Hysteroscopic Endometrial Resection in Women Treated With Tamoxifen for Breast Cancer Provides Definitive Diagnosis and Effective Long-Term Therapy.

We evaluated resectoscopic surgery for definitive diagnosis and long-term therapy in 16 symptomatic tamoxifen-treated women with breast cancer who presented with abnormal uterine bleeding and/or intrauterine anomalies. Seven pre-menopausal women had benign pre- and post-operative endometrial biopsy, and 4 had benign polyps. At a median of 7 years of follow-up (range 2-8 y), all remained amenorrheic. Of 9 post-menopausal women, pre-operative biopsy was inadequate in 4, benign endometrium was found in 4, and non-atypical endometrial hyperplasia was found in 1. Post-operatively, all had benign pathology, 8 having polyp and 1 leiomyoma. At a median follow-up of 7 years (range 2-13 y), all were amenorrheic, with no recurrence of breast cancer or uterine pathology.

Histopathology and Clinical Outcomes of 151 Women with Postmenopausal Bleeding Treated with Resectoscopic Surgery.

STUDY OBJECTIVE: Because postmenopausal bleeding (PMB) is associated with up to 10% of endometrial neoplasia and office endometrial sampling fails in approximately 10% and is inadequate in 30% of cases, the objective was to determine the role of hysteroscopic endometrial resection (HER) for the diagnosis and treatment of women with PMB. DESIGN: A retrospective cohort. SETTING: A university-affiliated teaching hospital. PATIENTS: One hundred fifty-one women with PMB (September 1990-December 2010). INTERVENTION: HER in the operating room. MEASUREMENTS AND MAIN RESULTS: The median (range) age and body mass index were 58 (50-87) years and 29 (21-52) kg/m2, respectively. Office endometrial biopsy failed in 30 (19.8%), was inadequate in 20 (13.2%), identified nonatypical endometrial hyperplasia (NAH) in 21 (14%), atypical hyperplasia (AH) in 4 (2.6%), and endometrial cancer (EC) in 2 (1.3%) women. HER in 151 women identified 7 new cases of AH (3 from failed/inadequate office biopsy and 4 from NAH) and 9 EC (5 from failed/inadequate office biopsy, 1 from proliferative endometrium, 2 from NAH, and 1 from AH). All 27 women with NAH were treated by HER alone. Of 8 women with AH, 6 were treated with HER and 2 with hysterectomy; no residual endometrium was found in hysterectomy specimens. Of the 11 women with EC, 2 refused hysterectomy and are well 10 and 15 years after HER. Hysterectomy was performed for 9 of 11 EC cases, 2 of 8 AH cases, and 1 for abnormal uterine bleeding. Six women had repeat HER for persistent abnormal uterine bleeding, and 10 were lost to follow-up. At a median follow-up of 11.5 years (range, 7-20 years), 132 (12 hysterectomies + 10 lost) of 151 (87.4%) women were satisfied with no further bleeding. CONCLUSION: In women with PMB, hysteroscopic endometrial resection concomitantly with resection of intrauterine pathology by experienced surgeons is feasible, safe, and effective for diagnosis in all cases and treatment of the majority of intrauterine pathology including NAH and selected cases of AH and EC.

Resolution of Uterine Arteriovenous Malformation and Maintenance of Reproduction in 20 Women Treated with a GnRH Agonist Concomitantly with an Aromatase Inhibitor and Tranexamic Acid.

OBJECTIVE: This study investigated the efficacy of GnRH agonists concomitantly with transient aromatase inhibitor and tranexamic acid to treat women with uterine arteriovenous malformations (AVMs) associated with abnormal uterine bleeding (AUB) to preserve fertility and determine reproductive outcome. METHODS: This was a prospective cohort study in a tertiary centre. Doppler ultrasound demonstrated AVM in 19 women with AUB 1-28 weeks following spontaneous or therapeutic abortion and in one woman 4 years after normal pregnancy while taking an oral contraceptive. On the basis of experience from the first three cases, 17 women were treated with tranexamic acid (1 g three times daily orally for 5 days), a GnRH agonist (3.75-11.25 mg, for 1-3 months), plus an aromatase inhibitor (letrozole 2.5 mg once daily for 5days) with the initial injection of GnRH agonist. Two women required blood transfusion, and one required uterine tamponade with Foley catheter balloon in the first 48 hours to control heavy bleeding (Canadian Task Force Classification II-2). RESULTS: All 20 AVMs resolved within 1-3 months of treatment. Of 16 women who attempted pregnancy, all (100%), including two who had uterine artery embolization (one after hysteroscopic septoplasty), conceived spontaneously with 18 live births. Two women are using contraception (one taking an oral contraceptive, one using a levonorgestrel intrauterine system), and one 40-year-old is not using contraception. One woman had hysteroscopic endometrial ablation followed by vaginal hysterectomy for AUB at 1 and 2 years later. CONCLUSION: A GnRH agonist in combination with transient aromatase inhibitor and tranexamic acid is an effective management strategy to treat and maintain reproduction in women with AVMs associated with AUB.

Long-term clinical outcomes following resectoscopic endometrial ablation of non-atypical endometrial hyperplasia in women with abnormal uterine bleeding.

STUDY OBJECTIVE: To determine the feasibility, efficacy, and long-term clinical outcomes of resectoscopic endometrial ablation as primary treatment of simple endometrial hyperplasia (SH) and complex endometrial hyperplasia (CH) without atypia in women with abnormal uterine bleeding (AUB). DESIGN: Prospective follow-up study (Canadian Task Force classification II-2). SETTING: Teaching hospital. PATIENTS: One hundred sixty-one women with hyperplasia, either SH (n = 107) or CH (n = 54). INTERVENTIONS: From January 1990 through December 2012, one of us performed 4729 primary resectoscopic endometrial ablation procedures in women with AUB. This group included 161 women with endometrial hyperplasia, identified either at office biopsy (n = 62) or incidentally during routine hysteroscopic endometrial ablation (n = 99). Endometrial tissue obtained at dilation and curettage and/or resected during resectoscopic surgery enabled identification of atypical hyperplasia in 6 patients (4 CH, 2 SH) and 1 patient with adenosarcoma. One patient with atypical CH and the patient with adenosarcoma underwent hysterectomy. The remaining 159 women, including 5 with atypical hyperplasia (3 CH, 2 SH), underwent resectoscopic endometrial ablation (102 SH, 52 CH) as primary treatment. Patient median age was 50 years (range, 30-87 years), and body mass index was 32 (range, 17-59). Comorbidities included hypertension in 25 patients, diabetes in 14, cerebrovascular disease in 3, cardiovascular disease in 7, and hypothyroidism in 8. Office biopsy demonstrated proliferative endometrium in 68 patients, SH in 43, CH in 19, and inadequate findings in 13. In 18 women, we were unable to perform biopsy because of cervical stenosis, morbid obesity, or patient intolerance. Endometrium was resected in 120 patients, electrocoagulated in 34, and a combination of procedures in 5, using a 9-mm (26F) resectoscope, 1.5% glycine, and 120W power. Patients were followed up annually. Three patients were lost to follow-up, and 1 died of an unrelated cause 5 years after surgery. MEASUREMENTS AND MAIN RESULTS: One uterine perforation occurred, which required no additional treatment. After endometrial ablation, SH was identified in 70 patients, and CH in 35 patients. At a median follow-up of 7 years (range, 1.5-18), 12 patients underwent hysterectomy to treat persistent bleeding (n = 6), benign ovarian cyst (n = 2), pelvic organ prolapse (n = 1), chronic pelvic pain (n = 2), or myomas (n = 1). Uterine histopathology in 11 patients demonstrated no residual endometrial hyperplasia. We were unable to obtain a pathology report for 1 patient. The remaining 138 women were satisfied with the treatment, with no further bleeding or pain in 132 (95.7%). Six patients (4.3%) had monthly spotting. CONCLUSION: When performed by surgeons experienced in hysteroscopy, resectoscopic endometrial ablation is feasible, safe, and effective for treatment of SH and CH without atypia in women with AUB.

Medical treatment of ureteral obstruction associated with ovarian remnants and/or endometriosis: report of three cases and review of the literature.

STUDY OBJECTIVE: Experience with low-dose intermittent danazol or prolonged gonadotropin-releasing hormone agonist (GnRH-a) with and without add-back therapy in endometriosis-associated ureteral obstruction. DESIGN: Retrospective case series (Canadian Task Force classification II-2). SETTING: University-affiliated teaching hospital. PATIENTS: Three women with endometriosis-associated ureteral obstruction. INTERVENTION: The regimen of GnRH-a alone or with add-back included (1) leuprolide acetate 3.75 mg intramuscularly monthly; (2) micronized 17α-estradiol 1 mg/day by mouth; (3) pulsed norethinedrone 0.35 mg/day by mouth, 2 days on and/or 2 days off; and (4) letrozole 2.5 mg by mouth for the first 5 days of the first GnRH-a injection. Danazol, 100 mg/day by mouth, was prescribed as a regimen of 3 months on, 3 months off, for 4 years. MEASUREMENTS AND MAIN RESULTS: The first case was a 50-year-old woman, gravida 3, para 3, body mass index (BMI) 27 kg/m(2), with multiple surgeries, including hysterectomy and bilateral salpingo-oophorectomy (HBSO), and history of a stroke. She presented with right-sided pain and hydro-uretero-nephrosis. Magnetic resonance imaging identified a right adnexal cyst (4.5 × 3.4 × 2.4 cm). She was treated with leuprolide acetate monthly injections and a ureteric stent. The cyst, pain, and hydro-uretero-nephrosis resolved after 12 months. The second case was a 45-year-old woman, G2P2, BMI 28 kg/m(2) with multiple surgeries, including HBSO. She presented with left-sided pelvic pain. Ultrasound identified a left adnexal cyst and hydronephrosis. After 3 months of leuprolide acetate and add-back therapy, the cyst, pain, and hydronephrosis resolved. The third case was a 46-year-old woman, G2P2, BMI 25 kg/m(2), who presented with left flank and pelvic pain. Magnetic resonance imaging indicated moderate left hydronephrosis and left adnexal pelvic side-wall involvement with possible endometriosis. Due to many previous surgeries, this patient was a high-risk surgical candidate, and therefore, she was offered medical therapy. After a normal serum liver and lipid profile, she was started on danazol, 100 mg/day for 3 months. After 3 months of therapy, there was complete resolution of the patient's hydronephrosis and pain. She was then advised to continue with a 3-month on, 3-month off regimen. She discontinued the danazol and remained asymptomatic with no recurrence of hydronephrosis at 3 years. CONCLUSIONS: Low-dose intermittent danazol or GnRH-a alone or with add-back, may be effective long-term therapies in endometriosis-associated ureteral obstruction when surgery is contraindicated, refused, or difficult to perform.

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.

Contexte : Dans le cadre de la fécondation in vitro, la récupération d'ovocytes guidée par échographie transvaginale constitue une intervention qui est régulièrement menée partout dans le monde et qui a permis d'atténuer le taux de lésion intra-abdominale de façon considérable, par comparaison avec le recours à des interventions laparoscopiques. Toutefois, ces lésions n'ont pas été éradiquées pour autant. Cas : Nous signalons le cas d'une patiente de 37 ans qui a eu recours à la FIV et qui a subi une lésion urétérale au cours de la récupération des ovocytes; la présence de cette lésion a été constatée tôt et a fait l'objet d'une prise en charge (au moyen d'endoprothèses urétérales) qui s'est soldée en une résolution complète. Dans le cadre d'un cycle de FIV subséquent, la présence d'endoprothèses dans les uretères a permis une meilleure visualisation, ce qui a mené à la réussite de la récupération d'ovocytes et de la grossesse subséquente. Conclusion : Des lésions urétérales peuvent survenir dans le cadre de la récupération d'ovocytes guidée par échographie transvaginale. La rapidité de l'identification de ces lésions est d'une importance cruciale pour la réussite du traitement. La pose d'endoprothèses dans les uretères constitue la modalité thérapeutique la plus courante et peut être utilisée pour mieux identifier les uretères dans le cadre des interventions subséquentes de récupération d'ovocytes.

Do multiple attempts at embryo transfer affect clinical pregnancy rates?

OBJECTIVE: During an in vitro fertilization treatment cycle, having embryos retained in the catheter after embryo transfer is a relatively uncommon and frustrating event. The reported incidence of retained embryos varies between 1% and 8%. It can be difficult to explain this unwanted event to patients. We wished to determine the incidence and the effect on pregnancy rates of having embryos retained in the transfer catheter, followed by immediate completion of transfer. METHODS: We performed a retrospective chart review of all IVF cycles with embryos retained in the transfer catheter, followed by repeat transfer, between October 2009 and March 2012. We reviewed IVF cycles with or without ICSI, and included fresh and frozen embryo transfer cycles. All embryos were transferred on the third day after oocyte retrieval. Transabdominal ultrasound was used for guidance during the embryo transfer. RESULTS: A total of 49 IVF treatment cycles with retained embryos that required re-transfer were identified. This represented 7.5% (49/652) of all IVF cycles with embryo transfer during that period. The clinical pregnancy rate in the repeat transfer group was 30.6% (15/49). The clinical pregnancy rate in all cycles in the same time period was 34.8% (227/652). These rates were not significantly different (P=0.521). CONCLUSION: Having to re-transfer embryos retained in the transfer catheter does not have any significant effect on clinical pregnancy rates during IVF treatment cycles.

Objectif : Au cours d'un cycle de traitement de fécondation in vitro, la rétention d'embryons dans le cathéter à la suite du transfert d'embryons est une situation frustrante et relativement peu courante. L'incidence signalée de la rétention d'embryons se situe entre 1 % et 8 %. Il peut s'avérer difficile d'expliquer un tel événement indésirable aux patientes. Nous souhaitions déterminer l'incidence et l'effet sur les taux de grossesse du fait de constater une rétention d'embryons dans le cathéter de transfert, suivi du parachèvement immédiat du transfert. Méthodes : Nous avons mené une analyse rétrospective des dossiers de tous les cycles de FIV dans le cadre desquels une rétention d'embryons dans le cathéter de transfert a été constatée, le tout ayant été suivi de la tenue d'un nouveau transfert, entre octobre 2009 et mars 2012. Nous avons analysé les cycles de FIV avec ou sans IICS et avons inclus les cycles de transfert d'embryons frais et cryoconservés. Tous les embryons ont été transférés le troisième jour à la suite de la récupération d'ovocytes. Nous avons eu recours à l'échographie transabdominale à des fins d'orientation au cours du transfert d'embryons. Résultats : Au total, 49 cycles de traitement de FIV qui ont connu une rétention d'embryons ayant nécessité un retransfert ont été identifiés. Cela représentait 7,5 % (49/652) de tous les cycles de FIV au moyen d'un transfert d'embryons au cours de cette période. Au sein du groupe « nouveau transfert ¼, le taux de grossesse clinique a été de 30,6 % (15/49). Dans l'ensemble des cycles au cours de la même période, le taux de grossesse clinique a été de 34,8 % (227/652). La différence entre ces taux n'était pas significative (P = 0,521). Conclusion : Le fait de devoir procéder au retransfert des embryons ayant été en rétention dans le cathéter de transfert n'exerce aucun effet significatif sur les taux de grossesse clinique au cours des cycles de traitement de FIV.

Pregnancy Rates in Women With Polycystic Ovary Syndrome (PCOS) Using Letrozole Versus Clomiphene Citrate: A Retrospective Record Review.

Background and objectives Polycystic ovary syndrome (PCOS) is a prominent cause of anovulation. Thus, this study aimed to compare the pregnancy rates of women with PCOS treated with letrozole (LE) or clomiphene citrate (CC) at King Abdulaziz University Hospital. Patients and methods A retrospective record review was conducted from April 2021 to August 2022 to review 1370 records of women with PCOS from January 2015 to December 2021. Sixty-one patients were included in this analysis. Chi-square tests and independent sample t-tests were used to analyze various associations. Statistical significance was set at P < 0.05. Results Letrozole was associated with a higher pregnancy rate (41.7%) than CC (32.0%). However, this relationship was not statistically significant (P = .619). Furthermore, patients treated with letrozole required fewer cycles to achieve pregnancy (two cycles compared to three cycles). The different age groups and body mass indexes did not affect the pregnancy rate in either group. Conclusion No significant difference was found between CC and LE in ovulation induction and outcome among PCOS patients. Studies with larger sample sizes and multiple centers should be conducted in Saudi Arabia to obtain more conclusive results, which will eventually lead to changes in guidelines for anovulation treatment in women with PCOS.

How Relevant is Obstetrician and Gynecologist Gender to Women in Saudi Arabia?

BACKGROUND: The patient-doctor relationship is one of the most important factors in determining the outcome of healthcare. The first step in establishing this relationship is choosing a physician. This study sought to identify patient preferences concerning the gender of their obstetrics and gynecology (OB-GYN) physician and the effect of religion and society on these choices. METHODS: A cross-sectional study was conducted at the OB-GYN outpatient clinics at King Abdulaziz University Hospital in Jeddah between February 2017 and June 2017. A total of 227 female patients were recruited. Eligible were women ages 18 years or older who had attended the clinic at least three times. A 30-item questionnaire was administered. RESULTS: Significantly, more female doctors were preferred for pelvic examination in lower income group (p=0.003), while male doctors were preferred for surgery (p=0.010) in higher income group. Significantly more male doctors were preferred for pelvic examination and gynecological surgery in >35-year age group (p=0.015 and p=0.017, respectively). With regard to predictors, embarrassment was the most significant factor reported for not choosing a male obstetrician/gynecologist (OB-GYN) in the younger age group. Nearly three-quarters (71.2%) of respondents with age ≤35 reported embarrassment as a factor for not choosing a male OB-GYN; 79.7% of this subgroup indicated that female doctors were more knowledgeable about women's health issues. CONCLUSION: Participants expressed a strong preference for female providers overall, although some women preferred male providers during certain circumstances (gynecologic surgery). Despite these gender preferences, more important to women in their choice of OB-GYN provider was the doctor's experience, qualifications, and reputation. Such trends are consistent with those culturally similar countries and in line with trends worldwide. These findings have the potential to significantly impact the personal health for women in Saudi Arabia and elsewhere in the Middle East where religious and cultural traditions are so important in decision-making.

Intraoperative and Postoperative Complications Following Open, Laparoscopic, and Hysteroscopic Myomectomies in Saudi Arabia.

Background The aim of this study was to broaden our knowledge regarding the complications of myomectomy to better understand how to prevent them from occurring. Another aim was to compare surgical approaches, especially with the current research limitations surrounding this topic in Saudi Arabia. Methods This retrospective study was conducted in a cohort of 263 women who underwent surgical myomectomy, without any exclusion criteria. We used our hospital electronic medical records program called Phoenix to obtain all the data regarding clinical presentation, intraoperative findings, intraoperative and postoperative complications, and hospital stay, and then statistically analyzed these findings. Results Results were divided depending on the type of surgery. The mean age of open, laparoscopic, and hysteroscopic myomectomy groups were 40.82 years, 42.05 years, and 44.43 years, respectively. There were 213 (80.98%) open, 34 (12.93%) laparoscopic, and 16 (6.09%) hysteroscopic myomectomies. The most common indication in all groups was bleeding. The mean estimated blood loss and duration of surgery for open, laparoscopic, and hysteroscopic myomectomy groups were: 576.13 mL and 103.05 min, 333.21 mL and 56.91 min, and 306.29 mL and 104.19 min, respectively. The total complication rate for each group was 10.8% in open, 2.94% in laparoscopic, and 6.25% in hysteroscopic myomectomies. Conclusion Laparoscopy is considered the more effective option for myomectomy than both laparotomy and hysterectomy in terms of surgery duration, hospital stay, and prevalence of complications. However, it is a technically challenging operation that requires experienced surgeons to perform. Based on the information we gathered, we recommend our institute to implement laparoscopy instead of laparotomy myomectomy, which is the current standard procedure in our hospital.

Anti-toxoplasma Antibody Prevalence and Cost-effectiveness in Pregnant Women at the King Abdulaziz University Hospital, Jeddah, Saudi Arabia.

BACKGROUND: Toxoplasma gondii (T. gondii) is one of the most prevalent infectious parasites in humans worldwide. The diagnosis of toxoplasmosis is based on serological screening through the detection of anti-toxoplasmosis antibodies: IgG, which indicates previous exposure and the presence of active immunity, and IgM, which indicates a recent infection. We aimed to determine the prevalence of anti-toxoplasma antibodies in pregnant women at King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia, and explore the cost-effectiveness of anti-toxoplasma screening. METHOD: This was an analytic retrospective study of women who underwent serology testing for anti-toxoplasmosis antibodies at KAUH in 2013-2018. Data were collected from hospital documentation and IBM Statistical Package for Social Sciences (SPSS Inc., Chicago, IL) version 22 was used for analysis. RESULT: Of the 9,098 pregnant women seen at KAUH, 2,754 had undergone the test, and 38 had a positive result, i.e., a seroprevalence rate of 1.4%. Most women were Saudis (57.9%), and almost all were multiparous. Of those with a positive result, 36.8% were in the third trimester. Most births were by spontaneous vaginal delivery (65.8%). Twelve (31.6%) of the women with toxoplasmosis experienced obstetric complications. The estimated total cost of screening the pregnancies was US $919,646.00 Conclusion: The prevalence of pregnant women with a positive anti-toxoplasmosis test result was low, and we believe there is no net benefit from screening all pregnant women for toxoplasmosis. Primary prevention should be through health education, and we recommend screening only women with high-risk pregnancies.

Maternal and Neonatal Outcomes among Obese Pregnant Women in King Abdulaziz University Hospital: A Retrospective Single-Center Medical Record Review.

INTORUCTION: Pregnancy results in different physiological changes to the pregnant body resulting in weight gain. This added weight can result in poor pregnancy outcomes in obese women. AIM: To assess the adverse maternal and neonatal outcomes among obese pregnant women. METHODS: This is a retrospective record review conducted on obese pregnant women who delivered in the last five years attending King Abdulaziz University Hospital, Jeddah, Saudi Arabia. Therefore, for analysis we used the following; 1- descriptive analysis, 2- Chi-square test, Pearson correlation, independent t-test, and one-way ANOVA to test the difference in obese and adverse pregnancy outcomes. Advance statistics such as binary, and multinomial logistic regression were used to examine the relationship between obesity and all adverse pregnancy outcomes. RESULTS: A total of 1037 obese pregnant women were enrolled in our study including 620 (59.8%) obese in class I (30-34.9), 262 (25.3%) obese in class II (35-39.9), and 155 (14.9%) obese in class III (40). About 74.73% of the population were Saudis. The average age was 31.96 (5.79) years. Out of 1037 obese pregnant women, 449 did develop undesired antepartum outcomes, while 729 and 163 had adverse neonatal, and postpartum outcomes. Antepartum variables such as preeclampsia, gestational diabetes mellitus, impaired glucose tolerance test, antiphospholipid syndrome, premature rupture of membranes, placenta previa, anemia, urinary tract infection, and oligohydramnios, and rate of Cesarean section were significantly associated with obesity (P<0.05). Postpartum variables such as vaginal laceration, perianal laceration, postpartum hemorrhage, and endometritis were also significantly associated with obesity (P<0.05). Moreover, adverse neonatal outcomes such as low APGAR scores at 1 and 5 minutes, birthweight, gestational age, admission to neonatal intensive care unit, intrauterine fetal death, and neonatal death, were significant significantly associated with obesity (P<0.05). CONCLUSION: As our study demonstrated, maternal obesity resulted in adverse outcomes for the mother and fetus. Hence, to yield a better outcome for these women and their offspring, periconceptional counseling, conducting health education, and comprehensive plan prior to their pregnancy should be enforced.

Outcomes and Complications After Repeat Cesarean Sections Among King Abdulaziz University Hospital Patients.

INTRODUCTION: Cesarean section (CS) is a surgical procedure that often saves the lives of both the mother and the baby, while a previous CS is one of the main indications for cesarean delivery in current pregnancy. AIM: Our aim was to determine the surgical and obstetrical outcomes and complication for the mother and the neonate after 4 or more CSs and compare it with mothers who had less than 4 previous CSs. METHODS: This case-control study was conducted by reviewing the records of all women who underwent multiple CSs from 2013 to 2018. Our study group comprised of 394 women who had 4 or more CSs, and our control group comprised of similar number of women who had previous history of two or three CSs. RESULTS: A total of 788 patients were enrolled in our study. We found that adhesions were the most common complications in our study group with a considerable increase in number of both moderate and severe adhesions in the study group compared to the controls with p-value of <0.001. CONCLUSION: Increasing number of CSs leads to an increase of the complications risk. Among the complications, adhesions were the most common in our study group, followed by intraoperative bleeding.

The Role Of Progestogens In Threatened And Idiopathic Recurrent Miscarriage.

It is well known that progesterone plays a major role in the maintenance of pregnancy, particularly during the early stages, as it is responsible for preparing the endometrium for implantation and maintenance of the gestational sac. The management of pregnant women at risk of a threatened or idiopathic recurrent miscarriage is complex and critical. Therefore, a group of obstetricians and gynecologists practicing in Saudi Arabia gathered to update the 2014 Saudi guidelines for threatened and recurrent miscarriage management. In preparation, a literature review was conducted to explore the role of oral, vaginal, and injectable progestogens: this was used as a basis to develop position statements to guide and standardize practice across Saudi Arabia.

Prevalence of human papillomavirus in Jeddah, Saudi Arabia.

BACKGROUND: Human papillomaviruses (HPVs) are small, non-enveloped, double-stranded DNA viruses that consist of more than 200 genotypes. Low-risk genotypes are associated with warts or benign lesions, whereas high-risk genotypes are usually associated with malignancies and cancers including cervical cancer. However, the real prevalence and incidence of HPV in Saudi Arabia may be understated due to a lack of comprehensive data reporting. OBJECTIVES: Determine the positivity rate of HPV in men and women in Jeddah, Saudi Arabia. DESIGN: Cross-sectional. SETTING: Tertiary care center in Jeddah. SUBJECTS AND METHODS: Self-collected vaginal swab samples were obtained from females attending the gynecological clinic in the period between October 2017 and April 2018 at a tertiary care center, Jeddah, Saudi Arabia. PCR-positive HPV samples were sequenced to determine genotype. Additionally, serum samples were collected from healthy male and female blood donors and screened for HPV IgG antibodies by ELISA. MAIN OUTCOME MEASURES: Molecular and serological positivity for HPV. SAMPLE SIZE: 119 self-collected vaginal swabs from females at a gynecology clinic and 966 serum samples from healthy blood donors. RESULTS: Of the 119 tested vaginal swabs, 7 samples (5.9%) were positive for HPV DNA. Several genotypes were identified. Most of the positive samples were from Saudi females in the age range of 31-50 years seeking care for infertility. Of the 966 serum samples, only 16 samples (1.7%) were positive for HPV IgG antibodies. CONCLUSION: While the prevalence of HPV in men and women in our sample from the western region of Saudi Arabia was low, our data clearly show that it is not uncommon among high-risk groups and people are still exposed to the risk of HPV infection. Most importantly, these data provide valuable information that could aid in enhancing national awareness about HPV and in introducing an HPV vaccination program. LIMITATIONS: Single hospital and a convenience sample CONFLICT OF INTEREST: None.

When helping hurts: the effect of surgical interventions on ovarian reserve.

This commentary reviews some of the major papers that have been published on the effect of ovarian reserve after surgical interventions. At the end, the authors outline a summary on the effect of these interventions, in terms of future fertility and menopause.

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.