Initiation and outcomes of women pursuing planned fertility preservation.

OBJECTIVE: To study cycle outcomes of women who choose to pursue oocyte cryopreservation, using published age-specific oocyte recommendations DESIGN: Retrospective Cohort SUBJECTS: A total of 5,915 patients seeking planned oocyte cryopreservation, 3504 ultimately underwent ovarian stimulation with oocyte retrieval and cryopreservation, 425 of this cohort subsequently thawed with intent to utilize with embryo transfer EXPOSURE: Planned oocyte cryopreservation MAIN OUTCOME MEASURES: Planned oocyte cryopreservation consultation, fertility preservation cycle(s) and ovarian stimulation outcomes RESULTS: 5,915 women were seen in initial consultation for planned fertility preservation (2012-2022). Ethnicity and highest level of education were significant in predicting who would move forward with oocyte stimulation for fertility preservation. Women who reported working within law and public policy and in the fields of health and medicine were statistically more likely to proceed with a cycle than those who listed other occupations (p < 0.001). Of 3,504 women in the study cohort who underwent ovarian stimulation and egg retrieval, 1331 (38.0%) achieved the age-based recommended number of oocytes to freeze. Only 57 (4.3%) of these women who met their age-based oocyte goal did so following their initial cryopreservation cycle. There was a significant association between ethnicity and number of cryopreservation cycles, specifically showing that Black or African American women were less likely to complete two or more cycles (p < 0.001). Patients whose education background included graduate or professional degrees were more likely to have completed more than one cycle (p = 0.007). CONCLUSION: Self-identified ethnicity was significantly associated with the odds of moving forward with oocyte stimulation for fertility preservation and egg retrieval following initial consultation (p<0.001) with ethnic minorities significantly less likely to continue treatment. Of those who undergo egg freezing, most women pursue more than one stimulation and cryopreservation cycle, yet the majority never meet their recommended number to freeze.

The PrEP resource: a mobile app for clinicians to facilitate screening, prescription and follow up of pre-exposure prophylaxis in the prevention of HIV.

Background Over 2million people worldwide receive a new HIV diagnosis annually. Pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV transmission, but is underprescribed, including in the US. Lack of clinician comfort and knowledge are the most cited reasons for this discrepancy. We aimed to develop a mobile application (app) to address these barriers and improve patient access to PrEP. Methods We established key criteria to develop a point-of-care app that could be utilised in low-resource settings by various clinicians poised to prescribe PrEP therapy. The app underwent two rounds of beta testing and improvement utilising anonymous survey feedback from US physicians in 2023. Results The PrEP Resource tool was developed. Eleven physicians completed the initial survey addressing prescribing practices and app functionality. A total of 27% (3/11) of participants were uncomfortable prescribing PrEP, with the most common reasons being lack of training, unfamiliarity with guidelines and infrequently prescribing the medication. Our follow-up survey, completed by eight physicians, showed that 100% of participants found the app easy to learn and comprehensive enough to initiate PrEP. Conclusion Clinician discomfort due to lack of knowledge and familiarity is the most common reason for not prescribing PrEP. The PrEP Resource is a free tool that guides healthcare professionals through common clinical scenarios regarding PrEP therapy and may improve clinician comfort levels. It can be used in low-resource and low-bandwidth settings typically encountered in lower-middle-income countries where HIV prevalence is the highest. Further study is required to validate its usefulness across different settings.

A Mixed-Methods Study to Evaluate Family Planning Desires and Barriers to Building Families Among Gay, Bisexual, and Lesbian Cisgender Military Service Members.

INTRODUCTION: Barriers to seeking infertility care for lesbian, gay, bisexual, transgender, intersex, queer/questioning, and asexual (LGBTIQA+) individuals are well documented in the literature. However, little is known about military LGBTIQA+ service members seeking infertility care within the Military Health System. Approximately 6.1% of active duty U.S. service members across all branches identify as LGBTIQA+, which underscores the need for a deeper understanding of the needs of this community to support and retain service members. We therefore sought to describe the lived experiences of lesbian and gay cisgender service members in building their families in order to understand their family-building desires and potential barriers to seeking infertility care. MATERIALS AND METHODS: We developed a survey to investigate the impact of military service on family planning. After Institutional Review Board approval, we distributed the survey throughout Walter Reed National Military Medical Center's obstetrics and gynecology clinic and posted the survey on multiple open and closed social media pages for LGBTIQA+ service members. We reported descriptive statistics of our survey and compared binary variables using the Fisher exact test. Following completion of this survey, participants could self-select to participate in semi-structured interviews. RESULTS: Sixty-eight respondents completed our survey and self-identified as either cis-male (n = 28) or cis-female (n = 40). Most respondents (67.9% cis-males, 92.5% cis-females) plan to build their families during their military commitment; however, approximately half (50.0% cis-male, 42.5% cis-female) reported a lack of support in this endeavor. Many respondents were unaware of resources that would assist in the pursuit of donor egg, donor sperm, or surrogacy (78.6% cis-males, 50.0% cis-females). Thirty-six participants elected to complete a follow-up interview. After coding the interviews, 5 themes emerged: (1) barriers to initiating care; (2) institutional barriers within the military; (3) political barriers; (4) knowledge sharing; and (5) implicit and explicit bias. CONCLUSIONS: Our results suggest significant barriers to LGBTIQA+ service members seeking infertility care. Overall, LGBTIQA+ service members did not feel supported by the military in building their families. Although the military has expanded access to infertility services, efforts to raise awareness and build support for LGBTIQA+ service members are warranted.

Cephalopagus twins diagnosed at 7 weeks gestational age following IVF/ICSI.

A patient in her 30s who was a G0 proceeded with in vitro fertilisation (IVF) for a history of male factor infertility. Following single embryo transfer, the patient was diagnosed with a conjoined twin pregnancy. During her IVF cycle, the patient was stimulated with an antagonist protocol for 13 days followed by a gonadotropin-releasing hormone agonist trigger. 13 eggs were retrieved, 9 were mature and 5 fertilised with intracytoplasmic sperm injection. Of those, two were cryopreserved. She had a successful frozen blastocyst embryo transfer. The patient's 7-week ultrasound demonstrated a single gestational sac, yolk sac and fetal pole. However, the crown-rump length appeared visually abnormal and two heartbeats were visualised. She was referred to maternal-fetal medicine (MFM) for a first-trimester ultrasound. Her ultrasound with MFM was notable for a fluid-filled chest, foreshortened limbs and early sacral agenesis. She was subsequently diagnosed with cephalopagus twins and underwent an induced abortion following consultation with MFM.

Impact of a Mentorship Program to Prepare Medical Students for the Military Residency Match.

INTRODUCTION: Mentorship programs have well-documented benefits to both mentees and mentors. Military medical students face unique challenges in medical school given their service-specific requirements and separate military match process. We therefore aimed to determine whether military medical students' participation in a mentorship program impacts their confidence in applying to obstetrics and gynecology (OB/GYN) residency. MATERIALS AND METHODS: First, a needs assessment survey regarding the use of a mentorship program was sent to medical students, residents, fellows, and attendings. A structured mentorship program was then developed for military medical students applying to OB/GYN residency based on the survey results. Mentors were randomly paired with mentees and asked to appraise curriculum vitaes, review personal statements, and perform mock interviews. Following completion of these activities, participants were sent a post-intervention questionnaire. This project was exempt by our institution's Institutional Review Board. RESULTS: Our program had 56 participants, with 29 individuals completing our post-intervention survey (response rate 51.8%). After participating in the program, 92.3% of mentors stated they plan to continue a relationship with their mentee. All the mentee respondents stated they would participate in this program again. Before participating in the program, 16.7% of mentees felt "prepared" or "extremely prepared" for the match, compared to 87.6% post-intervention. Most mentee respondents (75%) reported that this program made them a more competitive applicant. Following the mentorship program, 66.7% of participants successfully matched into OB/GYN residency. CONCLUSIONS: This reproducible, well-received intervention can be implemented to facilitate mentoring connections regardless of geographic location. As the OB/GYN specialty develops its own application process, civilian medical schools should consider adopting similar programs to aid their students in navigating the match process.

Assessing Knowledge, Counseling, and Referral Patterns Regarding Fertility Preservation Before Gonadotoxic Treatments Among Physicians in the Military Health System.

Purpose: We sought to evaluate physicians' baseline knowledge of fertility preservation services available to patients with a cancer diagnosis within the military health system (MHS). Methods: Data on current cancer prevalence of over 31,000 unique cancer diagnoses were obtained from a comprehensive nationwide MHS dataset. Additionally, a 22-item survey was distributed to physicians practicing within the MHS assessing knowledge of reproductive health benefits, oncofertility counseling practices, and subspecialist referral patterns. Results: From 2020 to 2022, there were 31,103 individuals of reproductive age with cancer receiving care at a military treatment facility. One hundred fourteen physicians completed our survey, 76 obstetrician gynecologists (OB/GYNs), 18 oncologists, and 20 primary care physicians (PCPs). Ninety-three percent of respondents felt conversations about fertility preservation for reproductive-aged patients with cancer were very important. A total of 66.7% of oncologists, 35.5% of OB/GYNs, and 0% of PCPs felt comfortable counseling patients on coverage. A total of 33.3% of oncologists, 29.3% of OB/GYNs, and 0% of PCPs were familiar with oncofertility Defense Health Agency guidelines. Conclusion: Primary care, OB/GYN, and oncology practitioners are well situated to provide fertility preservation counseling to all individuals with a cancer diagnosis, but differences in counseling and referral patterns and a lack of knowledge of current agency policies may impair a patient's timely access to these resources. We propose implementation of an electronic patient navigator to address gaps in oncofertility care and standardize patient counseling in the MHS. This patient-focused guide would serve as a valuable model in all types of health care settings.

Strengthening Abortion Training: A Dilation and Evacuation Checklist in Military Resident Education.

INTRODUCTION: A dilation and evacuation (D&E) is a safe and effective option for patients undergoing a second trimester abortion. Recent legislation and geographic restrictions threaten patients' access to this surgical procedure, prompting a call to action to strengthen abortion training. This quality improvement project aimed to assess if a standardized lecture and checklist would improve military trainee knowledge and comfort with performing D&Es. MATERIALS AND METHODS: Using society recommendations and incorporating available level I to III evidence, a standardized checklist for D&Es was created to include necessary equipment, procedural steps, perioperative considerations, and potential complications. The checklist and associated lecture were presented to gynecology residents from seven of the nine military training programs. Residents completed a six-question assessment regarding comfort and knowledge in performing D&Es prior to and following the intervention. Responses were ranked on a five-point Likert scale and analyzed with the Wilcoxon sign-rank test. This project was deemed exempt by the Institutional Review Board. The standard Plan, Do, Study, Act (PDSA) methodology was used for ongoing assessment of the efficacy of this quality improvement project. RESULTS: There were 67 trainees that completed the pre-intervention assessment and 44 who completed it post-intervention, with 27 responses paired for statistical analysis. All trainees self-reported improved comfort and knowledge in all procedural aspects of D&Es, with the largest improvement observed in equipment knowledge (mean difference 1.44, P <0.001), performing procedural steps (mean difference 1.26, P <0.001), and managing complications (mean difference 1.33, P <0.001). CONCLUSIONS: Use of an evidence-based checklist significantly improves resident knowledge and comfort with performing second trimester D&Es. In a post Dobbs environment, the military is an appropriate proxy for larger society and training programs need to develop alternatives and adjuncts to clinical training.

Improving Pre-exposure Prophylaxis Counseling at a Military Women's Health Care Clinic to Champion CDC and Defense Health Agency Recommendations.

INTRODUCTION: The CDC updated their guidelines in 2021 to recommend all doctors speak about pre-exposure prophylaxis (PrEP) against human immunodeficiency virus infection with all sexually active patients. In addition, there is a demonstrated need for physicians to counsel patients on PrEP to achieve military readiness. Results from the 2018 Health Related Behaviors Survey indicate 21.8% of U.S. service members were at high risk for human immunodeficiency virus. This improvement project aimed to assess deficiencies in providers' knowledge before and after an educational intervention and describe policies clinics can adopt to adhere to CDC recommendations. MATERIALS AND METHODS: A pre-intervention survey was distributed to providers at the Walter Reed National Military Medical Center Gynecologic Surgery and Obstetrics clinic. Based on results, an educational lecture and standardized intake form were developed. Following the intervention, a post-survey was distributed to providers. A chart review was performed to determine whether PrEP counseling increased following the intervention. RESULTS: Forty-seven gynecologic providers were sent a pre- and post-intervention survey. Thirty-seven individuals completed the pre-intervention survey (response rate 78.72%), whereas 18 people completed the post-intervention survey (response rate 38.30%). Descriptive analysis suggested comfort counseling on PrEP, comfort with Defense Health Agency guidance on PrEP, and knowledge of PrEP all increased. In terms of the chart review, 81 charts were reviewed pre- and post-intervention. Although we failed to meet our target counseling rate of 70%, the number of patients who were counseled on or prescribed PrEP following our intervention was statistically significant (P = .013). CONCLUSIONS: This improvement project increased provider knowledge and comfort with PrEP, but only marginally affected behavior changes among providers. This failure may be related to the specific clinic in which the study was implemented. Further research is needed to facilitate routine counseling of PrEP among military women's health care providers.

Herpes simplex meningitis presenting as headache in pregnancy: A case report.

Background: There are few case reports of meningitis caused by herpes simplex virus (HSV) as the initial presentation in a pregnant patient, making pregnancy management and delivery planning challenging for obstetricians encountering this patient presentation. Case: A 35-year-old parous woman at 35 weeks of gestation with prenatal care complicated by her history of pre-term delivery and systemic lupus erythematous (SLE) presented to the emergency department with worsening headache not responding to medication. Due to her history of SLE, rheumatology was consulted, although her flare symptoms were not consistent with her initial presentation. Neurology was consulted after she developed symptoms consistent with meningitis. She was started on broad-spectrum antibiotics while awaiting lumbar puncture results. The latter indicated the patient was positive for HSV-2 IgG, suggesting a recurrent process. She denied a personal history of HSV infection, although she had a positive unspecified HSV IgM titer upon chart review. The patient was transitioned to intravenous acyclovir and responded well. Upon clinical improvement, she was transitioned to oral antiviral therapy and subsequently discharged home. After consultation with the pediatrics and pediatric infectious disease departments, vaginal delivery was deemed to be safe. However, the patient elected for primary cesarean. Conclusions: Providers encountering a patient with an unrelenting headache in the absence of other causes should have a high suspicion for meningitis, regardless of clinical HSV history.

Increasing Medical Student Involvement in Research: Military Ob/Gyn HeadHunters.

INTRODUCTION: Our goal was to develop a successful research collaboration program, Military Ob/Gyn HeadHunters, to connect military medical students with residents, fellows, and staff physicians across the Military Health System (MHS) to foster research collaboration and mentorship. MATERIALS AND METHODS: We conducted a needs assessment of medical students from the Uniformed Services University and Health Professions Scholarship Program as well as staff physicians, residents, and fellows practicing in the MHS to better understand the barriers to initiating and conducting research within the MHS. We used the survey results to create a secure online spreadsheet to match medical students to researchers recruiting student researchers. A follow-up survey was sent to all respondents 3 months after the program launch to evaluate the program. RESULTS: Of the medical students who completed the needs assessment, 82.56% (n = 71/86) reported barriers in participating in research. The most common barrier was "I don't know where to look for research opportunities." Of the staff surveyed, 88.24% (n = 15/17) indicated that they were interested in medical student involvement in their research. However, 53.33% (n = 8/15) of the surveyed staff reported that they did not know any students who would be good candidates. Since the launch in April 2021, our 3-month follow-up survey had a response rate of 40.00% (n = 6/15) for staff and 47.06% (n = 32/68) for students. Hundred percent (n = 6/6) of faculty advertising projects recruited at least one student to join their project. 85.71% (n = 12/14) of students actively seeking participation joined a research team. CONCLUSIONS: Our novel research collaboration program successfully connected military medical students with active researchers in the MHS. Leaders in medical education can consider adopting this framework to improve trainee participation in research.

A description of teaching methods using an on-site instructor versus a distant site instructor to train laryngoscopy to medical students in Hanoi, Vietnam, from Omaha, Nebraska, by video communication.

This study demonstrated a method to train medical students at Hanoi Medical School in airway management from Omaha, Nebraska, using tele-mentoring techniques. Correct placement of the endotracheal tube was documented by tele-broncoscopy following intubation. This technology may increase medical training capabilities in remote or developing areas of the world. Medical care delivery could be performed using this technology by tele-mentoring a lesser trained medical provider at a distant site enabling them to accomplish complex medical tasks.

Development of a Tele ENT Program to Support Distant Military Treatment Facilities for the European Regional Medical Command.

Two hundred forty-five thousand patients seek care at Landstuhl Regional Medical Center. They battle lengthy commutes, costly procedures, and limited specialty care in order to consult their physicians. Implementing telemedical procedures at hospitals such at LRMC is believed to reduce travel time, decrease costs, and increase specialization. Healthcare providers who were trained in Tele ENT procedures unanimously accepted the technology as an alternative way to care for patients. Expansion of telemedical procedures in hospitals is deemed to reduce health care costs and to be accepted by providers.

Development of a tele-anesthesia preoperative clinic to support distant military treatment facilities for the European regional medical command.

Landstuhl Regional Medical Center (LRMC) provides primary care services for more than 65,000 beneficiaries and specialty care and hospitalization for 245,000 U.S. Service Members and their Families serving in Europe. These personnel are located in Germany, Italy and Belgium (See Fig 1). Anesthesia preoperative diagnosis/work was done by telemedicine at the distant, end user site, and significant cost savings and enhanced patient service was accomplished. A novel use of existing technologies was implemented to enhance provider and patient satisfaction and create a sustainable, user friendly system.

Virtual simulation training using the Storz C-HUB to support distance airway training for the Spanish Medical Corps and NATO partners.

In medicine, the advancement of new technologies creates challenges to providers both in learning and in maintaining competency in required skills. For those medical providers located in remote environments, access to learning can be even more formidable. This work describes a collaboration created to facilitate the use of new communication technologies in providing distance training and support to health care personnel deployed in remote areas.

Development of medical engagement training toolkits to support special operations military assistance programs in austere environments.

The Medical Seminar (MEDSEM) is a medical operation that shares culturally appropriate medical information with a defined indigenous population based upon a "train the trainer" concept. This work describes the development of a hand washing training toolkit designed to support a MEDSEM action in Afghanistan.