Obesity and Reproduction.

OBJECTIVE: To provide a comprehensive review and evidence-based recommendations for the delivery of fertility care to women with obesity. OUTCOMES: The impact of obesity on fertility, fertility treatments, and both short and long-term maternal fetal outcomes was carefully considered. EVIDENCE: Published literature was reviewed through searches of MEDLINE and CINAHL using appropriate vocabulary and key words. Results included systematic reviews, clinical trials, observational studies, clinical practice guidelines, and expert opinions. VALUES: The Canadian Fertility & Andrology Society (CFAS) is a multidisciplinary, national non-profit society that serves as the voice of reproductive specialists, scientists, and allied health professionals working in the field of assisted reproduction in Canada. The evidence obtained for this guideline was reviewed and evaluated by the Clinical Practice Guideline (CPG) Committee of the CFAS under the leadership of the principal authors. BENEFITS, HARMS, AND COSTS: The implementation of these recommendations should assist clinicians and other health care providers in counselling and providing reproductive care to women with obesity. VALIDATION: This guideline and its recommendations have been reviewed and approved by the membership, the CPG Committee and the Board of Directors of the CFAS. SPONSORS: Canadian Fertility & Andrology Society. RECOMMENDATIONS: Twenty-one evidence based recommendations are provided. These recommendations specifically evaluate the impact of obesity on natural fertility, fertility treatments, and maternal-fetal outcomes. Strategies to lose weight and BMI cut-offs are also addressed.

Endometrial Biopsy in an Outpatient Gynaecological Setting: Overinvestigation.

OBJECTIVE: We reviewed the indications for endometrial biopsy at the general gynaecology outpatient clinic of the Université de Montréal Hospital Center and measured their compliance with the Society of Obstetricians and Gynaecologists of Canada and other international guidelines. METHODS: Three hundred and seventy-one files of patients who had an endometrial biopsy between January and October 2015 were reviewed. Indication for endometrial biopsy and pathology results were noted. Files were separated into four categories. RESULTS: In the postmenopausal bleeding category, all files complied with the SOGC. We found hyperplasia or neoplasia in 13% of patients. In the asymptomatic endometrial thickening category, 9% of the files did not show sufficient indication for biopsy. None of the patients presented hyperplasia or neoplasia. In the abnormal uterine bleeding (AUB) - under 41 years old category, there was no indication for biopsy in 23% of the files. We found hyperplasia or neoplasia in 13% of patients, but only in patients with an indication for biopsy. In patients with AUB - over 40, non-compliance with SOGC was 3%. But according to international guidelines, 42% of patients with AUB between 41 and 45 years old did not have an indication for biopsy and none showed hyperplasia or neoplasia. CONCLUSION: We demonstrated clinically significant overinvestigation in patients with AUB. Indications should be reviewed carefully before performing an endometrial biopsy in women under 41. In addition, the value of endometrial biopsies in patients between 41 and 45 years old with menorrhagia and no additional risk factor should be reevaluated.

Fertility and Pregnancy in Turner Syndrome.

Turner syndrome (TS) occurs in one in 2500 live female births and is one of the most common chromosomal abnormalities in women. Pregnancies in women with TS, conceived with either autologous or donated oocytes, are considered high risk because of the associated miscarriages and life-threatening cardiovascular complications (aortic dissection, severe hypertension). Therefore, it is imperative to conduct a full preconception evaluation and counselling that includes cardiac assessment with Holter blood pressure monitoring, echocardiography, and thoracic MRI. Abnormal findings, such an aortic dilatation, mandate close monitoring throughout the pregnancy and the immediate postpartum period and could possibly contraindicate pregnancy. When in vitro fertilization using donated oocytes is performed in these women, only a single embryo should be transferred. Women with a Turner mosaic karyotype appear to have a lower risk of obstetrical and cardiovascular complications but should nevertheless undergo the full preconception evaluation. In this article, we offer guidelines on the management of women with TS in the preconception period, during pregnancy, and postpartum.

Enhancing surgical performance: the role of robotic surgery in myomectomies, a systematic review and metanalysis.

Examine the role, benefits, and limitations of robotic surgery in myomectomies compared to laparoscopic and open surgical approaches. This review sourced data from CENTRAL, Pubmed, Medline, and Embase up until May 1, 2023. Full articles comparing clinical outcomes of robotic myomectomy with open or laparoscopic procedures were included without language restriction. Initially, 2150 records were found. 24 studies were finally included for both qualitative and quantitative analyses. Two investigators independently assessed all reports following PRISMA guidelines. Meta-analysis was conducted using the software "Review Manager Version 5.4". Risk-of-bias was assessed using the Newcastle-Ottawa scale. Sensitivity analysis was conducted, when feasible. In a comparison between robotic and laparoscopic myomectomies, no significant difference was observed in fibroid weights and the size of the largest fibroid. Robotic myomectomy resulted in less blood loss, but transfusion rates were comparable. Both methods had similar complication rates and operative times, although some robotic studies showed longer durations. Conversion rates favored robotics. Hospital stays varied widely, with no overall significant difference, and pregnancy rates were similar between the two methods. When comparing robotic to open myomectomies, open procedures treated heavier and larger fibroids. They also had greater blood loss, but the robotic approach required fewer transfusions. The complication rate was slightly higher in open procedures. Open surgeries were generally faster, postoperative pain scores were similar, but hospital stays were longer for open procedures. Pregnancy rates were comparable for both robotic and open methods. Robotic surgery offers advancement in myomectomy procedures by offering enhanced exposure and dexterity, leading to reduced blood loss and improved patient outcomes. PROSPERO registration: CRD42023462348.

Predictors of success to weight-loss intervention program in individuals at high risk for type 2 diabetes.

This study aimed at identifying predictors of success (retention after one year of intervention with ≥5% weight loss) in subjects at high risk for type 2 diabetes enrolled in a lifestyle modification program. Fifty-one individuals with BMI ≥27kg/m(2) and pre-diabetes or metabolic syndrome were enrolled in an individualized multidisciplinary lifestyle intervention to induce weight loss. Subjects were assessed initially with a 16-item weight-loss readiness tool (WLRT) based on stages of change model; a 6-min walk test; and anthropometric measures. The most significant independent factor associated with no success was a lower result to the question "I am capable of doing more physical activity" (P=0.001). The second significant independent predictor was ≤0.5% weight loss 6 weeks after initiating intervention (P=0.01). Excluding subjects with both criteria would have reduced by 52% the number of subjects eligible for the program, decreased the dropout rate from 30% to 17%, and increased the proportion of subjects with ≥5% weight loss at one year from 51% to 80%. Importantly, only 4% of subjects would have been falsely identified as non-responders. These results indicate that a practical WLRT, in combination with early weight-loss response, is helpful to identify subjects with greater chances of success to lifestyle intervention.

Effectiveness of a multidisciplinary program for management of obesity: the Unité d'Enseignement, de Traitement et de Recherche sur l'Obésité (UETRO) database study.

BACKGROUND: Obesity is a worldwide health problem assuming epidemic proportions. Development of effective clinical interventions is needed to lower the impact of associated morbidity and mortality, without forgetting related costs. We have established an interdisciplinary clinic for obesity management, Unité d'Enseignement, de Traitement et de Recherche sur l'Obésité (UETRO), which consists of individual consultations combined with group sessions. We report here the effectiveness of this program for weight reduction over the first year of follow up. METHODS: We performed retrospective analysis of standardized patient records of the first 115 consecutive subjects referred to UETRO with available follow up for 1 year. RESULTS: Mean age, body mass index (BMI), and waist circumference (WC) of our cohort were 46 +/- 13 years, 44.7 +/- 0.9 kg/m(2), and 120.5 +/- 1.9 cm, respectively. Hypertension and diabetes were present in 46% and 23% of our patients. Weight and WC loss were gradual over 1 year and were significantly reduced by 6.6 +/- 0.8 kg and 6.7 +/- 0.7 cm, respectively (P < 0.001), without attainment of a plateau. Blood pressure and lipid profile significantly improved after 1 year of follow up. However, the proportion of patients taking metformin, lipid-lowering, antihypertensive, or antiobesity drugs increased significantly over follow up, reflecting intensification of treatment of co-morbidities and weight management. Significant weight and WC loss occurred independently of diabetes status and use of antiobesity medications. CONCLUSIONS: This program appears to be as effective for treating obesity as more intensive treatment programs. Future prospective studies are needed to evaluate the benefits and costs of this therapeutic approach.