Use of imaging software for assessment of the associations among zona pellucida thickness variation, assisted hatching, and implantation of day 3 embryos.

PURPOSE: The aim of this study was to determine if zona pellucida thickness variation (ZPTV) is associated with implantation and if this relationship changes with use of assisted hatching (AH). METHODS: Day 3 embryos from single or double embryo transfers (DETs) performed between 2014 and 2016 were included. ZPTV was assessed by examining photographs taken before transfer using an automated image processing platform to segment the zona pellucida (ZP) with an active contour technique. One hundred points were obtained of ZP thickness (ZPT) of each embryo to calculate ZPTV ([maximum ZPT-mean ZPT]/mean ZPT). Logistic regression was used to calculate the odds ratio (OR) and 95% confidence intervals (CI) of implantation by tertile of ZPTV. Maternal age and AH were adjusted for a priori. Other cycle and embryo characteristics were adjusted for if they altered the continuous effect estimate by >10%. RESULTS: There was no statistically significant association between ZPTV and implantation across tertiles although embryos with greater ZPTV showed a trend of decreased implantation (Tertile 2 (T2) versus Tertile 1 (T1), OR = 0.80, CI = 0.50-1.28; Tertile 3 (T3) versus Tertile 1 (T3), OR = 0.75, CI = 0.47-1.20). While similar nonsignificant trends for the association between ZPTV and implantation were observed across tertiles after stratification of embryos hatched or not, embryos with the greatest ZPTV had slightly higher odds for implantation when AH was utilized (T3 vs. T1: with AH, OR = 0.89, CI = 0.49-1.62; without AH, OR = 0.61, 0.29-1.27). CONCLUSION: ZPTV was not associated with implantation after day 3 transfer. This finding did not vary by use of AH.

The Role of Hysteroscopic and Robot-assisted Laparoscopic Myomectomy in the Setting of Infertility.

Fibroids, the most common gynecologic condition in women of reproductive age, have traditionally been treated with hysterectomy. As more women delay childbearing, myomectomy becomes an essential component of the gynecologist's armamentarium. Minimally invasive approaches to myomectomy have been shown to decrease morbidity and reduce care-related costs, while improving reproductive outcomes. Hysteroscopic myomectomy is a reproducible and easily learned technique for the treatment of submucosal fibroids. Robot-assisted laparoscopic myomectomy overcomes most of the technical challenges of laparoscopic myomectomy for intramural and subserosal fibroids. The combined adoption of these technologies will allow more patients with fibroids to benefit from a minimally invasive approach.

Effect of class III and class IV obesity on oocyte retrieval complications and outcomes.

OBJECTIVE: To assess the effect of class III (body mass index [BMI] 40-49.9 kg/m2) and class IV obesity (BMI ≥ 50 kg/m2) on oocyte retrieval complications and outcomes. DESIGN: Cohort study. SETTING: Academic center. PATIENT(S): Women who underwent an oocyte retrieval from January 1, 2012 to May 31, 2017. Women with BMI ≥ 40 kg/m2 (n = 144) were age-matched to women with BMI <25, 25-29.9, 30-34.9, and 35-39.9 kg/m2 (n = 1,016). INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Anesthetic and procedural outcomes during oocyte retrieval. RESULT(S): Overall, 1,924 of 1,947 oocyte retrievals (98.8%) were performed under total intravenous anesthesia. No patients with BMI ≥ 40 kg/m2 required intraoperative conversion to endotracheal intubation or hospital admission. Two patients (0.8%) with BMI ≥ 40 kg/m2 required a laryngeal mask airway intraoperatively owing to oxygen desaturation. An oral/nasal airway was used to resolve oxygen desaturation in 16 patients (6.25%) with BMI ≥ 40 kg/m2, compared with in 17 patients (1.0%) with BMI < 40 kg/m2. As BMI increased, a statistically significant increase in propofol dose, fentanyl dose, and procedure time was observed. Eighteen patients (7.0%) with BMI ≥ 40 kg/m2 underwent a transabdominal retrieval, compared with 15 (0.9%) with BMI < 40 kg/m2. CONCLUSION(S): Serious intraoperative and postoperative complications were uncommon across all BMI groups, though minor complications were more common with class III and class IV obesity. These patients were also more likely to require higher doses of propofol and fentanyl, have longer oocyte retrievals, and require a transabdominal retrieval. Overall, oocyte retrieval can be safely performed as an outpatient procedure in women with class III and class IV obesity.

Public support in the United States for elective oocyte cryopreservation.

OBJECTIVE: To determine whether public support for oocyte cryopreservation (OC) exists and if support varies by demographic factors. DESIGN: Cross-sectional electronic survey. SETTING: Not applicable. PATIENT(S): A nationally representative sample based on age, sex, and race of 1,064 people in the United States recruited by the company SurveyMonkey. INTERVENTIONS(S): Completion of an online questionnaire. MAIN OUTCOME MEASURE(S): Supporters of OC for various indications were compared with participants who were neutral or in opposition by means of log binomial regression to calculate risk ratios. Statistical models were adjusted for demographic characteristics, including sex, race, age, income, sexual orientation, education, marital status, state political party affiliation, and history of being a parent. RESULT(S): OC for cancer patients was the indication most supported (89%), followed by delayed childbearing for career advancement (72%), current lack of a partner (63%), and insufficient funds for child rearing (58%). Despite considerable support for OC, only 37% agreed employers should fund egg freezing for employees. Older age was associated with lower support for all indications of OC. Younger age, single status, never being a parent, identifying as a sexual minority, and atheist/agnostic religion were associated with the survey taker personally considering OC. Compared with women, men demonstrated lower support for women undergoing OC for "lack of a male partner," and for future use of cryopreserved oocytes without being married. CONCLUSION(S): In a nationally representative sample, the majority of respondents support elective OC. The indication for OC was associated with significant differences in support.

Robotic single-site myomectomy: initial report and technique.

OBJECTIVE: To report the first cases of robotic single-site (RSS) myomectomy with the use of the Da Vinci Si Surgical System with wristed semirigid instrumentation. DESIGN: Case series. SETTING: University hospital. PATIENT(S): Four patients with symptomatic uterine fibroids desiring conservative minimally invasive surgical treatment. INTERVENTION(S): Four RSS myomectomies were performed with the Da Vinci Single-Site platform. Data regarding patient characteristics, indication of surgery, and perioperative outcomes were collected. MAIN OUTCOME MEASURE(S): Safety and reproducibility of RSS myomectomy. RESULT(S): All RSS procedures were completed successfully. Median operative time was 210 minutes (range 202-254 min). Median blood loss was 103 mL (range 75-200 mL). No instrument failures were noted during the procedures. No operative or major postoperative complications occurred. Two patients were discharged on the day of surgery, and two were discharged after overnight observation. CONCLUSION(S): RSS myomectomy with the use of wristed semi-rigid instrumentation is a feasible procedure. Indications, safety, and use of the technique will be confirmed by growing experience.

Robotic single-site myomectomy: a step-by-step tutorial.

OBJECTIVE: To provide a step-by-step description of our published technique of single-site robot-assisted laparoscopic myomectomy with the goal of promoting its safe adoption. DESIGN: Surgical video tutorial. SETTING: University medical center. PATIENT(S): Ten women undergoing single-site robot-assisted laparoscopic myomectomy between November 2014 and March 2015. INTERVENTION(S): A 2.5-cm vertical incision is made within the umbilicus, through which a multilumen single-site port (da Vinci Single-Site; Intuitive Surgical) is seated. An 8.5-mm 0-degree laparoscope is introduced, and the teleoperator (da Vinci Si Surgical Platform; Intuitive Surgical) is docked, allowing subsequent placement of two curved 5-mm instrument cannulae. Two wristed, semirigid needle drivers are loaded onto robotic arms 1 and 2. An 8-mm assistant cannula is also placed through the multilumen single-site port; a flexible 2-mm CO2 laser fiber and all conventional 5-mm laparoscopic instruments are introduced through this cannula as needed. Intramyometrial dilute vasopressin is injected, and fibroid enucleation is performed. The hysterotomy is repaired in layers with unidirectional barbed suture (Stratafix; Ethicon). The teleoperator is undocked. The single-site port is exchanged for a self-retaining wound retractor with gel-sealed cap. An endoscopic pouch is placed in the abdomen, and the specimen is placed within the pouch. The edges of the pouch are exteriorized. Extracorporeal tissue extraction is performed with a scalpel. A running mass closure of the fascia and peritoneum is performed, followed by a subcuticular closure of the skin. MAIN OUTCOME MEASURE(S): Median number and size of fibroids removed, specimen weight, operative time, estimated blood loss, and perioperative complications. RESULT(S): The technique described in our video was successfully employed in our first 10 patients. The median number of fibroids removed was 2.5 (range: 1-8); the median size of the largest myoma was 6 cm (range: 4-8 cm); the median specimen weight was 70 g (range: 26-154 g); the median operating time was 202 minutes (range: 141-254 minutes); the median blood loss was 87.5 mL (range: 10-300 mL). No conversions to multiport robotic or open myomectomy occurred. No major complications occurred, and no patients required blood transfusion. CONCLUSION(S): Robot-assisted laparoscopic single-site myomectomy employing a multilumen port and wristed, semirigid needle drivers is a safe and reproducible technique. Our technique allows surgeons to offer myomectomy and contained, extracorporeal tissue extraction via a single 2.5-cm umbilical incision in select patients with low tumor burden.

Treatment of premenstrual dysphoric disorder.

Premenstrual dysphoric disorder (PMDD) is comprised of a cluster of affective, behavioral and somatic symptoms recurring monthly during the luteal phase of the menstrual cycle. The disorder affects 3-8% of menstruating women and represents the more severe and disabling end of the spectrum of premenstrual disorders, which includes premenstrual syndrome and premenstrual aggravation of underlying affective disorder. Rigorous and specific diagnostic criteria for PMDD were specified in the Diagnostic and Statistical Manual of Mental Disorders IV (1994) and reaffirmed in the Diagnostic and Statistical Manual of Mental Disorders V (2013) and, consequently, there has been a marked increase in well-designed, placebo-controlled studies evaluating treatment modalities. Although the exact pathogenesis of PMDD is still elusive, treatment of PMDD and severe premenstrual syndrome has centered on neuromodulation via serotonin reuptake inhibitor antidepressants, and ovulation suppression utilizing various contraceptive and hormonal preparations. Unlike the approach to the treatment of depression, serotonergic antidepressants need not be given daily, but can be effective when used cyclically, only in the luteal phase or even limited to the duration of the monthly symptoms. Less, well-substantiated alternative treatments, such as calcium supplementation, agnus castus (chasteberry), Hypericum perforatum (St John's wort) and cognitive/behavioral/relaxation therapies, may be useful adjuncts in the treatment of PMDD. This review provides an overview of current information on the treatment of PMDD.

Novel hormone treatment of benign metastasizing leiomyoma: an analysis of five cases and literature review.

OBJECTIVE: To evaluate novel hormonal therapies in patients with unresectable benign metastasizing leiomyoma (BML) disease. DESIGN: Case series. SETTING: National Institutes of Health (NIH). PATIENT(S): Five subjects with the diagnosis of BML based on imaging and/or histopathologic diagnosis. INTERVENTION(S): Four patients were treated with single or combination therapy of leuprolide acetate and/or an aromatase inhibitor. One patient was treated with an antiprogestin (CDB-2914). MAIN OUTCOME MEASURE(S): Response to therapy was measured by tumor burden on cross-sectional imaging employing RECIST (Response Evaluation Criteria in Solid Tumors) 1.1 guidelines. RESULT(S): Four patients treated with single or combination therapy of leuprolide acetate and/or an aromatase inhibitor demonstrated stable disease with reduction in tumor burden. The fifth patient treated with antiprogestin (CDB-2914) had degeneration of her tumor, progression of its size, and an improvement in symptoms. CONCLUSION(S): Hormone treatment with GnRH agonist and/or aromatase inhibition may be a therapeutic option to reduce tumor burden in unresectable BML disease or for those patients who wish to avoid surgical intervention. RECIST 1.1 guidelines, while traditionally used to evaluate tumor response to cancer therapeutics, may be useful in evaluating BML tumor burden response to hormone therapy.

Breast cancer close to the nipple: does this increase the risk of nodal metastasis at diagnosis?

BACKGROUND: Previous studies of patients with invasive breast cancer examined, with mixed results, tumour location as a predictor of axillary lymph node metastasis. This study assessed whether tumour location in relation to the nipple impacts the presence of axillary lymph node metastasis at the time of diagnosis. METHODS: A retrospective review was undertaken of the medical records and available imaging of 285 patients diagnosed with invasive breast cancer between January 2001 to June 2007 at Boston University Medical Center. The incidence of axillary lymph node metastasis was correlated with tumour location in relation to the posterior nipple line to control for variation in breast size. Bivariate analysis identified significant variables that were applied to a multiple logistic regression model. RESULTS: Axillary lymph node metastasis was not significantly associated with tumour proximity to the nipple. In the multivariate logistic regression analysis, known prognostic factors for axillary metastasis, such as surgical size, lymphovascular invasion, and age of diagnosis, were significant, whereas breast density, palpability, and histologic grade were no longer significant. CONCLUSIONS: Our study found that there was no evidence that correlates intramammary tumour proximity to the nipple with the presence of axillary lymph node metastasis at diagnosis. However, known prognostic factors, such as lymphovascular invasion, surgical size, and younger age at diagnosis, are strong independent predictors for axillary lymph node involvement.