To treat or not to treat: perceptions of the initial American Society for Reproductive Medicine COVID-19 recommendations among women's health providers.

PURPOSE: The objective of this study was to evaluate the perception of the initial ASRM COVID-19 recommendations for infertility treatment held by women's health providers within varying subspecialties, as well as their attitudes toward pregnancy and fertility during this time. METHODS: An electronic survey was sent to all women's healthcare providers, including physicians, mid-level providers and nurses, in all subspecialties of obstetrics and gynaecology (Ob/Gyn) at a large tertiary care university-affiliated hospital. RESULTS: Of the 278 eligible providers, the survey response rate was 45% (n = 127). Participants represented 8 Ob/Gyn subspecialties and all professional levels. Participants age 18-30 years were significantly more likely to feel that women should have access to infertility treatment despite the burden level of COVID-19 in respective community/states (p = 0.0058). Participants within the subspecialties of general Ob/Gyn, maternal foetal medicine and gynecologic oncology were significantly more likely to disagree that all women should refrain from planned conception during the COVID-19 pandemic, in comparison to those in urogynecology and reproductive endocrinology and infertility (p = 0.0003). CONCLUSIONS: Considering the immediate and unknown long-term impact of the COVID-19 pandemic on fertility care delivery, a better understanding of perceptions regarding infertility management during this time is important. Our study shows overall support for the initial ASRM recommendations, representing a wide spectrum of women's health providers.

Hysteroscopic Endometrial Polypectomy with Manual Vacuum Aspiration Compared to Mechanical Morcellation.

STUDY OBJECTIVE: To examine the effectiveness of hysteroscopy plus manual vacuum aspiration (MVA) for endometrial polypectomy compared with hysteroscopic morcellation. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Duke University Medical Center database. PATIENTS: Women who underwent hysteroscopic removal of endometrial polyps performed by Duke Fertility Center faculty physicians between January 1, 2015, and January 29, 2018, using either hysteroscopy plus MVA or hysteroscopic morcellation. INTERVENTIONS: The 2 groups were compared using the χ2 or Fisher's exact test, Student's t test, and multivariable regression analysis. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the duration of the procedure. Secondary outcomes were fluid deficit, rate of complete polyp resection, estimated blood loss, and operative complications. A total of 102 women undergoing endometrial polypectomy were identified. Patients in whom polyps were removed using only a hysteroscopic grasper and/or scissors (n = 31); patients who underwent an additional simultaneous procedure, such as laparoscopy (n = 12); and patients in whom the duration of the procedure was not recorded (n = 2) were excluded. Among the remaining 57 patients, 28 underwent hysteroscopy plus MVA and 29 underwent hysteroscopic morcellation. The mean duration of procedure was longer for hysteroscopic morcellation compared with hysteroscopy plus MVA (32 ± 10 minutes vs 20 ± 6 minutes; p = .04), and this difference remained significant after adjusting for age, body mass index, surgeon, and number and size of polyps. Mean fluid deficit was greater for morcellation than for hysteroscopy plus MVA (277 ± 204 mL vs 51 ± 97 mL; p < .001). Complete polyp resection was possible in all patients; however, the use of a hysteroscopic scissors and grasper was required for 1 patient in the MVA group. Estimated blood loss was minimal in all cases, and there were no operative complications. CONCLUSION: Hysteroscopy plus MVA is an effective method for removing large or multiple endometrial polyps, with outcomes comparable to hysteroscopic morcellation.

The Effect of Age and Body Mass Index on the Surgical Anatomy of Supraumbilical Port Insertion: Implications for Laparoscopic and Robotic Surgery.

BACKGROUND: Minimally invasive surgery is the preferred approach for performing many gynecologic procedures. Occasionally, supraumbilical port placement may be preferable to optimize visibility and maneuverability although the risks of complications are less well characterized compared to umbilical entry. METHODS: We conducted a retrospective review of computed tomograms from 92 patients to evaluate the anatomic considerations for umbilical and supraumbilical port entry based on patient age, body mass index (BMI), parity, abdominal wall thickness, and distance to the great vessels. RESULTS: Supraumbilical entry was not associated with differences in distance to the great vessels compared to the umbilicus. However, supraumbilical location and BMI were associated with greater abdominal wall thickness. Age and BMI were associated with greater distance to the great vessels, while age was associated with thinner abdominal wall. Multiple linear regression confirmed independent effects of age and BMI. No association between parity and distance to retroperitoneal vessels was observed. CONCLUSION: Younger patients may be at increased risk for great vessel injury and pre-peritoneal insufflation. Obese patients may be at risk for pre-peritoneal insufflation, while patients with BMI < 30, particularly with a skin-to-aorta distance < 7 cm, may be at an increased risk for great vessel injury. Surgeons should consider these factors when considering supraumbilical port entry.

Does progesterone supplementation improve pregnancy rates in clomiphene citrate and intrauterine insemination treatment cycles?

AIM: To investigate the effect of empiric use of luteal phase progesterone supplementation to improve endometrial receptivity in women undergoing treatment with clomiphene citrate in combination with intrauterine insemination (CC-IUI). DESIGN: Retrospective cohort analysis. SETTING: University fertility center. PATIENTS: 426 CC-IUI cycles from 292 patients with unexplained infertility. INTERVENTIONS: Patients were treated with micronized intravaginal progesterone 100 mg twice daily beginning approximately three days after CC-IUI. MAIN OUTCOME MEASURE(S): Clinical pregnancy per initiated cycle as defined by presence of fetal heart rate on ultrasound. RESULTS: Clinical pregnancy rate was higher in patients receiving luteal phase support compared to patients not receiving luteal phase support (odds ratio: 2.04; 95% confidence interval: 1.01-4.14) after adjusting for all factors in the analysis using a multivariate logistic regression model. Age at the start of the cycle, BMI and CC dose were not shown to have an effect on clinical pregnancy rates. Patients with endometrial lining (EML) thickness 6-8 mm and >8 mm had increased clinical pregnancy rates compared to EML <6 mm independent of luteal phase progesterone use. Patients who appear to receive the greatest benefit of progesterone supplementation are in the 6-8 mm EML cohort. CONCLUSIONS: Luteal phase progesterone supplementation in CC-IUI cycles can improve endometrial receptivity as judged by the improved clinical pregnancy rates as the primary outcome.

Relationship between human chorionic gonadotropin serum levels and the risk of ovarian hyperstimulation syndrome.

The object of this retrospective cohort study was to determine if hCG levels correlate with ovarian hyperstimulation syndrome (OHSS) risk after adjustment for other risk factors during in vitro fertilization (IVF). We measured serum hCG approximately 12 h after hCG trigger in women undergoing 406 cycles of controlled ovarian hyperstimulation for IVF between June 2006 and December 2009. Serum hCG levels were measured 12 h after trigger. Bivariate logistic regression was used to assess the association between patient and cycle characteristics and OHSS. In our series, mild to moderate OHSS occurred in 9% (38/406), and severe OHSS diagnosed in 1.5% (6/406) of IVF cycles. OHSS risk was increased in younger women (<30 years old: adjusted odds ratio: aOR 2.46, 95% confidence interval: CI 1.14-5.34), increased number of oocytes (11-20: aOR 6.79, 95% CI 1.97-23.40; >20: aOR 17.55, 95% CI 4.84-63.70), and increase E2 levels (≥3,000 pg/mL: aOR 2.59, 95% CI 1.33-5.05), but was unrelated to hCG level (100-200 IU/L: aOR 1.53, 95% CI 0.60-3.91; ≥200 IU/L: aOR 1.42 95% CI 0.48-4.20). These results indicate that OHSS risk during IVF is unrelated to serum hCG level measured approximately 12 h after trigger.

Proteoglycans of uterine fibroids and keloid scars: similarity in their proteoglycan composition.

Fibrosis is the formation of excess and abnormal fibrous connective tissue as a result of either a reparative or reactive process. A defining feature of connective tissue is its extracellular matrix, which provides structural support and also influences cellular activity. Two common human conditions that result from fibrosis are uterine fibroids (leiomyomas) and keloid scars. Because these conditions share a number of similarities and because their growth is due primarily to excessive extracellular matrix deposition, we compared the proteoglycans of uterine fibroids and keloid scars with corresponding normal tissues. Our analysis indicates that uterine fibroids and keloid scars contain higher amounts of glycosaminoglycans relative to normal myometrium and normal adult skin respectively. Proteoglycan composition is also different in the fibrotic tissues. Compared with unaffected tissues, uterine fibroids and keloid scars contain higher relative amounts of versican and lower relative amounts of decorin. There is also evidence for a higher level of versican catabolism in the fibrotic tissues compared with unaffected tissues. These qualitative and quantitative proteoglycan differences may play a role in the expansion of these fibroses and in their excessive matrix deposition and matrix disorganization, due to effects on cell proliferation, TGF (transforming growth factor)-ß signalling and/or collagen fibril formation.

Diagnosis and management of endometrial hyperplasia.

Endometrial hyperplasia (EH), with or without atypia, is a common gynecologic diagnosis and a known precursor of endometrial carcinoma, the most common gynecologic malignancy. During the reproductive years, the risk of EH is increased by conditions associated with intermittent or absent ovulation, in particular, polycystic ovary syndrome. After menopause when ovulation has ceased, EH is more common in women with conditions that increase levels of circulating estrogen such as obesity or estrogen replacement therapy. Women with EH are at increased risk for both concurrent and subsequent endometrial cancer. The risk of coexisting cancer in women with a diagnosis of EH at endometrial sampling is due to limitations in both endometrial sampling and the diagnostic reproducibility among pathologists. These diagnostic uncertainties add to the complexity of managing EH. This review offers a rational approach to prevention, diagnosis, and treatment of EH, including hormone therapy and conservative surgical methods.

The risk of umbilical hernia and other complications with laparoendoscopic single-site surgery.

STUDY OBJECTIVE: To estimate the risk of umbilical hernia and other latent complications in women who underwent laparoendoscopic single-site surgery (LESS) for a gynecologic indication. DESIGN: Retrospective, nonrandomized clinical study (Canadian Task Force classification II-2). SETTING: Four tertiary care academic medical centers. PATIENTS: Women undergoing LESS for a benign or malignant gynecologic indication from 2009 to 2011. INTERVENTIONS: A total of 211 women underwent LESS via a single 1.5- to 2.0-cm umbilical incision. All surgeries were performed by advanced gynecologic laparoscopists. Incisions were repaired with a running, delayed absorbable suture. Subject demographics and clinical variables were collected and surgical outcomes analyzed. MEASUREMENTS AND MAIN RESULTS: Median age and body mass index were 45 years and 30 kg/m(2), respectively. Approximately half of study subjects underwent a hysterectomy with or without salpingo-oophorectomy, and 15% had a diagnosis of cancer. Overall, 0.9% of women were diagnosed with a preoperative umbilical hernia, and 2.4% of women experienced a major perioperative complication. After a median postoperative follow-up time of 16 months, 2.4% had development of an umbilical hernia. However, 4/5 of these women had significant risk factors for fascial weakening independent of LESS, including requirement for a second abdominal surgery in 1 subject and a cancer diagnosis with postoperative chemotherapy administration in 2 subjects. When these subjects deemed "high risk" for incisional disruption were excluded from the analysis, the umbilical hernia rate was 0.5% (1/207). On univariable analysis, obesity was the only factor associated with complications (p = .04). CONCLUSION: When performed by advanced laparoscopic surgeons, laparoendoscopic single-site gynecologic surgery is associated with a low risk of major adverse events. Additionally, the overall umbilical hernia rate was 2.4% and was lower (0.5%) in subjects without significant comorbidities.

The potential for community exposures to pathogens from an urban dairy.

The objectives of the study described in this article were to evaluate the variation and transport of fungal and bacterial concentrations in the air of a northern Mexico dairy cattle confined animal feeding operation (CAFO) and to determine the concentration and incidence of antibiotic-resistant Staphylococcus aureus isolates. Two-stage viable cascade impactors were used to measure the culturable airborne fungal organisms and bacteria. S. aureus resistant to penicillin, ampicillin, or cefaclor was identified. Samples were collected at three locations that were designated as on site, upwind of the cattle, and downwind of the cattle. The highest concentrations of culturable bacterial bioaerosols were consistently recovered from the on-site location. More than half of the organisms were antibiotic resistant at the on-site location. Elevated levels of culturable bacterial bioaerosols were recovered from the upwind site that may have been associated with the surrounding community. Bioaerosol concentrations were found in higher amounts than in a facility in the southwestern U.S. examined in the authors' previous study. The urban setting of the CAFO resulted in a higher potential for immediate community exposures.

Current diagnosis and treatment of interstitial pregnancy.

The incidence of interstitial pregnancy is rising. Traditional treatment with laparotomy, hysterectomy, or cornual wedge resection is associated with high morbidity and detrimental effects on future fertility. A diverse array of alternate treatments has been introduced over the last 3 decades, with the common goal of achieving a minimally invasive, standardized management strategy. This has been facilitated by impressive strides towards prompt diagnosis, both radiologically and chemically. In this review, we explore the current state of the art diagnostic criteria and the clinically significant diverse therapeutic options with supporting literature. Finally, we propose a structured, best-practice management plan for the once-lethal interstitial pregnancy, based on the current literature.

Recognition and management of major vessel injury during laparoscopy.

Laparoscopy is one of the most commonly performed procedures in the United States. Injury to a major retroperitoneal vessel occurs in 0.3% to 1.0% of procedures, most commonly during laparoscopic entry while placing the Veress needle or primary trocar. Fatal outcome can be related to massive gas embolism or exsanguination. Recommended treatment for gas embolism can range from supportive measures to external chest compression and insertion of a central line to withdraw gas from the right side of the heart. Recommended treatment of major vessel injury with massive hemorrhage consists of rapid laparotomy and control of hemorrhage using direct pressure until a surgeon experienced in vascular procedures arrives. When a major vessel injury occurs in a surgical facility distant from a medical center and without an available surgeon with vascular experience, based on the trauma literature, we recommend temporary control of blood loss using abdominal packing and closure (i.e., "damage control surgery") and judicious resuscitation (i.e., "damage control resuscitation") before transportation to a medical center.

Mitochondria in Ovarian Aging and Reproductive Longevity.

Mitochondrial dysfunction is one of the hallmarks of aging. Consistently mitochondrial DNA (mtDNA) copy number and function decline with age in various tissues. There is increasing evidence to support that mitochondrial dysfunction drives ovarian aging. A decreased mtDNA copy number is also reported during ovarian aging. However, the mitochondrial mechanisms contributing to ovarian aging and infertility are not fully understood. Additionally, investigations into mitochondrial therapies to rejuvenate oocyte quality, select viable embryos and improve mitochondrial function may help enhance fertility or extend reproductive longevity in the future. These therapies include the use of mitochondrial replacement techniques, quantification of mtDNA copy number, and various pharmacologic and lifestyle measures. This review aims to describe the key evidence and current knowledge of the role of mitochondria in ovarian aging and identify the emerging potential options for therapy to extend reproductive longevity and improve fertility.

Left upper quadrant laparoscopic placement: effects of insertion angle and body mass index on distance to posterior peritoneum by magnetic resonance imaging.

OBJECTIVE: To determine the ideal angle for insertion of laparoscopic instruments at Palmer's point. STUDY DESIGN: Abdominal magnetic resonance images were reviewed for 75 women between ages 18 and 50 years old. The distance from the skin to the retroperitoneal structures were determined perpendicular to the spine and angled 45 degrees caudally. RESULTS: When instruments are inserted perpendicular to the skin in the axial plane and peritoneum perpendicular to the spine, the distance from skin to posterior was 10.0 +/- 0.2 cm and to the aorta was 11.3 +/- 0.2 cm. If instruments are inserted at an angle 45 degrees caudally, this distance increased to 16.6 +/- 0.2 cm. CONCLUSION: When inserting laparoscopic instruments at Palmer's point, insertion perpendicular to the skin in the axial plane and angled 45 degrees caudally in relation to the spine offers an increased margin of safety compared with insertion perpendicular to the spine, particularly in thin women.

Ectopic pregnancy: role of laparoscopic treatment.

Ectopic pregnancy is a common condition with the immediate risk of life-threatening hemorrhage and subsequent risks of infertility and recurrence. Despite remarkable advances in diagnosis and treatment, ectopic pregnancies account for 9% of all maternal deaths. Early diagnosis has led to the development of innovative surgical and nonsurgical options. The choice of treatment, including expectant, medical, and surgical approaches, depends on ectopic location, symptoms, gestational age, and future fertility desires. Goals are to make the diagnosis of ectopic pregnancy early and provide the most effective and least invasive procedure while sparing future fertility when desired.

Seasonal changes in airborne fungi and bacteria at a dairy cattle concentrated animal feeding operation in the southwest United States.

The objective of this study was to evaluate a dairy located in the arid southwest United States to determine the concentrations and seasonal variation of airborne fungi and bacteria and to determine the percentage of antibiotic resistant Staphylococcus aureus. The authors used two-stage ambient air sampling systems to measure the culturable airborne fungal organisms and bacteria on a monthly basis. The authors recovered the most fungal, bacterial, and S. aureus organisms during the spring months. The most common fungi identified were Cladosporium, Aspergillus, and Stemphylium, which were most common in the spring and least common in the summer. S. aureus made up 4.2% to 5.5% of the total bacteria, and greater than 50% of this bacteria were found to be resistant to ampicillin, penicillin, or cefaclor, with the greatest incidence of antibiotic resistance occuring in the fall. The incidence of S. aureus resistant to at least two antibiotics ranged from 14% in the spring to 54% in the fall.

Fertility and Ovarian Reserve among Women with Rheumatoid Arthritis.

OBJECTIVE: We sought to identify causes for infertility in women with and without rheumatoid arthritis (RA). METHODS: Women with RA were matched to healthy controls. Differences in anti-Müllerian hormone (AMH) and anovulation were analyzed. RESULTS: Women with RA had lower AMH (ß -1.05, 95% CI -2.09 to -0.005), but no difference was observed when AMH was log-transformed. No difference in anovulation was observed. Infertility prevalence was similar between groups, primarily attributable to polycystic ovary syndrome in healthy controls but largely unexplained in women with RA. CONCLUSION: AMH was lower in women with RA, but reasons for infertility among women with RA remain unknown.

Rectovaginal examinations and human papillomavirus: can we decrease the risk of colorectal infection?

Rectovaginal examination with gloves contaminated with vaginal secretions might increase the risk of human papillomavirus (HPV) inoculation of the rectum in women with genital HPV infections. Because of the high prevalence of asymptomatic genital HPV infections, and the association between HPV and colorectal malignancy, examination gloves should be changed between vaginal and rectal examinations.

Differential regulation of myometrial prostaglandin production by changes in length.

OBJECTIVE: The purpose of this study was to determine whether stretching and shortening of human myometrial strips alters prostaglandin production. STUDY DESIGN: We measured 6-keto prostaglandin F1alpha (PGF1alpha; a PGI2 metabolite) and PGF2alpha in the contraction baths of myometrial strips that were obtained at cesarean delivery from 5 term pregnant women. Fluid was collected after the stretching and after the strip lengths were decreased by 4%, 6%, or 8%. Prostaglandin concentrations were measured in triplicate by competitive enzyme immunoassay and compared by Kruskal-Wallis tests. RESULTS: Stretching myometrial strips increased the production of 6-keto PGF1alpha by 31%, but not PGF2alpha. Shortening strips had little effect on 6-keto PGF1alpha production, but increased PGF2alpha production by 158%. CONCLUSION: Stretching myometrial strips from pregnant women increases synthesis of PGI2; shortening strips increases synthesis of PGF2alpha. Differential prostaglandin synthesis that is related to myometrial stretching and shortening could play a role in uterine quiescence during gestation and increased contractility during parturition.

Clinical, Hormonal, and Metabolic Parameters in Women with Subclinical Hypothyroidism and Polycystic Ovary Syndrome: A Cross-Sectional Study.

BACKGROUND: Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in reproductive age women, yet its clinical presentation shares similarities with several other endocrine disorders such as thyroid disease. Hence, the objective of this study was to further evaluate this association by investigating the clinical, hormonal, and metabolic parameters between subclinical hypothyroidism (SCH) and PCOS. METHODS: This is a cross-sectional study conducted in a tertiary care clinic at Cleveland, Ohio, USA. A total of 137 women diagnosed with PCOS by Rotterdam criteria were examined. SCH was defined as thyroid-stimulating hormone >2.5 mIU/L in the absence of symptoms of overt hypothyroidism. The mean age, body mass index (BMI), fasting plasma glucose (FPG), glucose tolerance test, hemoglobin A1c, fasting insulin, a 2 hours insulin level after 75 g glucose load, cholesterol, LDL, HDL, and homeostatic model assessment (HOMA) were compared between women with and without SCH. Logistic regression was used to adjust for age and BMI. RESULTS: Among 137 women with PCOS, 21.9% had SCH. Comparison groups were similar in both age and BMI and there was no difference in the mean values of all endocrine and metabolic parameters tested. However, abnormal FPG levels (OR 3.01; CI: 1.12-8.07. p = 0.03) and abnormal HOMA (OR 3.7; CI: 1.14-12.00. p = 0.03) were more likely in women who had SCH than in women without SCH independent of age and BMI. CONCLUSIONS: Women with PCOS and SCH are more likely to have impaired FPG values and impaired insulin sensitivity even after adjusting for age and BMI. Hence, close monitoring of PCOS patients for SCH may be beneficial.

Effects of peritoneal closure and suture material on adhesion formation in a rabbit model.

OBJECTIVE: This study was designed to determine whether postoperative adhesions to the peritoneum beneath the anterior abdominal wall incision could be decreased by peritoneal closure using less reactive suture material. STUDY DESIGN: Six longitudinal abdominal incisions were made in each of 16 New Zealand white female rabbits. The peritoneum was randomly assigned to nonclosure or closure with chromic gut, braided nylon, braided coated polyglactin 910, polydioxanone monofilament, or poliglecaprone 25 suture. On postoperative day 14, adhesion formation was scored and evaluated microscopically. RESULTS: Peritoneal closure decreased adhesion scores, compared with nonclosure, regardless of type of suture, and no particular suture was superior. Braided coated polyglactin 910 resulted in the least chronic inflammation and fibrosis. CONCLUSION: Peritoneal closure of peritoneum immediately below laparotomy incisions results in decreased adhesion scores, compared with nonclosure in our rabbit model. Adhesion formation could not be decreased further using less reactive suture.