National Canadian Survey on the Management of Noneuploid Embryos.

OBJECTIVE: To comprehensively describe current preimplantation genetic testing for aneuploidy (PGT-A) practices and management of non-euploid embryos in Canada. METHODS: This was a cross-sectional study utilizing an online survey distributed by email to all medical directors of fertility clinics with independent in vitro fertilization (IVF) embryology laboratories. The survey was designed to determine practice patterns regarding PGT-A usage; PGT-A reference laboratory, platform, and thresholds for classifying embryos; and management of embryos classified as mosaic, inconclusive, or aneuploid. RESULTS: Twenty-five medical directors (69%) participated in the survey. The majority of clinics (91%) offered PGT-A screening, with 45% of clinics offering PGT-A as routine screening. The majority of clinics (90%) that offered PGT-A received mosaicism data; 61% of these clinics had transferred mosaic embryos, and 94% would transfer mosaic embryos. Clinics that performed ≥1000 IVF cycles annually were more likely to have transferred mosaic embryos (100% vs. 45.5%; P = 0.043). The mean percentage of IVF cycles using PGT-A was lower in clinics that had transferred mosaic embryos (12.3% vs. 30.4%; P = 0.033). Only 1 clinic had transferred an aneuploid embryo, but 2 other clinics would consider this option. The majority of clinics (61%) that receive mosaicism data would recommend noninvasive prenatal testing (NIPT) following mosaic embryo transfer, with 22% of clinics indicating that this would be the only genetic test offered. CONCLUSION: We report significant practice variation in PGT-A and management of non-euploid embryos across Canada and highlight areas where consensus should be encouraged.

Managing and preventing blood-borne viral infection transmission in assisted reproduction: a Canadian Fertility and Andrology Society clinical practice guideline.

Fertility care providers have an obligation to provide safe and effective care to patients. When a user of assisted reproductive technology (ART) is living with a blood-borne viral infection (BBVI: HIV, hepatitis C or hepatitis B), physicians and ART laboratory personnel need to know the requirements for providing quality care. Recent developments in the treatment of BBVI and understanding of transmission have changed these requirements. This guideline from the Canadian Fertility and Andrology Society (CFAS) provides comprehensive, evidence-based guidelines for reducing horizontal transmission and cross-contamination in the ART setting.

Safety and Assisted Reproductive Technology Outcomes of Hysteroscopic Tubal Microinserts Versus Laparoscopic Proximal Tubal Occlusion or Salpingectomy for Hydrosalpinges Treatment.

OBJECTIVE: This study sought to answer the following question: What are the complications and assisted reproductive technology outcomes among women with hydrosalpinges managed by hysteroscopic microinsert tubal occlusion compared with women with hydrosalpinges managed by laparoscopic proximal tubal occlusion or salpingectomy? METHODS: This was a retrospective cohort study conducted from January 2009 to December 2014 at two academic, tertiary care, in vitro fertilization centres in Toronto, Ontario. All patients (n = 52) who underwent hysteroscopic tubal occlusion for hydrosalpinges were identified. Patients who proceeded with embryo transfer cycles after hysteroscopic microinsert (n = 33) were further age matched to a cohort of patients who underwent embryo transfer after laparoscopic proximal tubal occlusion or salpingectomy (n = 33). Main outcome measures were clinical pregnancy rate per patient and per embryo transfer cycle. RESULTS: Among 33 patients, there were 39 fresh and 37 frozen embryo transfer cycles in the hysteroscopic group (group A); among 33 patients in the laparoscopic group (group B), there were 42 fresh and 29 frozen embryo transfer cycles. The cumulative clinical pregnancy rate in group A and group B was similar (66.7% vs. 69.7%, respectively; P = 0.8). The clinical pregnancy rate per embryo transfer cycle was also similar in both groups (28.9% in group A vs. 32.4% in group B; P = 0.6). There were two incidents of ectopic pregnancy in the laparoscopic group and no ectopic pregnancy in the hysteroscopic group. There were three major complications: tubo-ovarian abscess, distal migration of the coil after microinsert placement, and an acute abdomen following the hysteroscopic procedure. CONCLUSION: Pregnancy outcomes after hysteroscopic placement of a microinsert for hydrosalpinx management before embryo transfer were comparable to those following laparoscopic proximal tubal occlusion or salpingectomy. However, caution is advised regarding microinsert placement for hydrosalpinges before proceeding with assisted reproductive technology.

A Step Towards Equitable Access: Understanding the Use of Fertility Services by Immigrant Women in Toronto.

OBJECTIVE: The authors sought to study whether there is differential access to fertility services for immigrant women in a single-payer system. METHODS: A cross-sectional quantitative survey was administered to 265 patients over 3 months. All participants were female patients in heterosexual relationships at a university-affiliated hospital-based fertility clinic in a large metropolitan city. Data on sociodemographic characteristics, reproductive history, and experience accessing fertility services were collected. Statistical analysis, including chi-square and ANOVA regression, was completed using JMP software. RESULTS: The response rate of the survey was 86.6%. A total of 265 women participated, 124 (47%) immigrants and 141(53%) non-immigrants. Immigrants more commonly left questions unanswered. Long-term immigrants had a significantly longer average duration of infertility than non-immigrant women (47 months vs. 34 months; P = 0.04). There was a trend towards a delay in seeing a health care provider among long-term immigrants. The most commonly reported reasons for delaying fertility care were "not knowing there was a problem" and "treatments being too expensive." Although participants across all groups relied on their primary care provider to supply information on fertility services, a greater percentage (17%) of recent immigrants than non-immigrant participants (7%) used the Internet to obtain information. CONCLUSION: Immigrant women addressed their fertility needs even when they had fewer resources and less social stability than did non-immigrant women. However, they experienced a delay in receiving specialized care for infertility. Immigrant women also appeared less comfortable disclosing personal information in a health care setting.

Delaying Thyroxine Until Positive Beta-Human Chorionic Gonadotropin is Safe for Patients Receiving Fertility Therapy: Applying New ATA Guidelines to Subclinical Hypothyroidism.

OBJECTIVE: This study sought to examine the effect of changing TSH threshold recommendations from 2.5 to 4 mIU/L before fertility therapy on the prevalence of early gestational subclinical hypothyroidism (SCH) (TSH2 >2.5 mIU/L) and to evaluate implications on progression to clinical pregnancy (defined as detection of cardiac activity on ultrasound). METHODS: A retrospective chart review was performed in an academic fertility clinic on all patients with a measured pre-treatment TSH (TSH1) and positive beta-human chorionic gonadotropin following fertility treatment. The study assessed the effect of TSH2 on ongoing pregnancy, both in patients newly diagnosed with SCH and in patients previously receiving LT4, stratified by initial TSH. RESULTS: Of 482 women included in the study, baseline TSH (TSH1) was <2.5 mIU/L in 333 women (69%) and 2.5-4 mIU/L in 64 women (13.2%). Eighty-five women were taking LT4 at baseline (17.6%). Among women with a TSH1 between 2.5 and 4 mIU/L, the corresponding TSH in early pregnancy (TSH2) was <2.5 mIU/L in 35 women (55%). Overall, there was no difference in progression to clinical pregnancy between women with a TSH2 of 2.5-4 mIU/L compared with women with a TSH2 <2.5 mIU/L (OR 0.70; 95% CI 0.44-1.09). Similarly, when excluding women taking LT4 at baseline, there was no difference in progression to clinical pregnancy (OR 0.90; 95% CI 0.28-2.86). CONCLUSION: Rate of progression to clinical pregnancy was equivalent between women with an early pregnancy TSH (TSH2) <2.5 and women with a TSH2 of 2.5-4.0 mIU/L. Our findings support initiating LT4 in early pregnancy, as opposed to pre-pregnancy if the TSH remains above cut-off because there does not appear to be a difference in in early pregnancy outcomes if treatment is delayed.

Access to fertility services in Canada for HIV-positive individuals and couples: a comparison between 2007 and 2014.

In the modern era of HIV care, a multitude of clinical needs have emerged; one such need is the growing sub-specialty of HIV and reproductive health. In 2007, a study surveying Canadian fertility clinics found limited access to fertility services for HIV-positive patients. Given the extensive efforts made to address this lack of services, a follow-up assessment was warranted. This study aimed to compare the access to Canadian fertility clinics and services for HIV-positive individuals and couples in 2014 and 2007. Surveys were sent to medical or laboratory directors of assisted reproductive technology (ART) clinics in 2014 and results were compared to those sent in 2007. Main outcome measures included: the proportion of fertility clinics willing to provide ART to people with HIV, the specific services offered, and whether the 2012 Canadian HIV Pregnancy Planning Guidelines were implemented to inform practice. Across Canadian provinces, 20/34 (59%) clinics completed the survey. Ninety-five percent (19/20) of clinics accepted HIV-positive patients for consultation. Only 50% (10/20) of clinics in four provinces offered a full range of ART (defined as including in vitro fertilization [IVF]). Ten clinics (50%) in five provinces were aware that guidelines exist; half (n = 5) having read them and four reporting implementation of all the guidelines' recommendations in their practice. Compared to 2007, more clinics had implemented separate facilities (p = 0.028) to treat HIV-positive individuals, offered IVF (p = 0.013) for HIV-positive female partners, sperm washing (p = 0.033) for HIV-positive male partners, and risk reduction techniques to couples with HIV-positive men and women (p = 0.006). Access to fertility clinics for people with HIV has improved over time but is still regionally dependent and access to full ART remains limited. These findings suggest the need for advocacy targeted towards geographical-specific areas and optimizing access to comprehensive services.

End-of-Rotation Examinations in Canadian Obstetrics and Gynaecology Residency Programs: The Perspectives of Faculty Members and Residents.

The Royal College Competence by Design curriculum in obstetrics and gynaecology will launch in 2019, and it will depend heavily on multiple tools for accurate resident assessment. Several Canadian obstetrics and gynaecology residency programs use rotation-specific examinations at the end of various rotations for formative feedback. The obstetrics and gynaecology residency program at the University of Toronto adopted end-of-rotation examinations (EOREs) in 2014. We conducted a national survey to assess the current use of EOREs across Canada and to examine the attitudes and beliefs of residents and program directors regarding their use. We discuss faculty and resident experiences with EOREs and their perceptions of them. We also consider the role and benefit of these examinations in the context of the educational literature, and how they may integrate with future competency-based medical education frameworks.

Randomized Trial Comparing the Effect of Endometrial Shedding With Medroxyprogesterone Acetate With Random Start of Clomiphene Citrate for Ovulation Induction in Oligo-ovulatory and Anovulatory Women.

OBJECTIVE: A recent retrospective study demonstrated that anovulatory infertile women who did not have a progestogen-induced withdrawal bleed before treatment with clomiphene citrate (CC) had higher pregnancy rates than women who had a withdrawal bleed and those who had spontaneous menstrual bleeding. We sought to assess endometrial thickness at the time of ovulation in oligo-ovulatory and anovulatory women who took CC with or without a preceding progestogen-induced withdrawal bleed. METHODS: We conducted a pilot randomized trial in which women with infertility and oligomenorrhea or amenorrhea were randomly assigned to take either CC after a withdrawal bleed induced by medroxyprogesterone acetate (MPA) 10 mg daily for 10 days or to take CC without such a bleed. Study participants underwent cycle monitoring with ultrasound assessment of endometrial thickness at the time of LH surge or a human chorionic gonadotropin trigger, followed by timed intercourse or intrauterine insemination. Women who had not ovulated by cycle day 21 took an increased dose of CC, with or without an MPA-induced withdrawal bleed, to a maximum of three cycles. Participants and nurses were asked to complete a questionnaire about the study. RESULTS: There was no significant difference in endometrial thickness on the day of LH surge or human chorionic gonadotropin trigger between women who had a progestogen-induced withdrawal bleed and those who did not (P = 0.65). On average, the time to ovulation was 15 days longer in women who took MPA than in women who did not, but this difference was not statistically significant (P = 0.65). Satisfaction with the study was reported as high by both patients and nurses. CONCLUSION: In anovulatory or oligo-ovulatory women treated with CC, we found no significant difference in endometrial thickness whether or not the use of CC was preceded by a withdrawal bleed induced by MPA.

Laparoscopic myomectomy versus uterine artery embolization: long-term impact on markers of ovarian reserve.

OBJECTIVE: To compare the relative long-term effects on ovarian reserve of treating fibroids in reproductive-aged women with uterine artery embolization (UAE) versus laparoscopic myomectomy (LM), using sensitive measures including antral follicle count (AFC) and serum anti-Müllerian hormone (AMH). METHODS: We undertook a retrospective cohort pilot study to evaluate the utility and feasibility of carrying out a larger prospective trial. Thirteen women were evaluated in this study, including eight in the UAE group and five in the LM group. They were identified from a larger group of 125 women who had undergone LM and 200 women who had undergone UAE at a participating institution at least 12 months previously; of these, 32 who had UAE and 27 who had LM were of reproductive age and eligible to participate. Participants had an assessment of ovarian reserve including measurements of serum AMH, estradiol, and FSH, and ultrasound assessment of AFC and ovarian volume. RESULTS: Median serum AMH levels were significantly lower in women who had undergone UAE at least 12 months previously than in women who had undergone LM (0.78 ng/mL [range 0.67 to 1.28] vs. 2.17 ng/mL [range 1.17 to 2.38], P = 0.01). Median AFC per ovary was also significantly lower in women who had UAE than in those who had LM (3.5 [range 2 to 7] vs. 7 [range 6 to 11], P = 0.03). Median levels of FSH and E2 and of ovarian volume were not significantly different between the two groups. CONCLUSION: Reproductive-aged women who have undergone treatment of fibroids with UAE may have lower ovarian reserve over the long term (> 12 months) than women with fibroids treated with LM. This could have an adverse impact on future response to fertility treatment and/or fecundity. This finding may inform the choice of minimally invasive treatment for fibroids in reproductive-aged women who have not completed childbearing. It suggests that further study in this area is warranted before the application of UAE is expanded to young reproductive-aged women.

Objectif : Comparer, chez des femmes en âge de procréer, la prise en charge de fibromes par embolisation de l'artère utérine (EAU) à leur prise en charge au moyen d'une myomectomie par laparoscopie (ML), pour ce qui est des effets relatifs à long terme sur la réserve ovarienne (déterminés au moyen de mesures sensibles, dont la numération des follicules antraux [NFA] et le taux sérique d'hormone antimüllérienne [HAM]). Méthodes : Nous avons mené une étude de cohorte rétrospective pilote afin d'évaluer l'utilité et la faisabilité de mener un essai prospectif de plus grande envergure. Treize femmes ont été évaluées dans le cadre de cette étude (huit dans le groupe EAU et cinq dans le groupe ML). Elles ont été identifiées à partir d'un groupe plus étendu comprenant 125 femmes qui avaient subi une ML et 200 femmes qui avaient subi une EAU au sein d'un établissement participant au moins 12 mois au préalable; de ces femmes, 32 de celles qui avaient subi une EAU et 27 de celles qui avaient subi une ML étaient en âge de procréer et admissibles à l'étude. Les participantes ont été soumises à une évaluation de leur réserve ovarienne (mesures des taux sériques d'HAM, d'estradiol et de FSH, et évaluation échographique de la NFA et du volume ovarien). Résultats : Les taux sériques médians d'HAM étaient considérablement moins élevés chez les femmes qui avaient subi une EAU au moins 12 mois au préalable que chez les femmes qui avaient subi une ML (0,78 ng/ml [plage : 0,67 - 1,28] vs 2,17 ng/ml [plage : 1,17 - 2,38], P = 0,01). La NFA médiane par ovaire était également considérablement moins élevée chez les femmes qui avaient subi une EAU que chez celles qui avaient subi une ML (3,5 [plage : 2 - 7] vs 7 [plage : 6 - 11], P = 0,03). Le volume ovarien et les taux médians de FSH et d'E2 n'étaient pas considérablement différents d'un groupe à l'autre. Conclusion : Les femmes en âge de procréer qui ont fait l'objet d'une EAU visant la prise en charge de leurs fibromes pourraient présenter, à long terme (> 12 mois), une réserve ovarienne moins élevée que celle des femmes ayant vu leurs fibromes être pris en charge au moyen d'une ML, ce qui pourrait exercer un effet indésirable sur la fertilité et/ou sur la réaction à de futurs traitements de procréation assistée. Cette constatation pourrait éclairer la décision quant au recours à un traitement à effraction minimale pour assurer la prise en charge des fibromes chez les femmes en âge de procréer qui souhaitent encore connaître une ou des grossesses. Elle laisse également entendre que la tenue d'autres études dans ce domaine s'avère justifiée avant que le recours à l'EAU ne soit élargi aux jeunes femmes en âge de procréer.

Medical Students' Perspectives on Family Planning and Impact on Specialty Choice.

Importance: Physicians are known to delay childbearing compared with nonphysicians and to experience higher rates of age-related pregnancy complications. Delay of childbearing is more pronounced in surgical specialties, and family planning and building goals may influence specialty choice. Objective: To assess medical students' perspectives on the development of family planning goals and the timing of family building within a medical career to elucidate how these perceptions impact their choice of specialty. Design, Setting, and Participants: This qualitative study included fourth-year medical students at the University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada, and was conducted between May and August 2021. Participants were purposively sampled to maximize diversity of gender and specialty choice. Interviews were conducted via videoconferencing software that were recorded, transcribed verbatim, and verified for accuracy. Thematic analysis was completed independently by 2 researchers and consensus on final themes was reached through discussion among study investigators. Data were analyzed between September and December 2021. Main Outcomes and Measures: Participants were asked to share their perceptions of personal family planning goals, support currently in place, family planning education in medicine and factors contributing to their choice of specialty and program. Thematic analysis was completed. Results: A total of 34 fourth-year medical students (median [range] age, 26 [24-33] years; 23 females [67.6%]) were interviewed. Four main themes were identified: (1) there is no ideal time to family build in a medical career, (2) family planning is a taboo topic, (3) surgical specialties offer less support for family building, and (4) residents who have children are perceived to place a burden on their colleagues. Medical students considered their family planning while deliberating among specialty choices and their experiences were highly influential in shaping their specialty selection. Conclusions and Relevance: Results of this qualitative study suggest that medical students perceive that family building during training may have unfavorable implications for team dynamics and relationships with colleagues, and these perceptions may affect specialty choice and family planning goals. Integration of family planning discussions and support for family building into medical curricula is needed along with efforts to improve culture by supporting team dynamics and workload when students take parental leave.

Education of the clinical embryology laboratory professional: development of a novel program delivered in a laboratory medicine department.

Clinical embryologists are responsible for the handling, evaluation, and care of human gametes and preimplantation embryos within the context of an assisted reproductive technology laboratory. They are integral members of a team of professionals who provide care for fertility patients. Despite the increasing recognition of clinical embryologists as professionals, training requirements, continuing professional development, and appropriate credentialing have lagged in several countries. In many cases, individuals enter the profession with training limited to technical aspects provided by individual laboratory directors through an apprenticeship model. In this article, we present the rationale for rigorous formal training in clinical embryology, introduce CanEMB competencies for practicing professional clinical embryologists that are founded on CanMEDs role principles, and present a nascent Masters of Health Sciences degree program in Laboratory Medicine with a specialization in clinical embryology. This 2-year program has unique features including a Clinical Embryology Skills Development Laboratory, research capstone project, and 200-hour placement within a practicing assisted reproductive technology laboratory. Importantly, this program is delivered through a university-based Department of Laboratory Medicine and Pathobiology in partnership with a Department of Obstetrics and Gynecology. Thus, this program represents a formal acceptance of clinical embryology as a clinical laboratory science. It can be adopted elsewhere to provide a relevant, robust education that will meet current and future needs of the profession.

Access to infertility services in Canada for HIV-positive individuals and couples: a cross-sectional study.

BACKGROUND: Family and pregnancy planning issues are important among human immunodeficiency virus (HIV)-positive individuals and couples. However, access to fertility services may be limited for this population. The objective of this study was to estimate the types of services available in fertility clinics in Canada for these individuals. METHODS: A survey was sent to all registered fertility clinics in Canada to assess the availability of services (investigations and treatment) for infertility and/or viral transmission risk reduction in achieving pregnancy. The proportion and location of clinics willing to carry out investigations and treatments were determined. Logistic regression analysis was performed to assess differences in response rates, investigations, and treatments by province and by couple scenario. RESULTS: Completed surveys were received from 23/28 (82%) of clinics across eight Canadian provinces. Seventy-eight per cent (18/23) were willing to accept HIV-positive individuals in consultation, and 52% had actually seen at least one HIV-positive man or woman in the previous year. Clinics in every province were willing to offer infertility investigations, but only clinics located in five provinces were willing to offer fertility treatments. The most commonly available treatment was intrauterine insemination for couples in which the female partner was HIV-positive (52%). Other techniques, such as sperm washing (26%) or in vitro fertilization (17%), were less commonly offered. A smaller number of clinics were willing to offer risk reduction techniques in achieving pregnancy. CONCLUSIONS: Access to infertility investigations and treatments in Canada is limited and regionally dependent. TRIAL REGISTRATION: Registered with ClinicalTrials.gov at http://www.clinicaltrials.gov, registration number NCT00782132.

A clinical practice guide: What HIV care providers need to know about HIV pregnancy planning to optimize preconception care for their patients.

This clinical practice guide has been developed to support human immunodeficiency virus (HIV) care providers' use of the 2018 Canadian HIV Pregnancy Planning Guidelines (CHPPG) in their work with people and couples affected by HIV. HIV pregnancy planning has changed considerably in the last decade and requires a multidisciplinary team, and HIV care providers are often at the forefront of the team. It is, therefore, important to have clear guidance on how to provide HIV pregnancy planning care. This Clinical Practice Guide is intended for both primary and specialty HIV care providers, including doctors, nurses, and nurse practitioners. We have repackaged the 2018 CHPPG's 36 recommendations into five standards of care for ease of use. We have also included an initial algorithm that can be used with each patient to direct discussions about their reproductive goals. Pregnancy and parenting are increasingly normalized experiences in the lives of people and couples affected by HIV. While conception used to be a complicated decision, often heavily focused on minimizing the risk of HIV transmission, the current evidence supports more universal counselling and supports for HIV pregnancy planning. HIV care providers have a responsibility to be familiar with the unique considerations for pregnancy planning when supporting their patients. This counselling is critical to optimizing reproductive health outcomes for all people affected by HIV, including those who wish to prevent pregnancy.

Les présentes directives de pratique clinique visent à soutenir l'utilisation des Lignes directrices canadiennes en matière de planification de la grossesse en présence du VIH 2018 par les dispensateurs de soins aux personnes et aux couples touchés par le virus d'immunodéficience humaine (VIH). La planification de grossesse en présence du VIH a considérablement évolué depuis dix ans. Elle exige l'apport d'une équipe multidisciplinaire, et les dispensateurs de soins aux personnes infectées par le VIH y occupent souvent le premier rang. Il est donc important de disposer de directives claires sur le mode de prestation des soins pendant la planification de la grossesse en présence de VIH. Les directives de pratique clinique sont conçues pour les dispensateurs de soins primaires et spécialisés en matière de VIH, y compris les médecins, les infirmières et les infirmières praticiennes. Les Lignes directrices de 2018 contiennent 36 recommandations que les auteurs ont regroupées en cinq normes de soins pour en faciliter l'utilisation. Ils ont également inclus un premier algorithme à utiliser avec chaque patient pour orienter les échanges sur leurs objectifs de reproduction. La grossesse et le rôle de parent sont des expériences de plus en plus normalisées dans la vie des personnes et des couples touchés par le VIH. La conception a déjà été une décision complexe, souvent axée fortement sur la réduction du risque de transmission du VIH, mais les données à jour appuient la transmission de conseils plus universels et une aide à la planification de grossesse en présence du VIH. Il incombe aux dispensateurs de soins aux personnes touchées par le VIH de connaître les particularités de la planification de grossesse auprès de ces patients. Ces conseils sont cruciaux pour optimiser les résultats en santé génésique de toutes les personnes en cause, y compris la prévention des grossesses non désirées.

A Canadian, multicentre study comparing the efficacy of a levonorgestrel-releasing intrauterine system to an oral contraceptive in women with idiopathic menorrhagia.

OBJECTIVES: To evaluate the efficacy of a levonorgestrel-releasing intrauterine system (LNG-IUS) compared with a combined oral contraceptive containing 1 mg norethindrone acetate and 20 mg ethinyl estradiol (OC1/20) in reducing menstrual blood loss (MBL) in women with idiopathic menorrhagia. METHODS: A prospective, randomized, open-label study was conducted in nine centres in Canada. Healthy women over 30 years of age suffering from idiopathic menorrhagia were treated either with LNG-IUS (n = 20) or with OC1/20 (n = 19) over 12 months. The primary endpoint was the change in MBL from baseline to 12 months. Secondary endpoints included treatment success (defined as a MBL score < 100 after 12 months), hemoglobin levels, and the menorrhagia severity score. RESULTS: In both treatment groups, MBL decreased significantly from baseline to 12 months (P < 0.001). For the primary endpoint, the MBL score decreased significantly more in the LNG-IUS group (median from 228 to 13, mean percent change-83%) compared to the OC1/20 group (median from 290 to 72; mean percent change-68%) (P = 0.002) after 12 months. In the LNG-IUS group, 80% of subjects had treatment success compared with 36.8 % in the OC1/20 group (P < 0.009). Both treatments increased hemoglobin concentrations significantly between baseline and 12 months. The menorrhagia severity score was consistently lower in the LNG-IUS group at all study time points and was significantly lower (P = 0.045) at six months. Both treatments were well tolerated. CONCLUSION: Both the LNG-IUS and the combined oral contraceptive effectively decreased menstrual blood loss in women with idiopathic menorrhagia. The overall clinical benefit was more pronounced with LNG-IUS than with OC1/20.

Psychological side-effects of clomiphene citrate and human menopausal gonadotrophin.

OBJECTIVE: This study evaluated the psychological side-effects of clomiphene citrate (CC) and hMG in women undergoing fertility treatment. METHOD: This study was a cross-sectional, self-report survey of 454 women at various stages of treatment for infertility. At the time of study, 139 women had not taken fertility drugs and 315 women had taken one or more cycles of CC or hMG. All subjects were asked to complete the State-Trait Anxiety Inventory (STAI). Women taking CC or hMG were also asked to complete a self-administered questionnaire on the side-effects of their medications. RESULT(S): In the CC group (n = 162) and hMG group (n = 153), 77.8% (126 of 162) and 94.8% (145 of 153) reported at least one side-effect, respectively. Irritability, mood swings, feeling down, and bloating had high frequencies in both CC and hMG groups, with a higher mean number of side effects reported in the hMG group (4.4 +/- 3.7 for the CC group and 6.8 +/- 3.7 for the hMG group, p < 0.001). There was no significant difference among the CC, hMG and no medication groups for mean state and trait anxiety scores. However, there were significant differences among the three side-effect groups (those who reported 1 to 4, 5 to 7, and more than 7 side-effects) for the mean scores of state (df = 2, F = 8.7, p < 0.001) and trait (df = 2, F = 11.9, p < 0.001) anxiety in women taking fertility drugs. CONCLUSION(S): Women taking CC or hMG reported high frequencies of psychological side-effects, and should be advised of these before treatment.

Acute and chronic effects of hormone replacement therapy on the cardiovascular system in healthy postmenopausal women.

Previous studies have shown that conjugated estrogens and continuous medroxyprogesterone increases heart disease risk in healthy women. Little is known about the effects of the natural ovarian hormones estradiol and progesterone on cardiovascular function at rest and exercise. The purpose of this study was to investigate the short- and longer-term effects of a cyclic format of hormone replacement therapy (HRT) (1 mg estradiol daily with cyclic micronized progesterone, 200 mg for 10 d/month) on cardiovascular function at rest and during exercise in healthy, postmenopausal women. A double-blind, cross-over study was conducted in 31 patients. Peak oxygen uptake and ventilatory threshold in addition to submaximal cardiac output were determined. Peripheral measures of resting and peak ischemic blood flows were also determined. Measurements were made at baseline, after 4 h of estrogen/placebo exposure, and subsequently after 1, 2, and 3 months. The sequence of data collection was repeated after 6-wk washout. Oral estradiol with cyclic micronized progesterone increases peak ischemic peripheral blood flow chronically but fails to improve exercise tolerance and peak oxygen uptake. Similarly, submaximal central cardiovascular function is unaffected by HRT. This suggests that estradiol has a beneficial effect on peripheral blood flow, but this benefit offers little advantage in terms of peak exercise performance after 3 months of HRT.

Factors affecting academic promotion in obstetrics and gynaecology in Canada.

OBJECTIVE: (1) To determine if women faculty members in departments of Obstetrics and Gynaecology were less likely than men to achieve promotion; and (2) to assess gender differences in attitudes towards promotion. METHODS: Department chairs at the 16 medical schools in Canada were approached to participate in this study. A questionnaire was mailed to the obstetricians/gynaecologists in faculties of medicine at the 15 Canadian medical schools that agreed to participate. Likelihood of promotion for women and men was compared using survival analysis, controlling for other factors. Survival (event) time was the time in years between completion of residency and achieving promotion. RESULTS: The response rate was 72% (376/522). Overall, 37% of respondents were women, and 63% were men. The women respondents were younger than the men, with a mean age of 43.4 +/- 7.9 years compared to 52.8 +/- 8.9 years. Of those in an academic stream, 39% of women (29/75) and 62% of men (90/145) had attained senior academic ranks. Completing residency more recently was associated with a higher likelihood of promotion to Assistant Professor (hazard ratio [HR], 1.05; P <0.001). The likelihood of promotion to Professor was lower for women than for men (HR, 0.40; P = 0.05). Having a mentor was associated with a higher likelihood of promotion to Professor (HR, 2.33; P = 0.002). Women were more likely to perceive barriers to promotion, such as family care responsibilities (P <0.001). CONCLUSION: Independent of the respondent's gender, recent completion of residency and having a mentor were the most significant factors increasing the likelihood of promotion in Canadian medical school departments of Obstetrics and Gynaecology. As women were found to be less likely than men to achieve promotion to Professor, mentoring and strategies that focus on facilitating promotion for women should be encouraged to ensure there are academic leaders in obstetrics and gynaecology in the future.

Breast cancer, pregnancy, and breastfeeding.

OBJECTIVE: The primary objective of this guideline is to provide Canadian physicians up-to-date, accurate information and recommendations regarding: i) impact of pregnancy and lactation on risk of breast cancer; ii) prognosis of breast cancer diagnosed during pregnancy and lactation; iii) risk of recurrence of breast cancer with the occurrence of subsequent pregnancies; iv) feasibility of breastfeeding and its impact on the prognosis of women with breast cancer. OPTIONS: This guideline reviews evidence on whether pregnancy and breastfeeding change the lifetime risk for breast cancer in women, and whether breast cancer diagnosed during pregnancy or during lactation has a different prognosis. It offers the clinician advice on the diagnostic options to help identify breast cancer in pregnancy and/or during lactation, and offers evidence-based recommendations in managing an ongoing pregnancy and/or lactation when treatment for breast cancer is being planned. It also offers recommendations to clinicians in counselling their patients regarding future pregnancy and future breastfeeding for women who have been treated for breast cancer. OUTCOMES: These guidelines should help physicians counsel patients using evidence-based recommendations. These recommendations may also improve the prognosis of patients diagnosed with breast cancer during pregnancy and lactation, or of those patients who had breast cancer and are contemplating future pregnancies. EVIDENCE: A Medline search was carried out for all publications from 1990 through 2000, in the English language, related to breast cancer and pregnancy in terms of diagnosis, prognosis, and treatment, as well as for breast cancer and breastfeeding, with particular focus on impact of treatment of breast cancer on lactation and prognosis of breast cancer after lactation. The authors submitted the manuscript for review to members of the Breast Disease Committee, who also validated the levels of evidence. The final manuscript was submitted to the SOGC Council for approval and dissemination. The levels of evidence for recommendations have been determined using the criteria described by the Canadian Task Force on the Periodic Health Examination. BENEFITS, HARMS, AND COSTS: Canadian physicians will be able to counsel their patients on the impact of pregnancy and lactation on a woman's lifetime risk for breast cancer. Physicians and patients will be empowered to decide how to manage pregnancy and lactation when breast cancer is diagnosed in pregnancy, and to appreciate the ramifications of reproduction and breastfeeding after breast cancer. This guideline identifies areas where good evidence is lacking and advocates research in those areas. RECOMMENDATIONS: Women should be counselled regarding their risk for breast cancer and be informed that: 1. There is good evidence that there is a transient increase in risk of breast cancer in the first three to four years after delivery of a singleton baby (II-2B). Subsequently, their lifetime risk seems lower than that of women who remain nulliparous (II-2B). 2. There is good evidence that the risk for premenopausal breast cancer is reduced with lactation (II-2A). This protective effect seems to be best for women who had extended periods of breastfeeding during their lifetime (ll-2B). Women with familial risks could potentially benefit most from breastfeeding (II-2C). Since breast milk is the ideal nutrient for the newborn, and since breastfeeding is a modifiable risk factor, all women should be encouraged to breastfeed their children (II-2A). 3. All women should be encouraged to practice breast self-examination in pregnancy and during lactation (II-2B). Clinicians should screen all pregnant patients for breast cancer with thorough breast examination early in pregnancy (III-B). The clinician is advised to examine the breast in the postpartum period if the woman is not breastfeeding. The obstetrician is advised to examine the breast at any time in the postpartum period if the woman presents with breast symptoms (III-B). 4. Physicians should be encouraged to use ultrasltrasonography, mammography, needle aspiration, or breast biopsies to assess suspicious breast masses in pregnancy and during lactation, in the same timely fashion as for non-pregnant or non-lactating women (II-2A). Interruption of lactation during investigation is not necessary, nor is it recommended unless nuclear studies are entertained (III-B). 5. Once breast cancer is diagnosed, a multidisciplinary approach should be taken. This includes the obstetrician, surgeons, medical and radiation oncologists, and breast cancer counsellors (II-2A). 6. In early pregnancy, the patient should be counselled regarding the effect of proposed therapy on the fetus and on overall maternal prognosis. Termination of pregnancy should be discussed, but the patient should be counselled that prognosis is not altered by termination of pregnancy. Women should be advised that premature menopause may result from breast cancer treatments, especially if chemotherapy is given to patients who are past the age of 30. (II-2C) 7. Up until now, modified radical mastectomy was the cornerstone of surgical treatment of breast cancer during pregnancy. Adjuvant chemotherapy should be entertained and, if required, administered without delay. The patient should be counselled regarding the effect of chemotherapy on the fetus and/or the future reproductive potential of the patient (II-2B). In the third trimester, the risks and benefits of early delivery versus continuation of pregnancy, and the effect of chemotherapy on the fetus, should be addressed (II-2B). Women undergoing chemotherapy or tamoxifen treatment should not breastfeed (III-B). 8. Women treated for breast cancer and who wish to become pregnant should be counselled that pregnancy is possible and does not seem to be associated with a worse prognosis for their breast cancer (II-3C). However, they should be made aware that the evidence to support such advice is relatively poor. 9. Since most breast cancer recurrences appear within two to three years after initial diagnosis, patients should be advised to postpone pregnancy for three years (III-C). If a patient has axillary node involvement, the recommendation to defer pregnancy should be extended to five years, but this recommendation is based on opinion only (III-C). Prior to attempting pregnancy, a breast cancer survivor should be referred for a full oncologic evaluation. 10. There is no evidence that breastfeeding increases the risk of breast cancer recurring or of a second breast cancer developing, nor that it carries any health risk to the child. Women previously treated for breast cancer, who do not show any evidence of residual tumour, should be encouraged to breastfeed their children (III-B). VALIDATION: Level of evidence, quality of research in the recruited publications, and ensuing recommendations were reviewed and discussed by members of the SOGC Breast Disease Committee as well as by a member of the Gynaecological Oncology Committee. External reviewers with expertise in the area were also solicited for comments and criticism.