The Parental Leave Paradox in Obstetrics and Gynecology.

Medical school, residency, and fellowship occur during peak reproductive years for most trainees. This poses certain challenges for medical trainees as they approach family-building decisions. While the demands of residency have been well-elucidated, attempts at mitigating these demands alongside parenthood have long been neglected across various specialties. These challenges are perhaps most pronounced in Obstetrics and Gynecology residency programs, which are made-up of an 85% female-identifying workforce and whose training focuses on prenatal and postpartum health. Recent literature suggests an improvement in attitudes and policies towards parental leave during medical graduate education, however, there remains a lack of uniformity across specialties and programs. Through a recently developed Parental Leave Task Force made up of Obstetrics and Gynecology Trainees, we sought to conduct a review of the literature examining parental leave policies and their implications across various specialties as a call for uniform parental leave policies for all residents.

Factors Associated With Fertility Preservation in a Pediatric, Adolescent and Young Adult Population.

OBJECTIVE: To determine the patient characteristics associated with pursuing fertility preservation (FP) before gonadotoxic therapy in a pediatric, adolescent and young adult patient population. METHODS: This is a retrospective cohort study of patient data at Cincinnati Children's Hospital Medical Center. Demographics, clinical diagnoses, and treatment characteristics were compared between participants that selected FP versus those that declined. Variables were analyzed separately for males and females by logistic regression. RESULTS: Patients with a hematologic cancer were less likely to be eligible for preservation: 53.9% of ineligible males, P <0.001, and 51.8% of ineligible females, P <0.0001. Among patients who were candidates for FP, those receiving high-risk therapy were more likely to elect for FP (65.3% males, P <0.0001, and 87.5% of females, P <0.0001). Pubertal males were more likely to undergo preservation than prepubertal males (70.5% vs. 29.5%, P <0.0001; however, this trend was not demonstrated among female patients. In both males and females, race, ethnicity, religion, primary language, and insurance status were not shown to be statistically significant factors in predicting utilization of FP. CONCLUSION: Risk of infertility, type of cancer, and developmental status influenced decisions on pursuing FP in pediatric, adolescent and young adult patients facing iatrogenic infertility.

Analysis of the Literature and Patient Counseling Considerations for Planned Oocyte Cryopreservation.

As oocyte cryopreservation use increases among reproductive-aged women, health care professionals are challenged with counseling patients on fertility-sparing technology based on limited high-quality research. Since the first successful slow freezing of mouse embryos in England in 1972, reproductive scientists have employed various protocols for successful cryopreservation and warming of gametes. From outdated slow-freeze technologies to improved vitrification methods, science has successfully shifted the pendulum from cryoinjury-related cell death to the preservation of cellular immortality. The clinical applications of oocyte cryopreservation first increased among oncofertility patients faced with limited fertility-sparing options. Breakthroughs in oncofertility opened a window of opportunity for the transgender community, which also led to an entirely new frontier-planned oocyte cryopreservation for potential future use. Reasons for cryopreservation are complex and often overlap. Socially, these can include not having a support person to share childcare responsibilities, prioritizing career goals and aspirations, and the financial constraints of the ever-rising cost of childrearing. Medically, reasons can include diseases, primary ovarian insufficiency, traumatic injury, planned female to male gender transition, and fertility loss that occurs with aging. Women are faced with many, if not all, of the above scenarios during their "ideal" reproductive window. These women are presenting to fertility centers in hopes of allowing for future reproductive freedom. Owing to media influence, women may be misled of the success potential of cryopreserved oocytes as a guarantee of future biological children. Here, we review current literature and propose guidelines for counseling patients on planned oocyte cryopreservation.

Interstitial Ectopic Pregnancy in a 34-Year-Old Woman After Removal of Essure Microinserts and Reversal of Hysteroscopic Sterilization.

BACKGROUND Interstitial ectopic pregnancy, a pregnancy occurring in the part of the fallopian tube that is within the body of the uterus, poses a significant risk to patients, with a mortality rate of up to 2.5%, which is 7 times higher than for tubal ectopic pregnancies. Hysteroscopic sterilization reversal carries a potential risk of interstitial ectopic pregnancy; therefore, it is important to counsel patients appropriate and review the alternative option for in vitro fertilization. In vitro fertilization has been shown to have a superior pregnancy and live birth rate in comparison to sterilization reversal. Women who have undergone sterilization via hysteroscopic placement of the Essure device may complete in vitro fertilization with sterilization devices left in situ without significantly reducing the pregnancy rate. CASE REPORT A 34-year-old woman, G6P3023, presented to the Emergency Department after incidental detection of left interstitial ectopic pregnancy measuring 9 weeks of gestation. She had previously undergone a right salpingectomy for ectopic pregnancy soon after reversal of Essure sterilization via bilateral tubouterine reimplantation; this is a procedure that is infrequently performed due to limited evidence to suggest that this is a safe and efficacious method to achieve future pregnancies. This patient underwent an uncomplicated left cornuostomy and salpingectomy, rendering the need for in vitro fertilization to conceive in the future. CONCLUSIONS Patients seeking fertility treatment after hysteroscopic sterilization should be counseled that tubouterine reimplantation poses significant morbidity risk based on the nature of the surgery. Instead, patients who have undergone hysteroscopic sterilization who desire future pregnancy should be advised that in vitro fertilization, with or without salpingectomy, may be a safer and more efficacious option to achieve live birth.

Young Adult Males' Perspectives of Male Hormonal Contraception.

OBJECTIVE: To evaluate the willingness of young adult males to use male hormonal contraception and to determine the most desirable formulation. METHODS: An institutional review board-approved survey measuring the willingness to use MHC was dispersed to two distinct populations: University of Cincinnati postgraduate programs and Cincinnati Health Department clinics. Questions on the survey allowed for the collection of demographic characteristics, as well as the preferred method of MHC, and concerns regarding potential adverse effects. This survey was directed at young adult males; therefore, only male participants who were 18 to 35 years old were included for analysis. Results were reported as frequencies in each group and χ2 analyses were performed to compare groups, with a P < 0.05 considered significant. RESULTS: Of 162 total survey participants, 45% would use MHC, whereas 30.9% were unsure and 23.5% would not use MHC. Overall, the University of Cincinnati survey population was more likely to be interested in using MHC than the Cincinnati Health Department population (P < 0.05). In both populations, most were interested in using the injectable form. Cited concerns deterring participants from using MHC were different between these two populations, with University of Cincinnati participants more frequently expressing concerns about possible failure of the contraceptive method, whereas Cincinnati Health Department participants had concerns about potential adverse effects (P < 0.001). CONCLUSIONS: There is significant interest among young adult males in using various forms of MHC, especially in injectable form. Differences in views of MHC were seen in two distinct male populations. Specifically, males who achieved a higher level of education, were employed, or in a relationship were found to more frequently be willing to use MHC. With further research and funding, MHC may serve as a significant way to decrease unintended pregnancies in the future.

Altered evolution: are reproductive endocrinology and infertility specialists ready for the genetically engineered future?

Science, propelled forward by noble aspirations and, at times, human hubris, has the capacity to affect lives and alter the world in unanticipated ways. Even seemingly minor discoveries have repeatedly proven to have far reaching implications that experts within their respective fields could not have predicted. Nuclear technology is both a source of energy and a potential means of annihilation. The internet has both seamlessly connected the world but has also opened society to the misuse and manipulation of information. Both exemplify how new technologies have the potential for positive and negative outcomes that often go beyond what was initially intended. This is not a fault of science and innovation but rather an inherent occupational hazard as new discoveries exist within a gray zone between ignorance and comprehension. These gaps in our knowledge can only be filled over time as our knowledge expands. Innovations that were once seen as fringe, over time, become mainstream and that which was once revolutionary becomes a part of everyday life. Occasionally, a scientific advancement comes along that challenges societal norms and causes us to question what is feasible, acceptable, and ethical. Nowhere in the twenty-first century has this been more evident than within the fields of genetics and genetic engineering. As we gain a deeper understanding of the source code of life, from individual base pairs to epigenetic influences, the implications of new discoveries will go far beyond curing genetic diseases, and the possibilities will be endless. Reproductive endocrinology and infertility (REI) specialists utilize many tools including expanded carrier screening, preimplantation genetic testing, and embryo selection and have become some of the experts at the forefront of the ongoing genetic revolution. Now more than ever, there is a need for REIs to be trained in the fundamentals of genetics, exposed to novel gene sequencing and editing techniques, and involved in the coming ethical discussions in order to be prepared for the genetically engineered future.

Lesbian Women Undergoing Assisted Reproduction: Diverse, But Not Different.

The use of assisted reproduction among women in relationships with other women has increased in the United States over the past decade as a result of increased legal access and social acceptance. Despite this shift, limited studies currently exist to guide optimal fertility care for this growing patient population of women seeking assisted reproduction. In this Commentary, assisted reproduction will be meant to include ovulation induction, intrauterine insemination (IUI), and in vitro fertilization (IVF). Conflicting studies suggest that self-identified lesbian women may demonstrate an increased prevalence of polycystic ovarian syndrome. Most available studies find that a woman's sexual orientation does not affect the outcome of fertility treatment. Self-identified lesbian women undergoing donor sperm IUI and IVF have similar pregnancy and live-birth rates as heterosexual women. Better evidence regarding patient demographics and comorbidities, underlying etiologies of subfertility, and assisted reproductive outcomes among women building families with other women is needed to optimize care.

Emergency department utilization of case-managed patients following benign gynecologic surgery.

BACKGROUND: Case management has been shown to reduce the amount of unnecessary emergency department visits among Medicaid or uninsured patients. This study aims to determine whether case management is associated with decreased unnecessary emergency department visits among benign gynecology surgical patients in the first 30 days following surgery. RESULTS: Out of 875 patients, there were a total of 58 return visits to the emergency department within 30 days and only 6 readmissions. Twenty-four emergency department visits occurred in the case-managed group, and thirty-eight emergency department visits occurred in the non-case-managed group. The two factors that were statistically significant for increase odds of return to the emergency department were the type of surgery (inpatient versus outpatient) and case management. The odds for returning to the emergency department for those not receiving case management was found to be 4.53 to that of the case-managed group when controlling for BMI, age, marital status, and type of surgery. CONCLUSION: In an effort to reduce healthcare costs, case management is a promising intervention to help postoperative patients manage their care while minimizing emergency department visits.

Inconsistent Mandated Access to Fertility Preservation: A Review of Relevant State Legislation.

With improvement in cancer therapies, there has been an increasing emphasis on survivorship, including options for fertility preservation. Fertility preservation is the process of either protecting or saving gametes or reproductive tissues for potential future procreation. Methods and outcomes of fertility preservation have similarly been rapidly advancing. Before initiation of gonadotoxic therapy, health care providers must consider future fertility of patients and provide options for fertility preservation. Nonetheless, the cost of fertility preservation can be prohibitory. Depending on a patient's state of residence, insurance may be mandated to cover, or offer to cover, the cost of fertility preservation. State legislation continues to change; however, legislation at the federal level has been proposed to make this coverage more cohesive. This commentary reviews current state legislation regarding mandates to cover the cost of fertility preservation for patients at risk for iatrogenic infertility and outlines the importance of developing federal legislation to improve patient access to care.

Persistent Abdominal Pain 2 Years After Cesarean Delivery.

A 29-year-old multiparous patient is referred for chronic lower abdominal pain radiating into her groin since undergoing cesarean delivery 2-years previously. Laboratory and radiographic evaluation results are negative. She asks you, "Please tell me, why am I having this pain?"