European Society for Gynaecological Endoscopy (ESGE) Good Practice Recommendations on surgical techniques for removal of fibroids: part 1 abdominal (laparoscopic and open) myomectomy.

Uterine fibroids are the most common benign tumours of the female reproductive tract and can cause a range of symptoms including abnormal uterine bleeding, pain, pressure symptoms and subfertility. Surgery may be required for some symptomatic fibroids via abdominal or transvaginal routes. The European Society for Gynaecological Endoscopy Uterine Fibroids Working Group developed recommendations based on the best available evidence and expert opinion for the surgical treatment of uterine fibroids. In this first part of the recommendations, abdominal approaches to surgical treatment of fibroids including laparoscopic, robot- assisted and open myomectomy are described.

Structured hysteroscopic examination of uterine niches: a modified Delphi procedure.

Background: Uterine niches in the Caesarean section scar are seen in approximately half of women with a history of caesarean delivery. Whilst a structured ultrasound assessment of caesarean defects has been described, there is no consensus on a structured hysteroscopic evaluation. Objectives: To propose a methodology for a structured hysteroscopic evaluation of uterine niches. Materials and Methods: We conducted a modified Delphi procedure, including two online rounds and two face-to-face meetings of the members of the ESGE Uterine Niches Working Group. The taskforce members have extensive experience in hysteroscopic niche evaluation. The consensus was predefined as a Rate of Agreement of at least 75%. Results: Thirteen experts participated in this modified Delphi procedure. There was consensus on the need for a standardised methodology and the hysteroscopic definition of a niche as any indentation in the myometrium at the site of a previous CS. There was consensus that a hysteroscopic evaluation of a niche must be combined with ultrasound to measure the residual myometrial thickness. In addition, it was agreed that niches should be subclassified as 'simple', 'simple with one branch', or 'complex'. There was consensus that the following items should be described during a hysteroscopic niche evaluation: the number of niches, the size in relation to the size of cervical canal, the presence of polyps, crypts, cysts, fibrotic tissue, blood, mucus, placental remnants, a dynamic valve, the appearance of the endometrium, the number of blood vessels and bleeding from blood vessels within the defect. Conclusion: Using a modified Delphi procedure with international experts, consensus was achieved on the hysteroscopic evaluation and classification of niches in the uterine caesarean section scar. What is new?: A structured registration form was developed to aid consistency in hysteroscopic niche reporting.

The experience of transfeminine adolescents and their parents regarding fertility preservation via testicular sperm extraction (TESE): a qualitative study.

STUDY QUESTION: How do transfeminine adolescents and their parents experience fertility preservation via testicular sperm extraction (TESE)? SUMMARY ANSWER: Participants experienced the TESE process positively when provided with appropriate guidance to navigate the decisional dilemma between preserving future biological parenthood and the pressure to start puberty suppression early. WHAT IS KNOWN ALREADY: Sperm banking through ejaculation is not feasible for all transfeminine adolescents due to genital dysphoria and early puberty; for this group, TESE is the only alternative. However, during early puberty, they must postpone or pause puberty suppression until spermatogenesis is fully developed. STUDY DESIGN, SIZE, DURATION: All consecutive TESE patients in our centre and their parents were invited to participate. Between December 2022 and May 2023, we included 6 adolescents and 10 parents. We used a qualitative approach based on semi-structured interviews to study the experience of the transfeminine adolescents and their parents. PARTICIPANTS/MATERIALS, SETTING, METHODS: Transfeminine adolescents diagnosed with gender dysphoria in early puberty (Tanner stage ≥2) who underwent TESE before the start of puberty suppression or gender-affirming hormones participated in this study. The interviews were recorded, manually transcribed and analysed using reflective thematic analysis focusing on understanding the participants' experiences of puberty and fertility preservation and the various factors and social processes influencing their decision to undergo TESE. MAIN RESULTS AND THE ROLE OF CHANCE: Transfeminine adolescents decide to undergo invasive fertility preservation because of a possible, future desire for parenthood. Parents stressed the importance of preventing future decisional regret. They both saw masturbation to obtain a semen sample as unreachable. Even though TESE is a surgical procedure with possible complications and pain afterwards, this alternative seemed less dysphoric to them.Adolescents had to postpone the start of puberty suppression, waiting for spermatogenesis to complete. Given the unpredictable development of puberty, they felt a lot of stress and anxiety during this period and were primarily concerned about the lowering of their voice. Because of this puberty-related stress, they were constantly balancing their motivations for fertility preservation against the early start of puberty suppression to prevent unwanted irreversible pubertal body changes. To support this decisional dilemma, adolescents and their parents need adequate communication with each other and their healthcare providers to reflect on their stress for pubertal change. Furthermore, close, continuous surveillance of their current mental state by their parents, together with their psychologist and pubertal development by their physicians, is needed. Despite the challenging decision and postponement of puberty suppression, they retrospectively experienced it positively without any regret. LIMITATIONS, REASONS FOR CAUTION: All adolescents successfully underwent TESE, with viable spermatozoa obtained and without complications. This may result in a more positive reflective experience regarding fertility preservation. Furthermore, the perspectives of adolescents with the intention of TESE but who already started with puberty suppression before the preservation were not included. WIDER IMPLICATIONS OF THE FINDINGS: This study helps healthcare providers improve their counselling and guidance of transfeminine adolescents who consider postponing puberty suppression for fertility preservation via TESE. The adolescents and their parents know more clearly what to expect during fertility preservation. Specific peer-support programs may facilitate the decision process for upcoming adolescents. STUDY FUNDING/COMPETING INTEREST(S): No external funding was used for this study. None of the authors have any conflicts of interest. TRIAL REGISTRATION NUMBER: Not applicable.

Transgender persons' view on previous fertility decision-making and current infertility: a qualitative study.

STUDY QUESTION: How do adult transgender and gender diverse (TGD) people, who are infertile due to prior gender-affirming treatment, view their current infertility and their reproductive decisions made in the past? SUMMARY ANSWER: In a time where sterilization was mandatory, transgender adolescents prioritized gender-affirming treatment over their future fertility and would make the same choice today despite emotional challenges related to infertility experienced by some. WHAT IS KNOWN ALREADY: Under transgender law in the Netherlands, sterilization was required for legal gender recognition until 2014, resulting in permanent infertility. The long-term consequences of this iatrogenic infertility in transgender adolescents who have now reached adulthood remain underexplored. STUDY DESIGN, SIZE, DURATION: Qualitative study design based on 21 in-depth one-on-one semi-structured interviews. PARTICIPANTS/MATERIALS, SETTING, METHODS: TGD people in a stage of life where family planning may be a current topic were eligible for participation. They all received gender-affirming treatment in adolescence prior to the legislation change in 2014. A purposeful sampling technique was used from participants of another ongoing study. Eleven people assigned female at birth and ten people assigned male at birth were included. Interview transcripts were thematically analysed using a modified version of Braun and Clarke's six steps theory. MAIN RESULTS AND THE ROLE OF CHANCE: Six main themes were generated: (i) personal considerations regarding fertility and fertility preservation in the past; (ii) external considerations regarding fertility and fertility preservation in the past; (iii) current vision on past considerations and decisions; (iv) Current experiences and coping with infertility; (v) future family building; (vi) advice regarding fertility and fertility preservation decision-making. LIMITATIONS, REASONS FOR CAUTION: Selection, recall, and choice supportive bias may play a role in interpreting our results. WIDER IMPLICATIONS OF THE FINDINGS: This study highlights the importance of tailored counselling and comprehensive information on fertility preservation for transgender individuals, especially adolescents, undergoing gender-affirming treatment. STUDY FUNDING/COMPETING INTEREST(S): N/A. TRIAL REGISTRATION NUMBER: N/A.

How to perform standardized sonographic examination of Cesarean scar pregnancy in the first trimester.

Early diagnosis and appropriate management of Cesarean scar pregnancy (CSP) are crucial to prevent severe complications, such as uterine rupture, severe hemorrhage and placenta accreta spectrum disorders. In this article, we provide a step-by-step tutorial for the standardized sonographic evaluation of CSP in the first trimester. Practical steps for performing a standardized transvaginal ultrasound examination to diagnose CSP are outlined, focusing on criteria and techniques essential for accurate identification and classification. Key sonographic markers, including gestational sac location, cardiac activity, placental implantation and myometrial thickness, are detailed. The evaluation process is presented according to assessment of the uterine scar, differential diagnosis, detailed CSP evaluation and CSP classification. This step-by-step tutorial emphasizes the importance of scanning in two planes (sagittal and transverse), utilizing color or power Doppler and differentiating CSP from other low-lying pregnancies. The CSP classification is described in detail and is based on the location of the largest part of the gestational sac relative to the uterine cavity and serosal lines. This descriptive classification is recommended for clinical use to stimulate uniform description and evaluation. Such a standardized sonographic evaluation of CSP in the first trimester is essential for early diagnosis and management, helping to prevent life-threatening complications and to preserve fertility. Training sonographers in detailed evaluation techniques and promoting awareness of CSP are critical. The structured approach to CSP diagnosis presented herein is supported by a free e-learning course available online. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Visualisation of microvascular flow in benign uterine disorders: a pilot study of a new diagnostic technique.

Background: Uterine disorders have clear overlapping symptoms and ultrasound discrimination is not always easy. Accurately measuring vascularity is of diagnostic and prognostic value. Power Doppler is limited to imaging only the larger vessels. Assessment of the microvasculature requires advanced machine settings. Objectives: In this pilot study, we aimed to test the feasibility of microvascular flow imaging of benign uterine disorders. Material and Methods: Two experienced gynaecologists (JH, RL) randomly applied power Doppler and MV-flowTM mode during a single day, in ten patients each visiting the outpatient clinic. Images of eight patients were labelled with a diagnosis by the attending physicians and collected as coded data. Main outcome measures: Microvascular flow images of normal uterine architecture including the fallopian tube, and of benign disorders such as fibroids, adenomyosis, endometriosis and uterine niches were collected. For both Doppler techniques, qualitative descriptive evaluation of the vascular architecture and a quantitative vascular index of fibroids were provided. Finally, we evaluated the effect of the cardiac cycle. Results: All microvascular flow images showed more distinctive vascular structures than visible on power Doppler. Calculating a vascular index for fibroids on 2D MV-flowTM images was easily performed on-site. During the cardiac cycle a higher vascular index (VI 75.2) is obtained in systole as compared with diastole (VI 44.0). Conclusion: Microvascular flow imaging allowed detailed visualisation of the uterine vascular architecture and is easy to use. What is new?: Microvascular flow imaging may be of added value for diagnosing uterine disorders, as well as for pre- and post-operative assessment of suited surgical techniques. Yet, validation with histology and clinical outcomes is required.

The definition, diagnosis, and symptoms of the uterine niche - A systematic review.

Of all neonates, 21% are delivered by cesarean section (CS). A long-term maternal complication of an SC is a uterine niche. The aim of this review is to provide an overview of the current literature on imaging techniques and niche-related symptomatology. We performed systematic searches on imaging and niche symptoms. For both searches, 87 new studies were included. Niche evaluation by transvaginal sonography (TVS) or contrast sonohysterography (SHG) proved superior over hysteroscopy or magnetic resonance imaging. Studies that used SHG in a random population identified a niche prevalence of 42%-84%. Niche prevalence differed based on niche definition, symptomatology, and imaging technique. Most studies reported an association with gynecological symptoms, poor reproductive outcomes, obstetrical complications, and reduced quality of life. In conclusion, non-invasive TVS and SHG are the superior imaging modalities to diagnose a niche. Niches are prevalent and strongly associated with gynecological symptoms and poor reproductive outcomes.

Aetiology, risk factors and preventive strategies for niche development: A review.

The increase in caesarean sections (CS) has resulted in an increase in women with a uterine niche. The exact aetiology of niche development has yet to be elucidated but is likely multifactorial. This study aimed to give a systematic overview of the available literature on histopathological features, risk factors and results of preventive strategies on niche development to gain more insight into the underlying mechanisms. Based on current published data histopathological findings associated with niche development were necrosis, fibrosis, inflammation, adenomyosis and insufficient approximation. Patient-related risk factors included multiple CS, BMI and smoking. Labour-related factors were CS before onset of labour, extended cervical dilatation, premature rupture of membranes and presenting part of the fetus at CS below the pelvic inlet. Preventive strategies should focus on the optimal level of incision, training of surgeons and full-thickness closure of the myometrium (single or double-layer) using non-locking sutures. Conflicting data exist concerning the effect of endometrial inclusion. Future studies without heterogeneity in population, using standardized performance of the CS after proper training and using standardized niche evaluation with a relevant core outcome set are required to allow meta-analyses and to develop evidence-based preventive strategies. These studies are needed to reduce the prevalence of niches and prevent complications in subsequent pregnancies such as caesarean scar pregnancies.

The barriers and needs of transgender men in pregnancy and childbirth: A qualitative interview study.

OBJECTIVE: Transgender and gender diverse individuals are individuals whose gender identity differs from their sex assigned at birth. The discordance between gender identity and sex assignment may cause significant psychological distress: gender dysphoria. Transgender individuals may choose to undergo gender-affirming hormone treatment or surgery, but some decide to (temporarily) refrain from surgery and gender affirming hormone treatment and hence retain the possibility to become pregnant. Pregnancy may enhance feelings of gender dysphoria and isolation. To improve perinatal care for transgender individuals and their health care providers, we conducted interviews to explore the needs and barriers of transgender men in family planning, pregnancy, childbirth, puerperium and perinatal care. DESIGN: In this qualitative study five in-depth semi-structured interviews were conducted with Dutch transgender men who had given birth while identifying on the transmasculine spectrum. The interviews were conducted online through a video remote-conferencing software program (n=4) or live (n=1). Interviews were transcribed verbatim. An inductive approach was used to find patterns and collect data from the participants' narratives and constant comparative method was adapted in analysing the interviews. MEASUREMENTS AND FINDINGS: The experiences of transgender men regarding the preconception period, pregnancy and puerperium and with perinatal care varied widely. Though all participants expressed overall positive experiences, their narratives emphasized they had to overcome substantial hurdles pursuing pregnancy. For instance the necessity to prioritise becoming pregnant over gender transitioning, lack of support by healthcare providers and increased gender dysphoria and isolation during pregnancy KEY CONCLUSIONS: Since pregnancy in transgender men enhances feelings of gender dysphoria, transgender men comprise a vulnerable group in perinatal care. Health care providers are perceived as feeling unaccustomed for the care of transgender patients, as they are perceived to often lack the right tools and knowledge to provide adequate care. Our findings help strengthen the foundation of insight in the needs and hurdles of transgender men pursuing pregnancy and therefore may guide health care providers to provide equitable perinatal care, and emphasize the necessity of patient-centred gender-inclusive perinatal care. A guideline including the option for consultation of an expertise center is advised to facilitate patient-centered gender-inclusive perinatal care.

Desire for children and fertility preservation in transgender and gender-diverse people: A systematic review.

The decision to pursue one's desire for children is a basic human right. For transgender and gender-diverse (TGD) people, gender-affirming care may alter the possibilities to fulfill one's desire for children due to the impact of this treatment on their reproductive organs. We systematically included 76 studies of varying quality describing the desire for children and parenthood; fertility counseling and utilization; and fertility preservation options and outcomes in TGD people. The majority of TGD people expressed a desire for children. Fertility preservation utilization rates were low as there are many barriers to pursue fertility preservation. The most utilized fertility preservation strategies include oocyte vitrification and sperm banking through masturbation. Oocyte vitrification showed successful outcomes, even after testosterone cessation. Sperm analyses when banking sperm showed a lower quality compared to cis male samples even prior to gender-affirming hormone treatment and an uncertain recovery of spermatogenesis after discontinuing treatment.

Uterine junctional zone and adenomyosis: comparison of MRI, transvaginal ultrasound and histology.

The uterine junctional zone is the subendometrial area in the myometrium that contributes to peristalsis and aids in spermatozoa and blastocyst transport. Alterations in the appearance of the junctional zone on transvaginal sonography (TVS) or magnetic resonance imaging (MRI) are associated with adenomyosis. The lack of standardization of description of its appearance and ill-defined boundaries on both histology and imaging hamper understanding of the junctional zone and limit its role in the diagnosis of adenomyosis. The objectives of this review were to investigate the accordance in definition of the junctional zone across different diagnostic approaches and to examine how imaging findings can be linked to histological findings in the context of diagnosis of adenomyosis. A comprehensive literature review was conducted of articles describing the appearance on imaging and the histological structure of the uterine junctional zone. Our review suggests that the junctional zone is distinguished from the middle and outer myometrium by gradual changes in smooth-muscle cell density, extracellular space, connective tissue, water content and vascular properties. However, while the signal intensity from the junctional zone to the middle myometrium changes abruptly on MRI, the histopathological changes are gradual and its border may be difficult or impossible to distinguish on two-dimensional TVS. Moreover, the thickness of the junctional zone measured on MRI is larger than that measured on TVS. Thus, these two imaging modalities reflect this zone differently. Although a thickened junctional zone is often used to diagnose adenomyosis on MRI, the presence of adenomyosis can be described more accurately as interruptions of the junctional zone by endometrial tissue, which leads to direct signs on imaging such as subendometrial lines and buds on two- and three-dimensional TVS or bright foci on MRI. The histopathological criteria for diagnosis are based on enlargement of the uterus with severe adenomyosis, and might not reflect its early stages. Clinicians should be aware that findings on MRI cannot be extrapolated readily to ultrasound. An understanding of this is necessary when investigating the uterine junctional zone as a functional unit and the association between visualization of direct features of adenomyosis in the junctional zone and clinical symptoms. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Can serum human epididymis protein 4 (HE4) support the decision to refer a patient with an ovarian mass to an oncology hospital?

INTRODUCTION: The value of serum human epididymis protein 4 (HE4) in guiding referral decisions in patients with an ovarian mass remains unclear, because the majority of studies investigating HE4 were performed in oncology hospitals. However, the decision to refer is made at general hospitals with a low ovarian cancer prevalence. We assessed accuracies of HE4 in differentiating benign or borderline from malignant tumors in patients presenting with an ovarian mass at general hospitals. METHOD: Patients with an ovarian mass were prospectively included between 2017 and 2021 in nine general hospitals. HE4 and CA125 were preoperatively measured and the risk of malignancy index (RMI) was calculated. Histological diagnosis was the reference standard. RESULTS: We included 316 patients, of whom 195 had a benign, 39 had a borderline and 82 had a malignant ovarian mass. HE4 had the highest AUC of 0.80 (95%CI 0.74-0.86), followed by RMI (0.71, 95%CI 0.64-0.78) and CA125 (0.69, 95%CI 0.62-0.75). Clinical setting significantly influenced biomarker performances. Applying age-dependent cut-off values for HE4 resulted in a better performance than one cut-off. Addition of HE4 to RMI resulted in a 32% decrease of unnecessary referred patients, while the number of correctly referred patients remained the same. CONCLUSION: HE4 is superior to RMI in predicting malignancy in patients with an ovarian mass from general hospitals. The addition of HE4 to the RMI improved HE4 alone. Although, there is still room for improvement, HE4 can guide referral decisions in patients with an ovarian mass to an oncology hospital.

How to use power Doppler ultrasound in transvaginal assessment of uterine fibroids.

Measuring vascularization in uterine fibroids is important for their diagnosis, treatment and prognosis. Vascularization can be measured by power Doppler ultrasound. The power Doppler signal depends on fibroid characteristics and on a variety of ultrasound-machine settings. Literature describing which machine settings influence the power Doppler signal is limited. Each manufacturer names settings and presets at their own discretion, with little information available publicly. Consistency of machine settings is important for correct interpretation of images in daily practice and is essential in yielding reproducible data for research. The aims of this paper, drawing from both a literature search and semistructured interviews with ultrasound-machine engineers and clinical experts in gynecological ultrasound, were: (1) to provide comprehensive background information on ultrasound physics and fibroid characteristics; (2) to present an overview of machine settings relevant to both two- and three-dimensional power Doppler, including power Doppler frequency, pulse repetition frequency, gain, wall-motion filter, acoustic power, persistence and signal rise; and (3) to provide a step-by-step tutorial on the optimal settings for vascular evaluation of uterine fibroids using power Doppler. The step-by-step tutorial comprises six steps to optimize the power Doppler signal, create a preset and acquire a reliable three-dimensional volume. This step-by-step tutorial should help research groups and clinicians to use power Doppler correctly and reproducibly in the evaluation of uterine fibroids. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.