Laparoscopic Vecchietti procedure: pearls for success.

OBJECTIVE: To present an effective strategy for optimizing the care of patients with Müllerian agenesis who desire surgical management for the creation of a neovagina with the laparoscopic Vecchietti procedure. DESIGN: This video provides a framework for patient evaluation and selection, surgical strategy, and postoperative care regimen to provide optimal postprocedural outcomes. SETTING: Academic Hospital. PATIENT(S): This is a 22-year-old patient with Müllerian agenesis who was unsuccessful with conservative strategies for vaginal lengthening and sought care for neovagina creation. INTERVENTION(S): The patient underwent preoperative pelvic floor physical therapy and vaginal dilation, both of which were ineffective in producing adequate vaginal lengthening. We then performed a laparoscopic Vecchietti procedure. The procedure occurred at a large academic institution with two obstetrics-gynecology subspecialty surgeons providing perioperative care. MAIN OUTCOME MEASURE(S): A vaginal length of 7 cm was achieved, which was sustained at >12 months. RESULT(S): The patient was managed by a multidisciplinary team using our established care regimen, with follow-up demonstrating a sustained positive treatment outcome. The vaginal length at more than 1 year after the procedure measured 7 cm. CONCLUSION(S): Using a methodological, patient-focused approach and an experienced multidisciplinary team can optimize immediate- and long-term surgical outcomes for patients with Müllerian anomalies who do not have acceptable success with conservative methods.

If CE affects infertile women's outcomes after surgery?

OBJECTIVE: To investigate the prevalence of chronic endometritis (CE) in infertile patients and whether it affects spontaneous pregnancy after reproductive surgery in infertile patients. MATERIALS AND METHODS: In this study, we collected clinical information on infertility patients who underwent reproductive surgery at the Reproductive Medicine Centre of the Second Hospital of Lanzhou University from 2021.1 to 2022.8. All patients underwent laparoscopic and hysteroscopic surgery. Tubal lubrication was performed concurrently with endometrial sample collection and pathological examination. The specimens were immunohistochemically stained with CD38 and CD138, and those who tested positive at the same time were diagnosed with chronic endometritis. As of 2023.9, the patients were followed up by telephone to determine whether chronic endometritis impacted postoperative pregnancy. OUTCOME: A total of 81 patients were finally included in the study. Of these, 25 were in the chronic endometritis group, and 56 were in the non-chronic endometritis group. There were no appreciable differences between the two groups' demographic statistics. Furthermore, neither the bilateral appendages nor the uterus's intraoperative conditions showed a statistically significant difference. Patients in the chronic endometritis group had a longer time to conception from the time of surgery (7 (6.00-11.75) vs. 10 (6.50-16.00), p = 0.467) and a lower rate of spontaneous pregnancies (8/25 = 32.00 % vs. 28/55 = 50.00 %, p = 0.132) than patients with non-chronic endometritis. Among the patients who had successful spontaneous pregnancies after surgery, approximately 77.14 % had live births and 22.86 % had miscarriages, and the live birth rate between the two groups was not significantly different. (21/28 = 75.00 % vs 7/8 = 87.50 %, p = 0.651) CONCLUSION: Chronic endometritis affects approximately 31.82% of infertile patients, and following reproductive surgery, it has no discernible impact on spontaneous pregnancy.

Derivation and validation of the first web-based nomogram to predict the spontaneous pregnancy after reproductive surgery using machine learning models.

Objective: Infertility remains a significant global burden over the years. Reproductive surgery is an effective strategy for infertile women. Early prediction of spontaneous pregnancy after reproductive surgery is of high interest for the patients seeking the infertility treatment. However, there are no high-quality models and clinical applicable tools to predict the probability of natural conception after reproductive surgery. Methods: The eligible data involving 1013 patients who operated for infertility between June 2016 and June 2021 in Yantai Yuhuangding Hospital in China, were randomly divided into training and internal testing cohorts. 195 subjects from the Linyi People's Hospital in China were considered for external validation. Both univariate combining with multivariate logistic regression and the least absolute shrinkage and selection operator (LASSO) algorithm were performed to identify independent predictors. Multiple common machine learning algorithms, namely logistic regression, decision tree, random forest, support vector machine, k-nearest neighbor, and extreme gradient boosting, were employed to construct the predictive models. The optimal model was verified by evaluating the model performance in both the internal and external validation datasets. Results: Six clinical indicators, including female age, infertility type, duration of infertility, intraoperative diagnosis, ovulation monitoring, and anti-Müllerian hormone (AMH) level, were screened out. Based on the logistic regression model's superior clinical predictive value, as indicated by the area under the receiver operating characteristic curve (AUC) in both the internal (0.870) and external (0.880) validation sets, we ultimately selected it as the optimal model. Consequently, we utilized it to generate a web-based nomogram for predicting the probability of spontaneous pregnancy after reproductive surgery. Furthermore, the calibration curve, Hosmer-Lemeshow (H-L) test, the decision curve analysis (DCA) and clinical impact curve analysis (CIC) demonstrated that the model has superior calibration degree, clinical net benefit and generalization ability, which were confirmed by both internal and external validations. Conclusion: Overall, our developed first nomogram with online operation provides an early and accurate prediction for the probability of natural conception after reproductive surgery, which helps clinicians and infertile couples make sensible decision of choosing the mode of subsequent conception, natural or IVF, to further improve the clinical practices of infertility treatment.

Laparoscopic transfundal approach to cervical dilation: a novel treatment for cervical stenosis and cervical factor infertility.

OBJECTIVE: To demonstrate a novel technique used to restore cervical patency in a patient with severe iatrogenic cervical stenosis. DESIGN: Surgical video case report. SETTING: A single academic institution. PATIENT(S): We highlight the case of a 35-year-old nulliparous woman with a history of primary infertility. Her past medical history was significant for focal, invasive, well-differentiated squamous cell carcinoma of the cervix, for which she underwent a loop electrosurgical excision procedure. During her infertility assessment, she was found to have an extremely stenotic cervix that was refractory to conventional treatment options. INTERVENTIONS: This video highlights our innovative laparoscopic transfundal technique used to restore her cervical patency. MAIN OUTCOME MEASURES: None, as this is a descriptive case report. RESULTS: Postoperatively, the patient had continued cervical patency for >1 year with successful fertility treatment resulting in pregnancy. CONCLUSIONS: To our knowledge, this is the first case report describing a laparoscopic transfundal approach used to reestablish cervical patency. This approach may be considered for patients with cervical stenosis who have not responded to standard conservative therapies.

Unification and orificing of two functional noncommunicating uterine horns through the created neovagina using peritoneum.

OBJECTIVE: To demonstrate the surgical approach for Müllerian agenesis with bilateral uterine remnants containing functional endometrium. DESIGN: Stepwise demonstration of the technique with narrated video footage. SETTING: Reproductive surgery unit of a tertiary university hospital. PATIENT: An 18-year-old adolescent was admitted to a tertiary university hospital with complaints of primary amenorrhea and cyclic pelvic pain. Physical examination and magnetic resonance imaging scans suggested a complex Müllerian abnormality. The patient had uterine remnants with bilateral functional endometrium and cervicovaginal agenesis. INTERVENTION: An operation was planned to reconstruct her anatomy by providing a neovagina and anastomosing the uterine remnants. Gonadotropin-releasing hormone analogs were prescribed to suppress her menstruation until the procedure. The operation was performed in the third month after the initial diagnosis. A laparoscopy was conducted, revealing approximately 5 × 6-cm bilateral uterine horns with healthy adnexa. As the first step, a neovagina was created using a modified peritoneal pull-down technique, a standard approach in our clinic. A vaginal incision was made, and a blind vaginal dissection was performed to reach the peritoneum vaginally. Subsequently, an acrylic vaginal mold was inserted. The vaginal orifice was laparoscopically incised using ultrasonic energy with guidance from the inserted vaginal acrylic mold. The orifice was gradually dilated with larger molds. The entire pelvic peritoneum was dissected circularly, and the distal part of the dissected peritoneum was pulled down using four 2.0 Vicryl sutures at 0°, 90°, 180°, and 270° from the opened vaginal orifice. The uterine cavities of both remnants were incised, and two separate Foley catheters were placed in both cavities. A mold with a hole was used to insert the catheters through the vagina. Both catheters were secured in the cavities with Prolene sutures pulled up from the anterior abdominal wall. The next step involved uterine anastomosis. The uterine remnants were unified through continuous suturing, resulting in the formation of a normally shaped uterus. In the final step, the created uterus and neovagina were anastomosed. The patient received instructions on how to perform mold exercises and follow-up care. MAIN OUTCOME MEASURE: Description of laparoscopic management of a rare Müllerian abnormality. RESULTS: The postoperative magnetic resonance imaging scan at 1 month revealed healed unified uterine cavities and vagina. The patient experienced spontaneous menstruation in the second month after surgery and now maintains regular menses with an approximately 9-10 cm functional vagina. Within 3 months after surgery, the visual analogue scale scores for chronic pelvic pain and dysmenorrhea decreased from 9 to 2-3. CONCLUSIONS: Müllerian abnormalities are exceptionally rare, and their spectrum is broad, making it challenging to identify an exact surgical method to restore functional anatomy. Therefore, a customized surgical approach should be designed for each patient on the basis of their unique condition.

Comparison of orthotopic and heterotopic autologous ovarian tissue transplantation outcomes.

OBJECTIVE: To compare the outcomes of orthotopic and heterotopic ovarian tissue transplantation (OTT) techniques. DESIGN: Mixed prospective-retrospective cohort study. SETTING: Academic hospital. PATIENTS: A total of 14 recipients of autologous OTT. INTERVENTIONS: Of the 14 women, 12 who received orthotopic (n = 6) or heterotopic (n = 6) transplants met the inclusion criteria. All orthotopic transplants and one heterotopic ovarian tissue transplant were performed laparoscopically. Although 5 of the 6 remaining heterotopic transplants were performed subcutaneously under local anesthesia or intravenous sedation, one was performed with robotic assistance. With the exception of one recipient who solely desired restoration of endocrine function, all underwent oocyte retrieval either to cryopreserve oocytes and embryos before the graft function ceased or because they could not otherwise conceive (hysterectomy, radiation damage, and heterotopic transplant). MAIN OUTCOME MEASURES: Primary outcome measures were graft function and longevity, and the number of embryos generated per retrieval. RESULTS: The mean age at ovarian tissue harvesting and transplantation was lower in patients with orthotopic vs. heterotopic transplants, although the proportion of transplanted ovarian cortex was lower in heterotopic transplant cases. All grafts restored ovarian endocrine function. Fertilization rates, the number of embryos generated per retrieval, and the mean number of nonarrested embryos were significantly lower in heterotopic OTT. However, time to function and graft longevity were similar between the groups. Although 4 of the 6 women conceived and delivered 7 children among orthotopic ovarian tissue recipients, one recipient had 3 spontaneous live births after heterotopic OTT, presumably because of the induction of function in the remaining menopausal ovary. CONCLUSIONS: It appears that orthotopic OTT results in higher gamete and embryo quality. However, the endocrine function restoration rate and longevity are similar between the 2 approaches. When feasible, orthotopic OTT should be preferred for those who intend to conceive, although a less invasive heterotopic OTT can be performed for those who primarily desire ovarian endocrine function.

Repair of Isthmocele Following Embolization of Uterine Arteriovenous Malformation.

OBJECTIVE: To present a case of concurrent uterine arteriovenous malformation (AVM) and isthmocele, treated with ethylene vinyl alcohol copolymer (EVAC) embolization of the AVM followed by robotic isthmocele repair. DESIGN: A stepwise video demonstration with narration. SETTING: A tertiary care academic hospital. Patient is a 37-year-old with one previous cesarean section who presented with persistent heavy vaginal bleeding after a dilation and evacuation procedure. Imaging showed evidence of an isthmocele and an iatrogenic uterine AVM secondary to the dilation and evacuation procedure. Both entities are morbid conditions associated with significant operative blood loss. Embolization of the acquired AVM was first performed to stabilize bleeding. In addition, owing to the extensive uterine defect and history of infertility, surgical repair of the isthmocele was recommended. INTERVENTIONS: A multidisciplinary approach combining interventional radiology and gynecologic surgery expertise, implementing several strategies to minimize blood loss: 1. Image-guided uterine AVM embolization with EVAC [1] 2. Hysteroscopic identification of isthmocele and residual EVAC in the cavity, with fluorescence transillumination to clearly delineate isthmocele borders 3. Robot-assisted laparoscopic approach for bladder flap creation, as well as retroperitoneal space dissection to skeletonize uterine arteries 4. Transient occlusion of uterine arteries using vascular clamps to minimize operative blood loss given the isthmocele size and its proximity to the left uterine artery 5. Resection of the isthmocele and removal of residual intracavitary EVAC 6. Multilayer, bidirectional hysterotomy closure and vascular clamp removal to restore uterine blood supply CONCLUSIONS: Successful multidisciplinary treatment of concurrent uterine AVM and isthmocele. Cesarean delivery at 36 to 37 weeks' gestational age was recommended for future deliveries.

Could Testicular Tissue Be a New Arena for the Holmium Laser?

Introduction We aimed to observe the effects of holmium:yttrium-aluminum-garnet (Ho:YAG) laser on testicular tissue. Methods An ex vivo experiment was conducted using calf testicles. A 100 W laser generator with broad-spectrum settings of 10-80 W, 20-40 Hz, and 0.5-2 J, with a medium pulse duration, was tested. The laser effects on testicular tissues with and without the tunica layer were evaluated histopathologically by calculating the incision depth (ID), vaporization area (VA), coagulation area (CA), and total laser area (TLA=VA+CA) of the specimens. Results A total of 48 experiments were conducted. In testicular tissue without a tunica layer, the highest mean ID was determined at 1 J-20 Hz (0.247±0.0208 mm) and with a tunica layer at 2 J-40 Hz (2.673±0.032 mm). In the testicular tissue without a tunica layer, the highest mean VA was determined at 1.5 J-40 Hz (0.029±0.0016 mm2) and in tissue with a tunica at 2 J-40 Hz (6.173±0.114 mm2). The highest mean TLA in tissue without a tunica was detected at 2 J-20 Hz (0.038±0.0008 mm2) and in tissue with a tunica at 2 J-40 Hz (7.292±0.07 mm2). The mean ID, VA, CA, and TLA values of all the power outputs used were found to be statistically significantly higher in the testicular tissue with the tunica layer than in that without it (p<0.001). Conclusion The Ho:YAG laser has different effects on testicular tissue with and without a tunica layer. In testicular tissue without a tunica, the laser's effect was minimal on the surrounding tissue, especially in terms of the ID, VA, and TLA. This minimal effect of the laser can be an advantage in testicular surgery procedures such as testis-sparing surgery (TSS) or testicular sperm extraction (TESE).

Diode laser use in hysteroscopic surgery: current status and future perspectives.

Recent advances in surgical technology and innovative techniques have revolutionized surgical gynecology, including transcervical hysteroscopic procedures. Surgical lasers (Nd-Yag, Argon, diode, and CO2 lasers) have been promoted to remove a variety of gynecological pathologies. For hysteroscopic surgery, the diode laser represents the most versatile and feasible innovation, with simultaneous cut and coagulate action, providing improved hemostasis compared with CO2 laser. The newest diode laser devices exhibit increased power and a dual wavelength, to work precisely with reduced thermal dispersion and minimal damage to surrounding tissues. Their efficacy and safety have been validated both in the hospitals as well as in the office setting. Updated evidence reports that several hysteroscopic procedures, including endometrial polypectomies, myomectomies and metroplasties can be successfully performed with a diode laser. Therefore, this review aimed to give a deeper understanding of the role of laser energy in gynecology and subsequently in hysteroscopy in order to safely incorporate this technology into clinical practice.

Reproductive surgery: revisiting its origins and role in the modern management of fertility.

For years, reproductive surgery was the mainstay of reproductive care. With the evolution and ultimate success of in vitro fertilization (IVF), reproductive surgery became an adjuvant therapy, indicated mainly for severe symptoms or to enhance success rates with assisted reproductive technologies. As success rates for IVF have plateaued, and emerging data rekindles the enormous benefits of surgically correcting reproductive pathologies, there is renewed interest among reproductive surgeons in reviving research and surgical expertise in this area. In addition, new instrumentation and surgical techniques to preserve fertility have gained traction and will solidify the need to have skilled reproductive endocrinology and infertility surgeons in our practice.

Fertility and Sterility top videos from 2021.

OBJECTIVE: To objectively grade all video publications in Fertility and Sterility during the year 2021 and compile a list of the top 10 surgical videos. DESIGN: A descriptive presentation of the 10 highest-scoring video publications from Fertility and Sterility in the year 2021. SETTING: Not applicable. PATIENT/ANIMALS: Not applicable. INTERVENTIONS: J.F., Z.K., J.P.P., and S.R.L. acted as independent reviewers of all video publications. A standardized scoring method was used to score all videos. MAIN OUTCOME MEASURES: Up to 5 points were awarded for each of the following categories: scientific merit or clinical relevance of the topic; clarity of the video; use of an innovative surgical technique; and video editing or the use of marking tools on the video to highlight important features or surgical landmarks. This allowed a maximum score of 20 for each video. The number of YouTube views and likes was used as a tiebreaker if ≥2 videos scored similarly. The interclass coefficient from a 2-way random effects model was calculated to assess the agreement among the 4 independent reviewers. RESULT(S): A total of 36 videos were published in Fertility and Sterility during the year 2021. After averaging scores from all 4 reviewers, a top-10 list was created. The overall interclass correlation coefficient for the 4 reviews was 0.89 (95% confidence interval, 0.89-0.94). CONCLUSION(S): An overall substantial agreement was noted among the 4 reviewers. A total of 10 videos reigned supreme from a list of very competitive publications that had already undergone the peer review process. The subject matter of these videos ranged from complex surgical procedures, including uterine transplantation, to common procedures, such as GYN ultrasound.

Revisiting microsurgical principles for the minimally invasive surgeon.

OBJECTIVE: To demonstrate basic microsurgical techniques and revisit the importance of following microsurgical principles in minimally invasive surgery. DESIGN: Video demonstration of various surgical cases portraying proper microsurgical techniques as well as the consequences of deviating from these principles. SETTING: Tertiary referral practice. PATIENT(S): Reproductive-aged women with a desire to preserve reproductive organs and fertility potential. INTERVENTION(S): We present surgical cases demonstrating the management of tubal and paratubal pathologies in which extra care must be taken to avoid inadvertent injuries of normal anatomic structures. We also portray the proper management of ovarian dermoid cysts and endometriomas to maximize the preservation of ovarian reserve and minimize complications. We have stressed the importance of ensuring safe tissue containment and extraction to avoid complications such as port site metastasis along with parasitic and iatrogenic myomas. MAIN OUTCOME MEASURE(S): Implementation of microsurgical techniques including delicate tissue handling, judicious use of energy sources, and proper tissue containment and extraction. RESULT(S): Nonadherence to microsurgical principles can result in detrimental surgical outcomes, including adhesions, parasitic myomas, port site metastasis, peritonitis, and compromised ovarian reserve. CONCLUSION(S): Microsurgical principles are of paramount importance to improve patient outcomes in reproductive surgeries. These tenets should be uniformly applied in all surgical procedures. As surgeons who perform minimally invasive surgeries, we must revisit these principles and advocate for their training and universal implementation.

Laparoscopically assisted hysteroscopic removal of an interstitial pregnancy.

OBJECTIVE: To illustrate a combined technique of hysteroscopy and laparoscopy for the management of interstitial ectopic pregnancies. DESIGN: A description of a patient case and demonstration of a surgical technique. SETTING: Tertiary referral center. PATIENT(S): A 33-year-old woman, gravida 2, para 0-0-1-0 status post in vitro fertilization cycle with single embryo transfer, was diagnosed with an unruptured right interstitial pregnancy at 5 weeks of gestation. She has a history of a pregnancy of unknown location with her first in vitro fertilization transfer and received methotrexate. The beta-human chorionic gonadotropin level was 2,726 mIU/mL. She was counseled on treatment options and declined treatment with methotrexate because of the negative side effects she experienced previously. She opted for surgical management and desired to keep her fallopian tubes if possible because she wished to try for spontaneous conception. INTERVENTION(S): The patient underwent multipuncture video laparoscopy, and a bulge was seen at the right cornua. Video hysteroscopy initially revealed an empty uterine cavity. Using atraumatic graspers, the interstitial pregnancy was gently pushed further into the uterine cavity using a milking technique. The pregnancy was then able to be visualized hysteroscopically. Products of conception were gently dislodged and removed with graspers, followed by a suction curettage. MAIN OUTCOME MEASURE(S): This technique resulted in minimal blood loss, preservation of reproductive organs, and expedient return to conception planning. RESULT(S): The postoperative course was uncomplicated, and the patient was discharged the same day as surgery. After the procedure, weekly beta-human chorionic gonadotropin was drawn until the level reached <1 mIU/mL, which occurred after 4 weeks. Hysterosalpingography was performed 2 months after the procedure and demonstrated bilateral tubal patency. CONCLUSION(S): In select patients, an early interstitial pregnancy can be safely removed using the described technique. Although hysteroscopic removal of interstitial pregnancies is not a new concept, the addition of simultaneous video laparoscopy provides the benefit of allowing for fertility-sparing removal of the pregnancy, even if it is not initially visualized hysteroscopically. The use of this technique may result in minimal blood loss and preservation of the fallopian tubes. Furthermore, with the myometrium integrity maintained, the patient may resume sooner attempts at conception.

Microsurgical anastomosis of the fallopian tubes after tubal ligation: a systematic review and meta-analysis.

OBJECTIVE: Between 20% and 30% of women who have undergone tubal ligation regret their decision. The alternative to regain fertility for these women is either in vitro fertilization or tubal re-anastomosis. This article presents a systematic review with meta-analysis to assess the current evidence on the efficacy of tubal recanalization surgery in patients who have previously undergone tubal ligation. STUDY DESIGN: The search was conducted in the World of Science (WOS) database, The Cochrane Library and ClinicalTrials.gov record using the keywords "tubal reversal", "tubal reanastomosis" and "tubal anastomosis". The review was carried out by two of the authors. Data from 22 studies were evaluated, comprising over 14,113 patients who underwent the studied surgery, following strict inclusion criteria: articles published between January 2012 and June 2022, in English and with a sample size bigger than 10 patients were included. A random-effects meta-analysis was performed. RESULTS: The overall pregnancy rate after anastomosis was found to be 65.3 % (95 % CI: 61.0-69.6). The percentage of women who had at least one live birth, known as the birth rate, was 42.6 % (95 % CI: 34.9-51.4). Adverse outcomes after surgery were also examined: the observed abortion rate among women who underwent surgery was 9.4 % (95 % CI: 7.0-11.7), and the overall ectopic pregnancy rate was 6.8 % (95 % CI: 4.6-9.0). No differences were found between the outcomes when differentiating surgical approaches: laparotomy, laparoscopy, or robotic-assisted surgery. The patient's age was identified as the most significant determining factor for fertility restoration. Finally, when comparing the results of tubal reversal with in vitro fertilization, reversal procedures appear more favorable for patients over 35 years old, while the results are similar for patients under 35 years old, but more data is needed to evaluate this finding. CONCLUSION: Therefore, the available literature review demonstrates that surgical anastomosis following tubal ligation is a reproducible technique with relevant success rates, performed by multiple expert groups worldwide.

Is There Still a Place for Reconstructive Surgery in Distal Tubal Disease?

Tubal diseases account for 25-40% of female factor infertility. Mainly, they involve the distal part of the fallopian tube, and hydrosalpinx is the most severe manifestation. Usually, the management decision is made between reconstructive surgery and ART, depending on the severity of the tubal damage, patient age, ovarian reserve, and seminogram, as well as financial, religious, ethical, and psychological factors. Estimated live-birth rates after corrective surgery range from 9% to 69%. The success rate of IVF is about 30% live-birth rate per cycle initiated in women across all ages with tubal factor infertility. Surgery offers a long-term cure and patients may attempt conception many times but are burdened with perioperative adverse events. IVF bypasses potential complications of operative treatment; however, this has its own unique risks. The effectiveness of reconstructive surgery versus ART has not been adequately evaluated. The success of fertility management depends on a thorough interpretation of existing data and careful patient selection. The presented review provides updates on the most recent progress in this area.

Fertility and Sterility top videos of 2020.

OBJECTIVE: To objectively grade all video publications in Fertility and Sterility during 2020 and compile a list of the top 5 surgical videos. DESIGN: Descriptive presentation of the 5 highest scoring video publications from Fertility and Sterility in 2020 SETTING: Not applicable. PATIENT(S)/ANIMAL(S): Not applicable. INTERVENTION(S): J.F., Z.K., J.P.P., and S.R.L. acted as independent reviewers of all video publications. A standardized scoring method was used to score all videos. MAIN OUTCOME MEASURE(S): Up to 5 points were awarded for each of the following categories: scientific merit or clinical relevance of the topic, the clarity of the video, the use of innovative surgical technique, and video editing or the use of marking tools on the video to highlight the important features or surgical landmarks. This allowed a maximum score of 20 for each video. The numbers of YouTube views and likes were used as a tiebreaker if ≥2 videos scored similarly. The interclass coefficient from a 2-way random-effects model was calculated to assess for agreement between the 4 independent reviewers. RESULT(S): A total of 20 videos were published in Fertility and Sterility during 2020. After averaging scores from all 4 reviewers, a list of top 5 videos was created (Table 1). The overall interclass coefficient for the 4 reviews was 0.77 (95% confidence interval, 0.56-0.89). CONCLUSION(S): An overall substantial agreement was noted among the 4 reviewers. Five videos particularly stood out within the competitive peer reviewed publications. The subject matter of these videos ranged from complex surgical procedures, including transvaginal natural orifice surgery and advanced endometriosis to basic embryology laboratory topics that covered trophectoderm biopsy and novel intracytoplasmic sperm injection techniques.

Case Report: Laparoscopic Isthmocele Repair on an 8 Weeks Pregnant Uterus.

An isthmocele, also known as a caesarean scar defect, is a long-term complication of caesarean sections with an increasing incidence. Although is often asymptomatic, it is a novel recognised cause of abnormal uterine bleeding, and it is a major risk factor for caesarean scar pregnancies or uterine ruptures in subsequent pregnancies. Currently there are no guidelines for the diagnosis and management of this condition. Several surgical techniques for the correction of isthmocele are proposed, including laparoscopic excision, vaginal repair, a combined laparoscopic-vaginal approach or more recently hysteroscopic resection. We present the case of a GII PI, 29 years old patient with a previous c-section who presented in our clinic with a positive pregnancy test for pregnancy confirmation. The ultrasound examination revealed an intrauterine evolutive 8 weeks pregnancy and a caesarean scar defect. After counselling the patient opted for pregnancy continuation and laparoscopic correction of the isthmocele. The surgery was performed under ultrasound guidance. The defect was resected, and the uterus was closed with a continuous two-layer suture. No intraoperative or postoperative complications were present. The pregnancy continued uneventfully A caesarean section was performed at term revealing a fully healed scar.

Fertility-Preserving Surgical Management of a Cesarean Section Scar Ectopic Pregnancy.

STUDY OBJECTIVE: To demonstrate techniques used for fertility-preserving surgical management of a cesarean scar ectopic pregnancy. DESIGN: A narrated video case report demonstrating techniques and surgical approach. SETTING: With the increasing number of cesarean deliveries being performed, cesarean scar ectopic pregnancies (CSEP) have an increasing incidence affecting approximately 1 in 2000 pregnancies. CSEP can be associated with serious complications, which include maternal hemorrhage, uterine rupture, and even maternal death. This video highlights a case presentation of a 28-year-old G6P4014 with a history of 4 previous cesarean deliveries who presented with a persistent cesarean scar ectopic pregnancy that had failed previous medical management. INTERVENTIONS: This video highlights the techniques that allow for fertility-preservation with restoration of normal anatomy as well as minimizing blood loss with a potentially morbid procedure. Techniques used to allow for fertility preservation with restoration of normal anatomy: 1. Utilization of avascular spaces and identification of critical structures to restore anatomy that is often distorted by the CSEP. 2. Limited use of electrosurgery to allow for adequate postoperative healing. 3. Identification of the endometrial cavity to allow for complete removal of the CSEP and isthmocele repair. Techniques used to minimize blood loss: 1. Intracervical injection of dilute vasopressin. 2. Intrauterine injection of dilute vasopressin (20U in 60 cc of injectable saline). 3. Temporary occlusion of bilateral gonadal vessels using surgical clips. CONCLUSION: The surgical techniques highlighted in this video allow for the surgical removal of a cesarean scar ectopic pregnancy with concurrent repair of the uterine defect, allowing for restoration of normal anatomy. This is a safe and feasible fertility-preserving option that can be performed using a minimally-invasive approach.

On the shoulders of giants: perspectives in minimally invasive reproductive surgery.

The purpose of this video is to illustrate the evolution of minimally invasive surgery from the perspectives of several pioneering surgeons in the field of reproductive surgery who, among others, were present during its nascence and exponential growth. Interviews were conducted with five reproductive surgeons who had foundational roles in the innovation of operative laparoscopy and hysteroscopy. Surgeons interviewed include Drs. Victor Gomel, Togas Tulandi, Stephen Corson, Jacques Donnez, and Camran Nezhat. The interviews were conducted using standardized questions and recorded, edited, and grouped both thematically and in sequence to develop an illustration of their perspectives. A diverse array of reproductive surgeons has been instrumental in establishing minimally invasive surgery as a safe and effective means of diagnosing and treating patients with infertility. The transition from laparotomy to laparoscopy consistently has had distinct challenges for each but ultimately led to significant advances in surgical management and improvement in outcomes for patients with infertility and chronic pelvic pain. Through structured interviews from some of our surgical pioneers, they not only recognize their predecessors and contemporaries but also teach us valuable lessons about our history, sparking innovation, and newer surgical applications of reproductive surgery in reproductive endocrinology and infertility practice.