic approach. By 2012, more than 93% (411/439) of all hysterectomies were performed in a minimally invasive manner (including total laparoscopic hysterectomy [TLH], laparoscopic supracervical hysterectomy [LSH], total vaginal hysterectomy [TVH], and laparoscopy-assisted vaginal hysterectomy [LAVH]). More than 85% of the hysterectomies at NWH in 2012 were outpatient procedures. By this time, the surgeon's preference or lack of expertise was rarely cited as a factor leading to open hysterectomy. CONCLUSIONS: A large diverse gynecologic surgery department transformed surgical practice from primarily open hysterectomy to a majority (>72%) performed via the traditional laparoscopic route and a large majority (>93%) performed in a minimally invasive manner in less than 8 years, without the use of robotic technology. This paradigm shift was fueled by patient demand and by MIGS department surgical mentorship for generalist obstetrician/gynecologists.

Uterine rupture after uterine artery embolization for symptomatic leiomyomas.

BACKGROUND: There are few data regarding safety of pregnancy after uterine artery embolization. However, numerous women desire future fertility after this procedure. Uterine rupture without a history of cesarean delivery or uterine scarring is an exceedingly rare complication in pregnancy. CASE: We report a case of uterine rupture in a primigravid woman after uterine artery embolization. Her pregnancy was also complicated by placenta previa with placenta increta, resulting in a favorable neonatal outcome in an otherwise life-threatening situation for mother and fetus. CONCLUSION: Uterine artery embolization is a risk factor for abnormal placentation and uterine rupture in subsequent pregnancies.