Reproduction as a window to future health in women.

Cultivating awareness for reproduction as a window to future health presents an opportunity for early identification and modification of risk factors that can affect both individual and population-level morbidity and mortality. Infertility could serve as both a window into future health as well as a pathway to future pathology. The underlying mechanisms of infertility may share common pathways with long-term risk for health and well-being. Making this identification early in the disease process may improve opportunities for intervention, and deepen our understanding of long-term risk. Additionally, fertility treatments may increase individual risk. Only by making these associations and designing studies to understand how disease and treatment risk impact health can we truly fulfill our goal of building healthy families. The aim of this review is to discuss the short-term impact of fertility challenges and treatment, long-term associations of infertility with morbidity and mortality, and the role of parity in modifying these risk associations.

Racial and ethnic disparities in the surgical management of tubal ectopic pregnancy.

Objective: To evaluate racial and ethnic disparities in the surgical management of ectopic pregnancy over time. Design: Retrospective cohort study. Setting: None. Patients: Surgically-managed cases of patients with tubal ectopic pregnancy within the American College of Surgeons National Surgical Quality Improvement Program database between 2010 and 2019. Interventions: None. Main outcome measures: Surgical approach (laparoscopic compared with open) and procedure (salpingectomy compared with salpingostomy/other). Results: Of 7791 patients undergoing surgical management of tubal ectopic pregnancy, 21.8% identified as Hispanic, 24.5% as Black, 9.4% as Asian/other, and 44.3% as White. Use of laparoscopy increased 1.3% per year from 81.4% in 2010 to 91.0% in 2019 (95% confidence interval [CI], 0.010-0.016). Odds of undergoing laparoscopic surgery were lower in Black (adjusted odds ratio [aOR] 0.52; 95% CI, 0.45-0.61) and Hispanic patients (aOR 0.52; 95% CI, 0.44-0.61) compared with White patients and remained similar over time. The use of salpingectomy increased by 1.1% per year from 80.6% in 2010 to 94.7% in 2019 (95% CI, 0.009-0.014). Odds of undergoing salpingectomy were higher among Black (aOR 1.78, 95% CI 1.43-2.23) and Hispanic patients (aOR 1.54; 95% CI, 1.24-1.93) and lower among Asian patients (aOR 0.73, 95% CI, 0.56-0.95) compared with White patients. These ratios remained similar for Black and Asian patients over time. Conclusions: Despite the increased use of laparoscopy and salpingectomy in the surgical management of ectopic pregnancy over time, Black and Hispanic patients remain less likely to undergo minimally invasive surgery and more likely to undergo salpingectomy compared with White patients.

Impact of the COVID-19 pandemic on the perception of planned oocyte cryopreservation in the United States.

Objective: To assess the impact of the COVID-19 pandemic on attitudes toward planned oocyte cryopreservation (OC). Design: Cross-sectional study. Setting: Internet-based survey questionnaire distributed nationally. Patients: One thousand women aged 21-45 years, stratified by age ≤35 or >35 years. Interventions: None. Main Outcome Measures: Change in the likelihood of considering OC because of the pandemic. Results: Of the participants who reported that the pandemic altered their likelihood of considering OC (15.2%, n = 152), 52.6% (n = 80) reported an increased and 47.3% (n = 72) reported a decreased likelihood of considering OC. Vaccination status did not affect the likelihood of considering OC. In multivariable analysis, history of COVID-19 infection (odds ratio [OR] 1.57; 95% confidence interval [CI] 1.00-2.45), government-subsidized insurance (OR 1.47; 95% CI 0.97-2.21), loss of health insurance because of the pandemic (OR 2.32; 95% CI 1.15-4.66), working more (OR 2.99; 95% CI 1.62-5.51) or less (OR 2.54; 95% CI 1.65-3.90) because of the pandemic, and relationship status (divorced, separated, or widowed [OR 0.44; 95% CI 0.20-0.99]) were significantly associated with a change in the likelihood of considering OC because of the pandemic. Of those who believed that the COVID-19 pandemic influenced their childbearing plans (28.3%, n = 283), 64.0% (n = 181) deferred childbearing and 29.7% (n = 84) expedited childbearing. The pandemic's economic impact, concerns regarding safety of pregnancy/childbirth, and safety of childrearing were cited as most influential on childbearing (67%, 70%, 58%, respectively) and on the likelihood of considering OC (47%, 45%, and 34%, respectively). Conclusions: Through its negative impact on financial security and perceived safety, the COVID-19 pandemic has altered the likelihood of considering OC in >15% of reproductive-aged women and reproductive timelines in 30%. Vaccination has not significantly modified these changes.

Surgical uterine evacuation in patients with two cervices: a case series.

OBJECTIVES: To describe the clinical circumstances, surgical approach, intraoperative challenges, and outcomes of patients with two cervices undergoing uterine evacuation for spontaneous, incomplete, or induced abortion at our institution. STUDY DESIGN: We used diagnostic and procedure codes related to uterine anomalies and uterine evacuation to identify patients with cervical duplication who underwent uterine evacuation at Penn Medicine from January 2008 to December 2020. RESULTS: We identified 15 patients with cervical duplication in whom we performed uterine evacuations during 19 pregnancies. We describe in detail each patient's first pregnancy with uterine evacuation at our institution, of which providers performed 11 in the first trimester, and four in the second trimester. Ten patients had a known diagnosis of cervical duplication prior to pregnancy. Five patients did not have a diagnosis of cervical duplication prior to pregnancy and providers newly made this diagnosis intraoperatively either at our institution or referring clinics. Providers at outside institutions referred three patients to our institution for incomplete procedures. At our institution, one patient had a procedure notable for a major complication. Eight other cases were notable for surgical challenges including difficulty placing osmotic dilators, difficulty identifying the correct cervix for local anesthesia, and contralateral cervical and uterine horn instrumentation. CONCLUSIONS: This case series suggests surgical abortion in patients with two cervices is rare, but generally safe. The majority of patients did not have major complications, despite presenting a variety of unique procedural challenges. Surgical providers were sometimes the first to make the diagnosis of a second cervix. IMPLICATIONS: Uterine evacuation providers must be aware of the possibility of an undiagnosed cervical duplication, particularly when encountering surgical challenges in patients with congenital reproductive tract anomalies. Providers should consider procedures under ultrasound guidance regardless of gestational age for patients with any congenital reproductive tract anomaly or who had prior incomplete procedures.