Prevention of multiple pregnancies in gonadotropin-insemination cycles.

PURPOSE OF REVIEW: Although elective single embryo transfer has significantly reduced, the rate of multiple pregnancy in IVF cycles, this rate is still relatively high in gonadotropin-insemination cycles. Patients who fail to ovulate or to conceive with oral agents and have constraints for IVF are usually candidates for gonadotropin injections. The current review article provides an up-to-date summation of the different strategies that can be adopted to reduce the risk of multiple pregnancies in gonadotropin-stimulated intrauterine insemination cycles. RECENT FINDINGS: Gonadotropin-insemination treatments should be used judiciously by experienced providers. One should always start with the lowest effective gonadotropin dose (∼37.5 IU), monitor closely the ovarian response, and consider cycle cancellation or conversion to IVF whenever a high response is encountered. Therefore, every infertility practice should define its own cancellation and 'rescue IVF' criteria depending on the number of mature ovarian follicles and the age of the female partner. SUMMARY: These preventive measures amongst others should mitigate the risk of multiple pregnancies that can arise from gonadotropin-insemination cycles.

The evolution of mature cystic teratomas of the ovary into squamous cell carcinoma: two case reports and review of the literature.

Mature Cystic Teratomas (MCT) of the ovary or Dermoid Cysts are common benign tumours found in 10-20% of women. However, 0.2-2% of those cysts underwent malignant transformation. Squamous Cell Carcinoma (SCC) is the most frequent histological type reported in the literature.As 2021, there are limited reports of malignant tumours arising from MCT with no guidelines related to the management of these atypical cases. Herein, we describe two cases of MCT that evolved into SCC with different stages and prognosis and we review the current literature to date highlighting the potential risk of malignant transformation of these considered benign cysts and the need for strong evidence protocols for staging and treatment of this atypical entity.IMPACT STATEMENTWhat is already known on this subject? Mature Cystic Teratomas are found in 10-20% of women. However, a malignant behavior is observed in 2% of cases.What do the results of this study add? Our paper will describe two cases of malignant transformation of dermoid cyst in an effort to highlight the possible malignant risk of this entity and the need for specific management guidelines.What are the implications of these findings for clinical practice and/or further research? The prognosis of this converted cyst is very poor. By elaborating a standard management protocol for this tumour and operating every large cyst (>10 cm) in postmenopausal women, we may prevent this event.

Predictive factors of lymph node metastasis and pattern of repartition in patients with epithelial ovarian cancer.

Aim: To determine the rate, repartition and risk factors of lymph node (LN) metastasis in patients with epithelial ovarian cancer. Methods: We reviewed retrospectively the pathological and clinical data of 184 patients with epithelial ovarian cancer at a tertiary care center in Beirut, Lebanon. Results: 88% of patients received a pelvic and para-aortic lymphadenectomy. 70% of patients presented LN metastases at both pelvic and para-aortic levels, while isolated pelvic or para-aortic LN metastases were seen in 16 and 14% of cases, respectively. In a univariate analysis, the rate of positive LNs was higher in patients with serous histology (65 vs 33%; p < 0.001), high-grade tumors (68 vs 26%; p < 0.001), bilateral adnexal involvement (74 vs 27%; p < 0.001), advanced clinical stage (p < 0.001), interval debulking surgery (63.2 vs 36.8%; p = 0.003) and positive peritoneal cytology (79 vs 26%; p < 0.001). In a multivariate analysis, the rate of LN involvement was significantly higher in patients with higher grade, advanced clinical stage and positive peritoneal cytology. Conclusion: Serous histology, grade 3 tumors, positive peritoneal cytology, advanced clinical stage, interval surgery and bilateral adnexal involvement can predict LN metastasis in patients with epithelial ovarian cancer.

Rheumatic diseases and pregnancy: a national survey about practice patterns among rheumatologists and obstetricians.

OBJECTIVES: Management of rheumatic diseases (RD) is often problematic in pregnant patients, hence the need for guideline implementation. This survey-based study aimed to assess beliefs among obstetricians and rheumatologists about managing RD in pregnant Lebanese patients. METHODS: Questionnaires were completed by a representative sample of rheumatologists and obstetricians practicing throughout Lebanon. Collected data included physicians' information, opinion on pregnancy in RD patients, compatible drugs with fertility, pregnancy and breastfeeding, references used in their clinical management, referral to specialists, and knowledge about guidelines. Qualitative variables were analysed using Chi-square or Fisher's exact tests, and quantitative variables using Wilcoxon or Student t-tests. Results were matched against a scoring system based on the EULAR/BSR guidelines. p-value <0.05 indicated statistical significance. RESULTS: Analysis showed high response rates of physicians, especially among rheumatologists. Overall, physicians practice was in concordance with international guidelines and only few misconceptions were reported. Systemic lupus erythematosus (SLE) was associated with risk on fertility, foetal malformation and eclampsia while anti-phospholipid (APL) syndrome was associated with miscarriage and vasculitis with eclampsia. Spondyloarthritis was considered 'safe' in pregnancy. Most physicians think that cyclophosphamide, leflunomide, methotrexate, mycophenolate mofetil and azathioprine compromise fertility, pregnancy, and breastfeeding. CONCLUSIONS: Our data showed relatively good concordance of the physicians' beliefs with the current literature and recommendations. However, we identified misconceptions about anti-rheumatic drugs safety in pregnancy and discrepancy between rheumatologists and obstetricians practices; hence the need for promoting collaboration between both specialties and disseminating knowledge to physicians and patients in the Middle East region.

PREGNANCY AND RENAL TRANSPLANTATION.

Pregnancy is common nowadays in kidney transplant female patients because of medical and surgical advances. However, pregnancy is a high risk one in these patients. Fertility is rapidly restored after the transplantation; thus, contraception is a good option in the first year. Adding to that, pregnancy can endanger the allograft function in the presence of hypertension, a moderate to severe kidney disease and proteinuria. Medical complications are more prevalent in kidney transplant population, such as infections, gestational hypertension and diabetes and anemia. Low birth weight infants and premature delivery are two other major concerns in this population. Acute rejection of the allograft is another major complication that can be avoided with close monitoring of the graft and convenient immunosuppression. Immunosuppressive drugs must be continued during pregnancy except for mycophenolic acid and sirolimus that can be teratogen. Delivery of kidney transplant patients should be vaginal and spontaneous. Cesarean section should be reserved for obstetrical indications. Prophylactic antibiotics should be administered for every invasive procedure. Patients treated with corticosteroids can breastfeed their babies. Kidney donating women can have a safe pregnancy but with a slight risk of gestational diabetes and hypertension. In summary, a multidisciplinary medical team should follow pregnant kidney transplant patients in a tertiary center. International and national registries are a must to collect data concerning this particular high-risk population in order to solve unanswered questions.

[Infertility and kidney transplantation]. / INFERTILITÉ ET GREFFE RÉNALE.

Renal failure impairs the endocrine system, especially in women, due to hyperprolactinemia, altering fertility, ovulatory cycles, libido and growth in adolescents. Renal transplantation is considered the best solution to the problems of renal failure and and of dialysis, as evidenced by comparing the rate of hyperprolactinemia (100% in chronic renal failure, 60% in patients on dialysis and 35% in post-transplantation). Kidney transplant is less efficient for restoring perfect function of the hypothalamic-pituitary-gonadal axis due in part to the immunosuppressant regimens prescribed. When these drugs are properly managed, transplantation will restore near normal sexual function.

Surgical management of pelvic organ prolapse in women: how to choose the best approach.

Although benign, pelvic organ prolapse is a real public health problem, affecting mostly women above sixty-five. Eighty-year-old women have an 11.1% lifetime risk of undergoing surgery for prolapse or stress urinary incontinence and 29% will need a second procedure. Surgical approach may be abdominal (sacrocolpopexy by laparotomy, laparoscopy or robot-assisted) or vaginal (autologous, or prosthetic reinforcement). In addition to anatomical correction, surgical objectives include: improvement of the patient's quality of life, prolapse symptoms relief, normal urinary, digestive and sexual functions and especially, avoiding iatrogenic sequelae. Thus, the choice of the surgical approach does not only depend upon the site and the severity of the prolapse. Urogynecological surgeons should take into consideration the patient's expectations and life style, her age--a determinant factor in deciding upon the best approach -, and her relapse risk factors. They should master both approaches, and the management of surgical complications. Therefore, an apprenticeship in a reference pelviperineology center is a must. In addition, surgeons should be aware of and consider contraindications to each procedure, for instance contraindications to transvaginal prosthesis reinforcement like risk factors of bad healing or infection. Urogynecology specialists have to take into consideration known anatomical and functional results of each technique as cited in the medical literature and act in accordance with international recommendations. The surgery's main objective is to ameliorate the patient's discomfort and her quality of life without causing iatrogenic dysfunctional symptoms (urinary, digestive, sexual). The pelvic organ prolapse being a benign pathology, the patient's satisfaction is the main marker of the procedure success. In short, regarding the surgical management of pelvic organ prolapse in women the answer to the question How to choose the best approach? is not binary. It depends on several factors, and regardless of the choice, it must

[From the open approach to laparoscopy. Background, rationale, technique]. / La promontofixation: de la voie ouverte a la coelioscopie. Historique, rationnel, technique.

Genital prolapse is a frequent functional pathology in women. Its surgical treatment depends specially upon the suspension and fixation of the vaginal vault. Thus, sacrocolpopexy has become a gold standard technique to correct genital prolapse. Laparoscopy is a procedure resulting in less bleeding and decreased hospital stay than open sacrocolpopexy and is presently the approach of choice. Its objective and subjective correction rates are > 90%. Some authors proposed a dual abdominal and perineal approach to help fixing the posterior mesh and repairing the perineal body. Robotics is the actual surgeons' gadget.Its results are similar to laparoscopic sacrocolpopexy albeit a higher cost and a longer operating time. The ideal mesh is monofilamentous with large pores. Sacrocolpopexy consists in fixing two meshes, one on the anterior vaginal wall and one on the posterior vaginal wall, on the anterior sacral ligament, without tension for the posterior mesh, with or without subtotal hysterectomy, and with closure of the peritoneum at the end. In the case of associated stress urinary incontinence, proved on the clinical exam or urodynamical exam, appropriate surgical treatment is done with sacrocolpopexy. In the near future, robotics will replace laparoscopy when costs will be reduced and medical staff well trained to perform robotic or robot-assisted sacrocolpopexy.

Effect of COVID-19 vaccinations on menstrual cycle and postmenopausal bleeding among health care workers: A cross-sectional study.

OBJECTIVE: To determine the effect of coronavirus disease 2019 (COVID-19) vaccination and its association with sociodemographic factors on the menstrual cycle in premenopausal women and on postmenopausal bleeding. METHODS: This is a retrospective cross-sectional study conducted between September 22, 2022, and November 30, 2022, via a questionnaire distributed to 359 health care workers (HCWs) at Lebanese American University Medical Center-Rizk Hospital and St John's Hospital. Inclusion criteria included female Lebanese HCWs who were vaccinated and aged 18 to 65 years. RESULTS: Change in cycle length was significantly associated with age (P = 0.025 after the first dose and P = 0.017 after the second dose), level of education (P = 0.013 after the first dose and P = 0.012 after the second dose), and fibroids (P = 0.006 after the second dose and P = 0.003 after the third dose). The change in cycle flow was significantly associated with age (P = 0.028), fibroids (P = 0.002 after the second dose and P = 0.002 after the third dose), bleeding disorders (P = 0.000), and chronic medications (P = 0.007). The change in symptoms was associated with polycystic ovary syndrome (P = 0.021), chronic medications (P = 0.019 after the second dose and P = 0.045 after the third dose), and fibroids (P = 0.000). CONCLUSION: COVID-19 vaccination can influence the menstrual cycle. Age, body mass index, level of education, underlying comorbidities, and use of chronic medications are significantly associated with changes in menstrual length, flow, and symptoms following vaccination.