Pathology perspective on gynaecologic malignancy screening questions in electronic consultation.

INTRODUCTION: The electronic consultation service, eConsult, is an asynchronous web-based platform for provider-to-provider consultation with specialists. This study described the utilization of eConsult by primary care providers to obtain specialist opinion in gynaecologic malignancy screening, with a specific focus on pathology-related inquiries. METHODS: This is a cross-sectional retrospective review of eConsults submitted to obstetrics/gynaecology between September 2011 and December 2016. All questions pertaining to gynaecologic cancer screening and their pathologies were included. Each question was classified based on a pre-determined taxonomy. The mandatory primary care providers' exit surveys were analysed to determine eConsult's influence on patient care, primary care providers' referral patterns, primary care providers' satisfaction and educational value. RESULTS: In total, 1,357 electronic consultations were submitted to the obstetrics and gynaecology service during the study period, of which 329 met inclusion criteria. Indications for a screening test based on patient risk factors made up 36% of consults pertaining to gynaecologic malignancy screening and 17% were inquiries about test intervals based on previous results. Primary care providers pointed out gaps in current screening guidelines. In total, 38% of primary care providers reported the eConsult service helped avoid a specialist referral, whereas 47% of primary care providers received new or additional courses of action. Pathology report interpretation accounted for 5% of eConsults and 6% of primary care providers wished for clarification of incidental pathology findings. CONCLUSION: This study uncovered areas of uncertainty among primary care providers regarding gynaecologic cancer screening and gaps in current clinical guidelines. Furthermore, the role of pathology consultants in an eConsult platform is explored and may be extrapolated into practice.

Outcomes of an Overnight-Stay Unit for Urogynecologic Surgery: Feasibility and Risk Factors for Failure of Next-Day Discharge.

OBJECTIVE: To evaluate outcomes of patients undergoing urogynecologic procedures with postoperative care in an overnight-stay unit at a tertiary care center. METHODS: A retrospective cohort study of 1644 women admitted to an overnight-stay unit at a Canadian tertiary care center after urogynecologic surgery between 2014 and 2018 was completed. A multivariable logistic regression model was fit to identify risk factors for failed next-day discharge, defined as a delayed discharge of more than 24 hours, readmission within 30 days of surgery, or emergency room assessment within 7 days of surgery. RESULTS: One thousand five hundred seventy-eight patients (96%) were discharged within 24 hours of surgery. Mean patient age was 53.7 ± 15.1 years, with 21.2% 70 years or older. Surgical approaches included laparotomies (8.9%), major vaginal surgery (70.9%), and open retropubic procedures (2.1%). Hysterectomies were performed in 1120 patients (68.1%). One hundred one patients (6.1%) were assessed in the emergency department within 7 days of surgery, and 57 (3.5%) were readmitted to hospital within 30 days of their procedure. Multivariable regression identified the following as risk factors for failed next-day discharge: pulmonary disease (odds ratio [OR], 3.26; 95% confidence interval [CI], 1.32-8.06; P = 0.010), longer operating time (OR, 1.40; 95% CI, 1.10-1.79; P = 0.006, per 60 minutes), and intraoperative hemorrhagic complications (OR, 22.64; 95% CI, 5.83-88.00, P < 0.001). CONCLUSIONS: Admission to an overnight-stay unit with next-day discharge is feasible for most patients undergoing urogynecologic surgery. Factors associated with requiring a longer hospital stay, presentation to an emergency department, or readmission to hospital within 7 days include pulmonary disease, longer operating times, and intraoperative hemorrhagic complications.

Occult Vaginal Evisceration: A Case Report.

BACKGROUND: Vaginal evisceration is a rare gynaecologic emergency that necessitates surgical intervention. It may manifest with obvious vaginal rupture, or it may be occult, specifically in patients with chronic pelvic organ prolapse. CASE: A 66-year-old woman with a history of bowel cancer and irradiation presented with occult vaginal evisceration. This was discovered during a routine follow-up appointment. It was repaired in two layers with xenograft derived from porcine intestinal mucosa (Surgisis, Cook Medical, Bloomington, IN) interposition and a concomitant colpocleisis. Long-term complications of the procedure included recurrent prolapse, but her vaginal vault evisceration did not recur. CONCLUSION: In patients with chronic pelvic organ prolapse, especially in those with additional risk factors for poor tissue strength, the possibility of vaginal vault evisceration or dehiscence should be considered. These patients would benefit from close follow-up.

Patient-targeted websites on overactive bladder: What are our patients reading?

AIMS: Patients often turn to the Internet for information on medical conditions. We sought to evaluate the quality and readability of highly visible websites on overactive bladder (OAB). METHODS: A survey of 42 consecutive patients attending outpatient urogynecology clinics was performed to identify the most commonly used Internet search engines and search terms for information on OAB. The three most commonly used search engines (Google, Bing, and Yahoo!) were then queried using the three most commonly used search terms. The first 20 relevant websites from each search were reviewed. After excluding duplicates, 35 websites were analyzed. Website quality of information on OAB was evaluated using the DISCERN score, JAMA benchmark criteria, and Health on the Net code (HONcode) accreditation status. Readability was assessed using the Simplified Measure of Gobbledygook (SMOG) and Dale-Chall indices. RESULTS: Websites were classified as advertisement/commercial (31%), health portal (29%), professional (26%), patient group (6%), and other (9%). The overall mean DISCERN score was 44 ± 18 (maximum possible score of 80). Three websites (9%) met all four JAMA benchmark criteria. Seventeen percent of websites provided adequate information on content authorship and contributions. Median SMOG and Dale-Chall indices were 9.9 (IQR 9.3-11.2) and 9.0 (IQR 8.1-9.4), respectively. Nine websites (26%) were HONcode certified. CONCLUSIONS: Popular websites on OAB are of low quality, written for a high school to college-level readership, and often lack adequate information to assess the potential for commercial bias. Patients should be cautioned that incomplete and potentially biased information on OAB is prevalent online.

Evaluation of an Electronic Consultation Service in Obstetrics and Gynecology in Ontario.

OBJECTIVE: To describe the effectiveness of an electronic consultation (eConsult) service by examining the number of traditional referrals that were avoided as a result of the service, to characterize the type and content of the clinical questions being asked, and to describe the time required for the specialist to complete each eConsult. METHODS: This is a retrospective electronic chart review study. All eConsults directed to obstetrics and gynecology from July 2011 to January 2015 were reviewed. Each eConsult was categorized by clinical topic and question type in predetermined categories. Mandatory post-eConsult surveys for primary care providers were analyzed to determine the number of traditional consults avoided and to gain insight into the perceived value of eConsults. The amount of time reported by the specialist to answer each eConsult was analyzed. RESULTS: A total of 394 of 5,597 eConsults were directed to obstetrics and gynecology (7.0%). In 34.3% of eConsults, primary care providers indicated that a traditional consult was avoided. Pregnancy issues and gynecologic cancer screening issues were the most common queries. Primary care providers highly valued the eConsult and the majority of eConsults were completed within 15 minutes (98.8%). CONCLUSION: Electronic consultations were effective at reducing the number of traditional consults requested over 3.5 years. This initiative has potential to reduce current wait times for traditional consultation in Canada and to make the consultation process more effective. The service was feasible and well-received by primary care providers.

A comparison of outcomes from in vitro fertilization cycles stimulated with either recombinant luteinizing hormone (LH) or human chorionic gonadotropin acting as an LH analogue delivered as human menopausal gonadotropins, in subjects with good or poor ovarian reserve: a retrospective analysis.

OBJECTIVES: To compare rates of pregnancy and IVF parameters in subjects who were stimulated with FSH plus recombinant human luteinizing hormone or menopausal gonadotropins. To determine whether responses to type of LH differ in poor or good responders. STUDY DESIGN: Retrospective analysis at a university-based fertility center. Subjects were women with good and poor ovarian reserve, who underwent in vitro fertilization during a 2 year period, as part of a long agonist (N=122), or microdose flair (N=79) protocol. Measurements included FSH and LH dose, number of oocytes collected, number of embryos obtained, and pregnancy and clinical pregnancy rates. RESULTS: Patients treated with r-hLH (n=105) had higher numbers of eggs retrieved and of embryos while using less FSH than their hMG-treated (n=96) counterparts. Pregnancy and clinical pregnancy rates were significantly higher with r-hLH than with hMG protocols (p=0.008 and 0.009, respectively). If patients had a baseline serum FSH level ≥10IU/L, clinical pregnancy rates were higher when r-hLH was used. When the antral follicle count was below 6 no significant differences in stimulation parameters or outcomes were detected between the groups. CONCLUSION: r-hLH may be beneficial when compared to hMG and used for in-vitro fertilization, except in subjects with baseline follicle counts less than 6. Further data should be obtained.

Effect of high LH/FSH ratio on women with polycystic ovary syndrome undergoing in vitro maturation treatment.

OBJECTIVE: To determine whether high luteinizing hormone/follicle-stimulating hormone (LH/FSH) ratios have a clinical impact on women with polycystic ovary syndrome (PCOS) undergoing in vitro maturation (IVM) treatment. STUDY DESIGN: Women with PCOS who underwent IVM treatment were divided into those with LH/FSH ratio > 1.5 and LH/FSH 0.5-1.5. We analyzed baseline characteristics of the patients, number of oocytes retrieved, number of mature oocytes, and pregnancy rates. RESULTS: Women with LH/FSH ratio of > 1.5 had higher basal serum testosterone (2.2 vs. 1.4, p < 0.005, CI 0.1-1.0) and estradiol (188.7 +/- 16.2 vs. 143.7 +/- 6.9, p < 0.01, CI 23-96). The antral follicle count (AFC) was also higher in the patients with high LH/FSH (46.2 +/- 3.5 vs. 32.9 +/- 1.3, p < 0.001, CI 7-21). The total number of retrieved oocytes and number of mature oocytes was also significantly higher in women with LH/FSH ratio of > 1.5 than in those with a lower ratio. However, the pregnancy rate in women with LH/FSH ratio of > 1.5 (16.7%) was significantly lower than in those with a ratio of 0.5-1.5 (40.4%), p < 0.05, odds ratio 0.32. CONCLUSION: PCOS patients with LH/FSH ratio of > 1.5 had higher basal testosterone, E2, and AFC but decreased pregnancy rate. This could be due to the deleterious effect of LH on folliculogenesis and endometrial receptivity.

Ovarian reserve and response to IVF and in vitro maturation treatment following chemotherapy.

BACKGROUND: Chemotherapy and radiotherapy can result in ovarian failure and premature menopause. However, there is still a paucity of information on the ovarian reserve and efficacy of assisted reproduction treatment (ART) procedures in patients with cancer previously exposed to chemotherapy or radiotherapy. The aim of our study was to evaluate the ovarian reserve and ovarian response to IVF or in vitro maturation (IVM) treatment in women who had previously been treated with chemotherapy. METHODS: In this retrospective cohort study, we compared 23 women with cancer who had undergone chemotherapy and subsequently underwent fertility treatment with IVF (n=14) or IVM (n=9). In the IVF group, patients mostly had hematologic, gynecologic, gastro-intestinal, bone and soft tissue cancers, whereas in the IVM group patients had estrogen-receptor positive breast cancer, hematologic and brain cancers. The control (unexposed) group consisted of 70 age-matched women with male factor infertility undergoing the same treatment protocol (IVF n=42 and IVM n=28). All women were aged<42 years and undergoing their first cycle of ART. RESULTS: There were no differences in age and FSH levels between the cancer and the control groups. However, the antral follicle count (AFC) was lower in the cancer-IVF group (median: 5, range: 3-12) than in the control group (median: 15, range: 12-18; P=0.0009). Women with cancer treated with IVF had lower peak estradiol levels on the day of hCG administration than controls (P=0.006) and lower number of oocytes retrieved [median: 4.5, range: 2-7; versus 12 (8-16) in controls; P<0.0001]. In patients with cancer treated with IVM, the AFC was lower than in the control group (median: 14, range: 9.5-17; versus median: 20.5 range: 16-23, respectively; P=0.0007). Likewise, the number of oocytes retrieved was lower in the cancer-IVM group (median: 6, range: 4-10) than that in the control group (median 10.5, range: 7.5-17; P=0.01). The percentage of mature metaphase II oocytes was comparable in the cancer and control groups. CONCLUSIONS: The ovarian reserve, response to gonadotrophins and number of oocytes retrieved are adversely affected by previous chemotherapy. This study reports the first series of IVM outcomes in cancer patients with a prior history of chemotherapy. In women with estrogen-receptor positive breast cancer, IVM of oocytes with cryopreservation of oocytes or embryos is a viable option. Since the efficacy of ART is significantly reduced after chemotherapy, early referral for fertility preservation before gonadotoxic treatment will give these young women the best chance to conceive.

Clinical and economic analysis of rescue intracytoplasmic sperm injection cycles.

OBJECTIVE: To identify clinical and embryological factors that may predict success in rescue intracytoplasmic sperm injection (ICSI) cycles (after total fertilization failure has occurred) and to evaluate the cost effectiveness of rescue ICSI strategy. Additionally, follow-up of 20 rescue ICSI pregnancies is reported. DESIGN: Retrospective analysis of total fertilization failure cycles. SETTING: University-based tertiary medical center. MATERIAL AND METHODS: In total, 92 patients who had undergone conventional in-vitro fertilization (IVF) cycles with total fertilization failure were included. The patients were divided into two subgroups: those who conceived through rescue ICSI and those who did not. RESULTS: The pregnant members of the rescue ICSI subgroup were found to be significantly younger (32.9 ± 4.2 vs. 36.3 ± 4.5, respectively, p = 0.0035,) and to have better-quality embryos than those who did not conceive (cumulative embryo score: 38.3 ± 20.4 vs. 29.3 ± 14.7, p = 0.025). Cost effectiveness analysis showed 25% reduction in the cost per live birth when rescue ICSI is compared to cycle cancellation approach. The pregnancies follow-up did not show adverse perinatal outcome. CONCLUSIONS: Rescue ICSI is an option for salvaging IVF cycles complicated by total fertilization failure. Success in rescue ICSI was found to be associated with younger age and higher quality of embryos. Furthermore, the cost effectiveness of rescue ICSI in terms of total fertilization failure was found to be worthwhile.

Is young maternal age really a risk factor for adverse pregnancy outcome in a canadian tertiary referral hospital?

OBJECTIVE: To assess the risk of adverse pregnancy outcome among teenage mothers within a large tertiary referral center in Canada. METHODS: All nulliparous singleton births in the McGill University Health Centre during 2001-2007 were retrieved using the "MOND" database. Patients were divided according to maternal age: <20 years (teenage), and between 20 and 39 years. Obstetric and neonatal complications were compared. RESULTS: 9744 nulliparous women were included; 250 (2.6%) were teenage and 9494 (97.4%) were 20-39 years old. Teenage mothers tended to deliver earlier (38.0 vs 39.2 weeks gestation, P < 0.001) and had higher rates of extreme prematurity (OR 4.5, 95% CI 2.5-8.1). Babies of teenage mothers had lower birth weights (3014 g vs 3326 g, P < 0.001), higher rates of NICU admission (OR 2.1, 95% CI 1.5-3.0), congenital anomalies (OR 1.8, 95% CI 1.2-2.6) and combined perinatal and neonatal mortality (OR 3.8, 95% CI 1.9-7.5). Logistic regression analysis showed an association between young maternal age and the risk to have at least one adverse outcome (P < 0.001). CONCLUSIONS: Even within a large tertiary referral hospital, teenage mothers carry a greater risk of adverse pregnancy outcome, mainly due to preterm births.

Ovarian reserve, response to gonadotropins, and oocyte maturity in women with malignancy.

OBJECTIVE: To study the ovarian reserve, ovarian response to gonadotropins, and oocyte maturity in women with cancer undergoing in vitro fertilization (IVF) before chemotherapy or radiotherapy. DESIGN: Case-control study. SETTING: University teaching hospital. PATIENT(S): We evaluated all women with malignancy who underwent fertility preservation from the year 2003 to 2010. We compared 41 women with cancer undergoing IVF treatment with a control group of 48 age-matched women undergoing IVF for male factor infertility with the same protocol. INTERVENTION(S): In vitro fertilization. MAIN OUTCOME MEASURES(S): Ovarian reserve, ovarian response to gonadotropins, number of oocytes retrieved, and oocyte maturity. RESULT(S): There were no significant differences in age, antral follicle count, serum FSH, total dose of gonadotropins required for stimulation, duration of stimulation, or peak E(2) levels on the day of hCG administration between women with cancer and the control group. No significant differences were observed in the number of retrieved oocytes between the malignancy and control groups. The percentages of mature oocytes in patients with hematologic malignancy (83.3%), gynecologic and intestinal malignancy (94%), and brain cancer (86%) and in the control group (82.1%) were similar, as were the fertilization rates. CONCLUSION(S): In young women with malignancy, ovarian reserve, response to gonadotropins, oocytes retrieved, and oocyte maturity remain unaltered by the neoplastic process. This is in contrast to the impairment of spermatogenesis before therapy in men with cancer.

Age-related normograms of serum antimüllerian hormone levels in a population of infertile women: a multicenter study.

OBJECTIVE: To produce age-related normograms for serum antimüllerian hormone (AMH) level in infertile women without polycystic ovaries (non-PCO). DESIGN: Retrospective cohort analysis. SETTING: Fifteen academic reproductive centers. PATIENT(S): A total of 3,871 infertile women. INTERVENTION(S): Blood sampling for AMH level. MAIN OUTCOME MEASURE(S): Serum AMH levels and correlation between age and different percentiles of AMH. RESULT(S): Age-related normograms for the 3rd, 10th, 25th, 50th, 75th, 90th, and 97th percentiles of AMH were produced. We found that the curves of AMH by age for the 3rd to 50th percentiles fit the model and appearance of linear relation, whereas the curves of >75th percentiles fit cubic relation. There were significant differences in AMH and FSH levels and in antral follicle count (AFC) among women aged 24-33 years, 34-38 years, and ≥39 years. Multivariate stepwise linear regression analysis of FSH, age, AFC, and the type of AMH kit as predictors of AMH level shows that all variables are independently associated with AMH level, in the following order: AFC, FSH, type of AMH kit, and age. CONCLUSION(S): Age-related normograms in non-PCO infertile women for the 3rd to 97th percentiles were produced. These normograms could provide a reference guide for the clinician to consult women with infertility. However, future validation with longitudinal data is still needed.

Effects of ovarian endometrioma on embryo quality.

The proportions of good, fair, and poor embryos in 13 women with bilateral endometriomas were compared with those of 39 women without endometriomas and were found to be similar (47.2% vs. 41.1%, 28.3% vs. 32.8%, and 24.3% vs. 26.0%, respectively). Therefore, it appears that the presence of bilateral endometriomas during IVF treatment is not associated with reduced embryo quality.

Ovarian reserve and oocyte maturity in women with malignancy undergoing in vitro maturation treatment.

OBJECTIVE: To evaluate ovarian reserve and oocyte maturity in women with malignancy. DESIGN: A case-control study. SETTING: University teaching hospital. PATIENT(S): We evaluated all women with malignancy who underwent in vitro maturation treatment for fertility preservation from the year 2003 to 2009. The results were compared with those of an age-matched infertile control group. INTERVENTION(S): In vitro maturation treatment. MAIN OUTCOME MEASURE(S): Ovarian reserve and oocyte maturity. RESULT(S): Women with malignancy of the breast (n = 87), hematologic malignancy (n = 16), gynecologic or abdominal malignancy (n = 9), and other malignancies (n = 16) were compared with infertile control women (n = 79). The age was similar in all groups except in women with hematologic malignancy where they were younger than the control group (24.9 ± 1.1 years vs. 30.8 ± 0.4 years, confidence interval 4.0-9.5). Baseline FSH in this group was also lower than in the control group. Women with breast cancer had a lower number of retrieved oocytes than the control group (95% confidence interval 0-5). There were no significant differences in antral follicle count, percentage of mature oocytes on collection day, and percentage of metaphase II oocytes matured in vitro among all groups of women. CONCLUSION(S): Women with breast cancer have fewer numbers of retrieved oocytes than infertile controls. Ovarian reserve and oocyte maturity in other types of malignancy are similar to those in the control group.

A systematic review of intravenous immunoglobulin for treatment of unexplained recurrent miscarriage.

OBJECTIVE: To estimate whether intravenous immunoglobulin (IVIG) improves the probability of a live birth in women with unexplained recurrent miscarriage (RM). DESIGN: A computerized search in Medline, Embase, Central, Ovid Medline In-Process, and Other Non-Indexed Citations Databases and randomized controlled trial (RCT) registries was performed. Abstracts of the American Society of Reproductive Medicine and European Society of Human Reproduction and Embryology annual meetings and reference lists of identified reports were searched. SETTING: None. PATIENT(S): Women with unexplained primary (without a prior live birth) or secondary (subsequent to a live birth) RM. INTERVENTION(S): IVIG or placebo control intervention. MAIN OUTCOME MEASURE(S): Live birth rate per randomized woman. RESULT(S): Six relevant RCTs were identified including 272 women with unexplained RM. The overall odds ratio for live birth is 0.92, with a 95% confidence interval of 0.55-1.54, indicating a lack of a treatment effect with IVIG. Similarly, IVIG was not found to be beneficial when women with primary and secondary RM were analyzed separately. CONCLUSION(S): A beneficial effect of IVIG in treatment of RM was not observed. Given the absence of a proven mechanism of action, and the lack of a diagnostic algorithm to identify patients who are likely to benefit from such treatment, IVIG administration for treatment of recurrent miscarriage is not justified outside the context of properly designed RCTs.

Age-related normogram for antral follicle count: McGill reference guide.

OBJECTIVE: To produce age-related normograms for antral follicle count in an infertile population without polycystic ovaries. DESIGN: Retrospective cohort analysis. SETTING: University teaching center. PATIENT(S): Eighteen hundred sixty-six infertile patients. INTERVENTION(S): Baseline transvaginal ultrasound examination between days 2 and 4 of the menstrual cycle. MAIN OUTCOME MEASURE(S): Correlation between age and different percentiles of antral follicle count. RESULT(S): The age-related normogram for the 3rd, 10th, 25th, 50th, 75th, 90th, and 97th percentile of antral follicle count showed a biphasic mode of antral follicle count decline with two different rates of antral follicle count loss: a steep-slope phase (high rate of antral follicle count loss) and a moderate-slope phase (restrained rate of antral follicle count losses). In the low antral follicle count percentiles (3rd, 10th, 25th), the phase of high loss rate of follicles preceded the phase of slow loss rate, whereas in the high antral follicle count percentiles (75th, 90th, 97th) the opposite was found. CONCLUSION(S): Age-related normograms in infertile women without polycystic ovaries demonstrate a biphasic pattern of decreased antral follicles. These normograms could provide a reference guide for the clinician in consulting with women with infertility. However, future validation with longitudinal data is still needed.

Difference between serum beta-human chorionic gonadotropin levels in pregnancies after in vitro maturation and in vitro fertilization treatments.

OBJECTIVE: To compare ß-hCG levels measured as the first pregnancy test in women who conceived after in vitro maturation (IVM) or IVF. DESIGN: Retrospective matched cohort analysis. SETTING: University-based medical center. PATIENT(S): Women treated with IVM or IVF. INTERVENTION(S): We studied the first serum ß-hCG levels in 104 pregnant women who were successfully treated with IVM and in another 104 women with IVF treatment. Blood samplings for ß-hCG were drawn on day 12-15 after ET. The two groups were matched by age, order of pregnancy, and day of blood sampling. MAIN OUTCOME MEASURE(S): First ß-hCG levels. RESULT(S): Serum ß-hCG levels on days 12 to 13 after ET of IVM viable singleton pregnancies were significantly higher than those of IVF pregnancies (343.2±48.4 vs. 264.0±29.2 IU/L, 95% confidence interval [CI] 22-229). Similarly, ß-hCG levels on days 14 to 15 after ET of IVM viable singleton pregnancies were higher than those of IVF pregnancies (350.1±126.4 vs. 284.4±30.2 IU/L). Similar trends were found in ß-hCG levels on days 12 to 13 after ET of twin viable pregnancies (IVM, 682.1±97.7 vs. IVF, 434.5±41.8 IU/L; 95% CI 44-662). Grouped linear regression with covariance analysis showed a significant difference between IVM and IVF regression lines. CONCLUSION(S): The first serum ß-hCG levels in pregnancies after IVM are consistently higher than those after IVF treatment. More studies are needed to elucidate these findings.