Growing evidence that endometriosis is a systemic disease.

The pathophysiology of endometriosis remains unclear. Retrograde menstruation could be a phenomenon that initiates the process, but it may not explain the entire pathophysiology of endometriosis. Current evidence suggests that endometriosis is a type of chronic inflammatory disease. Many conditions that affect the vascular endothelium, including atherosclerosis, cardiovascular disease and pre-eclampsia, have been shown to be associated with endometriosis. Evidence to date suggests a complex interaction in endometriosis between angiogenesis, hormones and immunological changes stemming from chronic inflammation, with the inflammatory cells releasing cytokines and chemokines including tumour necrosis factor-α (TNF-α). Indeed, TNF-α is considered to be one of the possible markers of endometriosis in the blood, endometrium or menstrual blood. We emphasize the importance of pursuing research for novel and safer anti-inflammatory and immunomodulatory drugs that can be used by patients with endometriosis on a long-term basis.

Prevalence and Quality of Life among Overweight and Obese Women with Different Severity and Types of Urinary Incontinence.

OBJECTIVE: Urinary incontinence (UI) is an involuntary leakage of urine and affects the social, physical, and psychological aspects of many individuals worldwide. The purpose of our study was to examine the prevalence, quality of life (QoL), severity, and different types of UI in overweight and obese women. METHODS: We conducted a cross-sectional study of 1,351 consecutive patients, who were recruited between June 2021 and May 2022. RESULTS: The mean age of the patients was 39.7 ± 14.2 years with less than a half in the 19-35-year age group (46.9%); 65% of the subjects were overweight or obese. The overall prevalence of UI was 61.2%. Overweight and obesity accounted to 70.2% of patients with mild to very severe UI. The risk estimates to have UI were 1.84 in overweight and 5.4 in obese group. The risk estimate for severe and very severe UI was 2.33 in overweight and 10.34 in obese group. When considering all subtypes, 67.9% of women with overweight and obesity had any of the subtypes, urge UI, stress UI, and mixed UI. Overweight and obesity were significantly associated with poor QoL in women with UI (p < 0.0001). Among 36.1% of all patients with poor QoL, 79.9% were overweight and obese. CONCLUSIONS: Overweight and obesity are important risk factors of UI affecting daily activity and QOL considerably. As the number of people with obesity is increasing, the prevalence of UI with increased severity is likely to increase in young to mid-aged women. Weight loss should be considered as first-line treatment for this patient population.

Immunomodulation for unexplained recurrent implantation failure: where are we now?

In brief: Immune dysfunction may contribute to or cause recurrent implantation failure. This article summarizes normal and pathologic immune responses at implantation and critically appraises currently used immunomodulatory therapies. Abstract: Recurrent implantation failure (RIF) may be defined as the absence of pregnancy despite the transfer of ≥3 good-quality blastocysts and is unexplained in up to 50% of cases. There are currently no effective treatments for patients with unexplained RIF. Since the maternal immune system is intricately involved in mediating endometrial receptivity and embryo implantation, both insufficient and excessive endometrial inflammatory responses during the window of implantation are proposed to lead to implantation failure. Recent strategies to improve conception rates in RIF patients have focused on modulating maternal immune responses at implantation, through either promoting or suppressing inflammation. Unfortunately, there are no validated, readily available diagnostic tests to confirm immune-mediated RIF. As such, immune therapies are often started empirically without robust evidence as to their efficacy. Like other chronic diseases, patient selection for immunomodulatory therapy is crucial, and personalized medicine for RIF patients is emerging. As the literature on the subject is heterogenous and rapidly evolving, we aim to summarize the potential efficacy, mechanisms of actions and side effects of select therapies for the practicing clinician.

Association between Endometriosis and Risk of Preeclampsia in Women Who Conceived Spontaneously: A Systematic Review and Meta-analysis.

OBJECTIVE: To evaluate the association between endometriosis and the risk of preeclampsia and other maternal outcomes in spontaneously conceived women. DATA SOURCES: PubMed, MEDLINE, Embase, Scopus, Cochrane Library, Web of Science, and Google Scholar were systemically searched for studies published from inception to November 2021 (CRD42020198741). Observational studies published in English or French that investigated the risk of preeclampsia in women with endometriosis who conceived spontaneously were included. METHODS OF STUDY SELECTION: A total of 610 articles were reviewed once duplicates were removed. Inclusion criteria included spontaneous conception and surgical and/or imaging ascertainment of an endometriosis diagnosis. Exclusion criteria included conception using assisted reproductive technologies, multiple pregnancies, chronic hypertension, and unclear diagnoses of endometriosis. TABULATION, INTEGRATION, AND RESULTS: Data of selected studies were extracted, and analysis was performed on Review Manager, version 5.4. Quality assessment of included studies for potential risk of bias was evaluated using the Newcastle-Ottawa Scale for cohort studies. Three cohort studies of spontaneous pregnancies were included. Endometriosis was associated with an increased risk of preeclampsia (risk ratio [RR] = 1.47, 95% CI 1.13 -1.89, p = .003; I2 = 0%; n = 3 studies). A sensitivity analysis excluding a study with adenomyosis cases yielded similar risk (RR = 1.44; 95% CI, 1.11-1.87; p = .006; I2 = 0%; n = 2 studies). Having endometriosis did not significantly increase risk of cesarean delivery (RR = 1.38; 95% CI, 0.99-1.92; p = .06; I2 = 80%; n = 2 studies) or postpartum hemorrhage (RR = 1.16; 95% CI, 0.46-2.91; p = .76; I2 = 50%; n = 2 studies). CONCLUSION: We detected an increased risk of preeclampsia in women with endometriosis who conceived spontaneously. Endometriosis did not seem to increase the risk of cesarean delivery and postpartum hemorrhage, but the number of studies was limited, and the heterogeneity was high.

MYO10 promotes transzonal projection-dependent germ line-somatic contact during mammalian folliculogenesis†.

Granulosa cells of growing ovarian follicles elaborate filopodia-like structures termed transzonal projections (TZPs) that supply the enclosed oocyte with factors essential for its development. Little is known, however, of the mechanisms underlying the generation of TZPs. We show in mouse and human that filopodia, defined by an actin backbone, emerge from granulosa cells in early stage primary follicles and that actin-rich TZPs become detectable as soon as a space corresponding to the zona pellucida appears. mRNA encoding Myosin10 (MYO10), a motor protein that accumulates at the base and tips of filopodia and has been implicated in their initiation and elongation, is present in granulosa cells and oocytes of growing follicles. MYO10 protein accumulates in foci located mainly between the oocyte and innermost layer of granulosa cells, where it colocalizes with actin. In both mouse and human, the number of MYO10 foci increases as oocytes grow, corresponding to the increase in the number of actin-TZPs. RNAi-mediated depletion of MYO10 in cultured mouse granulosa cell-oocyte complexes is associated with a 52% reduction in the number of MYO10 foci and a 28% reduction in the number of actin-TZPs. Moreover, incubation of cumulus-oocyte complexes in the presence of epidermal growth factor, which triggers a 93% reduction in the number of actin-TZPs, is associated with a 55% reduction in the number of MYO10 foci. These results suggest that granulosa cells possess an ability to elaborate filopodia, which when directed toward the oocyte become actin-TZPs, and that MYO10 increases the efficiency of formation or maintenance of actin-TZPs.

Postoperative Discharge Opioid Consumption, Leftover, and Disposal after Obstetric and Gynecologic Procedures: A Systematic Review.

OBJECTIVE: To perform a systematic review on consumption, leftover, and disposal of prescribed opioids after surgery in obstetrics and gynecology (The International Prospective Register of Systematic Reviews ID 249856). DATA SOURCES: Electronic database searches on PubMed, Embase, Cochrane Library, and MEDLINE and other search methods including all studies published between the years 2000 and 2021 were used. METHODS OF STUDY SELECTION: We included all randomized trials, cohorts, case-control studies, and clinical trials. The search was limited to studies related to obstetrics and gynecology. Studies that pertained to opioid consumption, leftover, and disposal patterns were selected. We excluded review articles, meeting abstracts, case series and case reports, and abstracts without access to full texts. The search was limited to trials in humans and published in English language. Study population included women who were prescribed opioids after obstetric and/or gynecologic procedures. Information on opioid consumption, leftover, and disposal patterns were extracted and compared among different procedures. Potential risk of bias was evaluated using the Newcastle-Ottawa Scale for cohort studies and the National Heart, Lung, and Blood Institute Study Quality Assessment Tool of Controlled Interventional Studies for clinical trial. TABULATION, INTEGRATION, AND RESULTS: Of 2343 articles, 10 were used in the analysis: 9 cohorts and 1 randomized clinical trial. We found that among patients who underwent obstetric and gynecologic procedures, a considerable number of opioids are unused. The total number of consumed opioids after discharge in patients who underwent cesarean delivery was 21.8 oral morphine equivalent (OME); vaginal hysterectomy, 55.7 OME; abdominal hysterectomy, 105.8 OME; and laparoscopic hysterectomy, 89.0 OME. The number of opioids leftover in the vaginal, abdominal, and laparoscopic hysterectomy groups was 67.6 OME, 115.5 OME, and 95.3 OME, respectively. On average, 77.5% of leftover opioids were not disposed/kept, whereas only 20% discarded their medication through a disposal program. Five studies were deemed to have fair quality, and the rest were rated as good quality. CONCLUSION: Compared with those after cesarean delivery, patients undergoing gynecologic procedures consumed a large number of opioids, especially after abdominal hysterectomies. Abdominal hysterectomy was also associated with a high number of opioids leftover. Most patients did not use the entire prescribed opioids and were either keeping their unused opioids or unsure about what to do with them. We recommend perioperative opioid-specific counseling and education on opioid consumption, potential hazards of unused medication, and proper disposal for patients. Strategies to reduce opioids prescription by physicians should be considered.

Evaluation of Hysteroscopic Endometrectomy: A Reappraisal.

Endometrial ablation can be performed using a variety of techniques, including resectoscopic or non-resectoscopic approaches. In this study, we compared 2 resectoscopic endometrial ablation techniques. The first technique was rollerball coagulation followed by endometrectomy (type A; n = 103), and the second was the reverse (type B; n = 107). Besides excessive bleeding in 4 cases, the procedures were uneventful in both groups of patients. We did not encounter uterine perforation or cervical laceration. Satisfaction rates were 97% and 99% with an overall hysterectomy rate of 2.9%. These results compared favorably with those in the literature. The results of our study show that hysteroscopic endometrectomy is effective with few associated complications.

Is There an Association Between Sperm Parameters and Sexual Orientation? A Cross Sectional Study.

OBJECTIVE: To evaluate whether sexual orientation affects sperm parameters. METHODS: This was a cross-sectional study using existing data from an academic reproductive centre for the period of April 01, 2009, to March 31, 2021. We compared the results of sperm analysis from male patients who were in same-sex relationships (study group) with those of men in heterosexual relationships who did not have male-factor infertility (control group). A subsequently comparison of both groups with World Health Organization (WHO) reference values was also performed. RESULTS: Thirty-nine samples from the study group were compared with 494 samples from the control group. All parameters, apart from morphology, were comparable. The median sperm concentrations were 64 (interquartile range [IQR] 32.1-102.9) million/mL and 50.1 (IQR 25.3-92.5) million/mL in the study and control groups, respectively (P = 0.252), whereas the median percentage of progressive motile sperm was 50% (IQR 34-65) in the study group and 52% (IQR 33-65) in the control group (P = 0.198). The median percentage of morphologically normal sperm was higher in the control group than in the study group (6% vs. 5%; P = 0.019). However, no significant difference was found when sperm morphology was dichotomized with the cut-off of ≥4% (74.1% and 74.4%, respectively; P = 0.966). When compared with the WHO reference group, the percentage of men with total motile sperm counts ≥10 million and the percentage of men with normal morphology were significantly lower in both groups. CONCLUSION: Our study suggests that there is no relationship between sexual orientation and sperm parameters.

Hereditary breast cancer and fertility preservation outcomes.

PURPOSE: To determine the frequency of hereditary breast cancer associated with different mutated genes and to evaluate fertility preservation (FP) outcomes among young women with hereditary breast cancer when compared to non-hereditary breast cancer. MATERIAL AND METHODS: A retrospective cohort study of women with breast cancer who underwent fertility preservation treatment at our academic fertility center between 2005 and 2019. We included all women with breast cancer aged < 40 years who had a genetic testing and underwent fertility preservation before starting gonadotoxic therapy (n = 132). Our objective was to evaluate the total number of oocytes retrieved, mature oocytes MII, embryos (where appropriate), cryopreserved oocytes, and/or embryos. RESULTS: Of 132 women with breast cancer, 40 women were found to be genetically positive (31.4%), 31 women of 40 (77.5%) had a BRCA mutation, 3 (7.5%) had ATM, 2 (5%) had CHK2, and one (2.5%) for each of the following genes: PALP2, NF, MUTYH.c.536A, and TP53. There was no significant difference between the groups in the total number of eggs retrieved and the number of MII oocytes and cryopreserved oocytes. The numbers of fertilized oocytes and cryopreserved embryos in the hereditary (n = 40) and non-hereditary (n = 92) group were (5.15 ± 6.6 vs 2.90 ± 4.2, P = 0.054) and (3.35 ± 3.7 vs 1.9 ± 2.8, P = 0.046) respectively. CONCLUSION: More than three quarters of positive mutated genes in women with breast cancer are BRCA mutations. Compared to those with non-hereditary breast cancer, women with hereditary breast cancer attained higher number of cryopreserved embryos.

Effects of embryo retention during embryo transfer on IVF outcomes.

PROPOSE: To investigate embryo retention (ER) rate in embryo transfer (ET) cycles and its effects on reproductive outcomes in a large database. METHODS: A matched retrospective cohort study in a tertiary academic hospital-based reproductive center. A total of 15,321 ET cycles were performed from January 2008 to December 2018. Each woman was matched with three separate control subjects of the same age (± 1 year), embryo condition, main causes of infertility, and type of protocol used for fresh or frozen ET cycles. The main outcomes were ER rate, and implantation, clinical pregnancy, ectopic pregnancy, and live birth rates. RESULTS: The overall incidence of ER was 1.4% (213/15,321). There was no difference in the rate of ER rate in fresh ET cycles compared with frozen transfer cycles (P = 0.54). We matched 188/213 (88%) of cases in the ER group to 564 non-ER cases. There were no cases of the blood in the catheter seen in the ER group. Pregnancy outcomes were similar between the ER and the non-ER cycles: clinical pregnancy rate (31.3% vs. 36.1%, P = 0.29), implantation rate (26.2% vs. 31.3%, P = 0.2), live birth rate (20.3% vs. 24%, P = 0.53), ectopic pregnancy rate (0.5% vs. 0.4%, P = 0.18), and miscarriage rate (10.7% vs. 11.3%, P = 0.53). CONCLUSION: Our results suggest that ER rate does not affect the reproductive outcomes including clinical pregnancy rate, implantation rate, and live birth rate. Patients and physicians should not be concerned about the retention of embryos during transfer since there is no effect on pregnancy outcome.

Management of Hydrosalpinx in the Era of Assisted Reproductive Technology: A Systematic Review and Meta-analysis.

OBJECTIVE: To conduct a systematic review and meta-analysis evaluating the effect of hydrosalpinx on pregnancy outcomes, to compare different types of management of hydrosalpinx and their impact on pregnancy rates as well as on the ovarian reserve. DATA SOURCES: Electronic search using Pubmed, EMBASE, Ovid MEDLINE, Google Scholar, ClinicalTrials.gov, and Cochrane Central Register of Controlled Trials and including all published studies that examined tubal infertility and its management (assisted reproductive technology or surgery) as well as the effects on ovarian reserve. The following medical subject headings (Mesh) terms combinations were used: "fallopian tube disease," hydrosalpinx," "tubal or salpinx occlusion or obstruction," "in vitro fertilization," "fallopian tube surgery," "salpingectomy," "salpingostomy," "infertility," "subfertility," "sterility" and "ovarian reserve." METHODS OF STUDY SELECTION: All randomized trials, cohort, and case controls studies were included. We excluded review articles, meeting abstracts, case series and case reports, and abstracts without access to full texts. The search was limited to trials in humans and published in English. TABULATION, INTEGRATION, AND RESULTS: Our electronic search initially retrieved 6354 articles. Finally, 19 studies were included in the quantitative evaluation of the effects of hydrosalpinx: 23 in the qualitative evaluation and 5 in the quantitative evaluation of different types of hydrosalpinx treatments; and 17 in the quantitative evaluation of ovarian reserve. The presence of a hydrosalpinx was associated with decreased rates of implantation and clinical pregnancy, and increased rates of ectopic pregnancy and miscarriage. Management of hydrosalpinx with salpingectomy, tubal occlusion, or hydrosalpinx aspiration led to better in vitro fertilization pregnancy rates. We found no difference in ovarian response to stimulation after salpingectomy except a decrease in antimüllerian hormone compared to no surgery. CONCLUSIONS: The presence of hydrosalpinx is associated with decreased pregnancy rate and increased rates of ectopic pregnancy and miscarriage. Management of hydrosalpinx, regardless of the type of treatment, leads to an increased chance of pregnancy.

Technicity in Canada: A Nationwide Whole-Population Analysis of Temporal Trends and Variation in Minimally Invasive Hysterectomies.

STUDY OBJECTIVE: The objective of our study was to provide a contemporary description of hysterectomy practice and temporal trends in Canada. DESIGN: A national whole-population retrospective analysis of data from the Canadian Institute for Health Information. SETTING: Canada. PATIENTS: All women who underwent hysterectomy for benign indication from April 1, 2007, to March 31, 2017, in Canada. INTERVENTIONS: Hysterectomy. MEASUREMENTS AND MAIN RESULTS: A total of 369 520 hysterectomies were performed in Canada during the 10-year period, during which the hysterectomy rate decreased from 313 to 243 per 100 000 women. The proportion of abdominal hysterectomies decreased (59.5% to 36.9%), laparoscopic hysterectomies increased (10.8% to 38.6%), and vaginal hysterectomies decreased (29.7% to 24.5%), whereas the national technicity index increased from 40.5% to 63.1% (p <.001, all trends). The median length of stay decreased from 3 (interquartile range 2-4) days to 2 (interquartile range 1-3), and the proportion of patients discharged within 24 hours increased from 2.1% to 7.2%. In year 2016-17, women aged 40 to 49 years had significantly increased risk of abdominal hysterectomy compared with women undergoing hysterectomy in other age categories (p <.001). Comparing women with menstrual bleeding disorders, women undergoing hysterectomy for endometriosis (adjusted relative risk [aRR] 1.36; 95% confidence interval [CI], 1.28-1.44) and myomas (aRR 2.01; 95% CI, 1.94-2.08) were at increased risk of abdominal hysterectomy, whereas women undergoing hysterectomy for pelvic organ prolapse and pelvic pain (aRR 1.47; 95% CI, 1.41-1.53) were at decreased risk. Using Ontario as the comparator, Nova Scotia (aRR 1.35; 95% CI, 1.27-1.43), New Brunswick (aRR 1.25; 95% CI, 1.18-1.32]), Manitoba (aRR 1.35; 95% CI, 1.28-1.43), and Newfoundland and Labrador (aRR 1.18; 95% CI, 1.10-1.27) had significantly higher risks of abdominal hysterectomy. In contrast, Saskatchewan (aRR 0.75; 95% CI, 0.74-0.77) and British Columbia (aRR 0.86; 95% CI, 0.85-0.88) had significantly lower risks, whereas Prince Edward Island, Quebec, and Alberta were not significantly different. CONCLUSION: The proportion of minimally invasive hysterectomies for benign indication has increased significantly in Canada. The declining use of vaginal approaches and the variation among provinces are of concern and necessitate further study.

Evaluation of Open-Access Journals in Obstetrics and Gynaecology.

A retrospective observational study was conducted to evaluate open-access journals in obstetrics and gynaecology, published between 2011 and 2019. Journals were classified based on their registration in open-access journal directories. Of 176 journals, 47 were not registered. Journals registered in the Directory of Open Access Journals (DOAJ) demonstrated good overall quality, and their journal metrics were significantly higher than those of non-registered journals or journals registered in other directories. The lack of editor names and indexing information on a journal's website are the most distinctive features of non-registered journals. Non-registration in an open-access journal directory indicates a lack of transparency and may ultimately indicate that a journal is predatory.

Complete Erosion of Abdominal Cerclage Into the Bladder.

BACKGROUND: Abdominal cerclage is indicated for some women with cervical insufficiency. Long-term complications from cerclage are rare. CASE: Here we report the case of a patient who presented with recurrent urinary tract infection and hematuria 5 years after laparoscopic abdominal cerclage. Cystoscopy revealed bladder stones surrounding a foreign body. Another cystoscopy 3 months later showed complete erosion of the cerclage into the bladder. CONCLUSION: This case reminds us that differential diagnosis of urinary symptoms in women who have undergone cervical cerclage should include suture erosion into the bladder. Cerclage removal can be offered to women who have completed childbearing to prevent this rare complication.

Association Between Bowel Obstruction or Intussusception and Endometriosis.

OBJECTIVE: To evaluate the association between endometriosis and bowel obstruction or intussusception using a large population database. METHODS: This was a population-based study using data from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-NIS) from 2005 to 2014. We studied women aged 18 to 55 years without inflammatory bowel disease or cancer. Multivariate logistic regression was used to examine the association between endometriosis and bowel obstruction. RESULTS: Of the 18 427 520 women who met the criteria for inclusion, 96 539 had experienced bowel obstruction, for an overall prevalence of 52 per 10 000, and 3825 had experienced intussusception, for an overall prevalence of 2 per 10 000. When adjusted for sociodemographic characteristics, women with pelvic endometriosis had a consistently higher likelihood of bowel obstruction (odds ratio [OR] 2.6; 95% confidendence interval [CI] 2.3-3.00, P <0.01). In particular, intestinal endometriosis was associated with a 14.6-fold increased risk of bowel obstruction (95% CI 11.4-18.8, P <0.01), while rectovaginal endometriosis was associated with a 2.00-fold increased risk (95% CI 1.5-2.6, P <0.01). Pelvic endometriosis was significantly associated with adhesive bowel obstruction (adjusted OR: 3.2; 95% CI 2.6-3.9) and non-adhesive bowel obstruction (adjusted OR 2.4; 95% CI 2.0-2.8). The rates of endometriosis among women with or without intussusception were comparable. CONCLUSIONS: Pelvic endometriosis, in particular rectovaginal and intestinal endometriosis is strongly associated with bowel obstruction, independent of the presence of intra-abdominal adhesions. We did not find any association between pelvic endometriosis and intussusception.

Directive clinique no 414 : Prise en charge des grossesses de localisation indéterminée et des grossesses ectopiques tubaires et non tubaires.

OBJECTIF: Fournir un algorithme fondé sur des données probantes pour orienter le diagnostic et la prise en charge de la grossesse de localisation indéterminée et de la grossesse ectopique tubaire ou non tubaire. POPULATION CIBLE: Toutes les patientes en âge de procréer. BéNéFICES, RISQUES ET COûTS: La mise en œuvre de la présente directive a pour objectif de bénéficier aux patientes ayant obtenu un résultat positif pour la sous-unité bêta de la gonadotrophine chorionique et de fournir aux médecins un algorithme normalisé pour l'expectative et le traitement pharmacologique ou chirurgical en cas de grossesse de localisation indéterminée et de grossesse ectopique tubaire ou non tubaire. DONNéES PROBANTES: Les termes de recherche suivants ont été entrés dans les bases de données PubMed-Medline et Cochrane en 2018 : cesarean section, chorionic gonadotropin, beta subunit, human/blood, fallopian tubes/surgery, female, fertility, humans, infertility, laparoscopy, methotrexate, methotrexate/administration & dosage, methotrexate/therapeutic use, pregnancy (abdominal, angular, cervix, cornual, ectopic, ectopic/diagnosis, ectopic/diagnostic imaging, ectopic/drug therapy, ectopic/epidemiology, ectopic/mortality, ectopic/surgery, heterotopic, interstitial, isthmo-cervical, ovarian, tubal, unknown location), recurrence, risk factors, salpingectomy, salpingostomy, tubal pregnancy, ultrasonography, doppler ultrasonography et prenatal. Les articles retenus sont des essais cliniques randomisés, des méta-analyses, des revues systématiques, des études observationnelles et des études de cas. Des publications supplémentaires ont été sélectionnées à partir des notices bibliographiques de ces articles. Seuls les articles en anglais ont été examinés. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la solidité des recommandations en utilisant la méthodologie GRADE (Grading of Recommendations Assessment, Development and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et faibles). PUBLIC VISé: Obstétriciens-gynécologues, médecins de famille, urgentologues, sages-femmes, infirmières autorisées, infirmières praticiennes, étudiants en médecine, résidents et moniteurs cliniques. DÉCLARATIONS SOMMAIRES (CLASSEMENT GRADE ENTRE PARENTHèSES): RECOMMANDATIONS (CLASSEMENT GRADE ENTRE PARENTHèSES).

Guideline No. 414: Management of Pregnancy of Unknown Location and Tubal and Nontubal Ectopic Pregnancies.

OBJECTIVE: To provide an evidence-based algorithm to guide the diagnosis and management of pregnancy of unknown location and tubal and nontubal ectopic pregnancy. TARGET POPULATION: All patients of reproductive age. BENEFITS, HARMS, AND COSTS: The implementation of this guideline aims to benefit patients with positive ß-human chorionic gonadotropin results and provide physicians with a standard algorithm for expectant, medical, and surgical treatment of pregnancy of unknown location and tubal pregnancy and nontubal ectopic pregnancies. EVIDENCE: The following search terms were entered into PubMed/Medline and Cochrane in 2018: cesarean section, chorionic gonadotropin, beta subunit, human/blood, fallopian tubes/surgery, female, fertility, humans, infertility, laparoscopy, methotrexate, methotrexate/administration & dosage, methotrexate/therapeutic use, pregnancy (abdominal, angular, cervix, cornual, ectopic, ectopic/diagnosis, ectopic/diagnostic imaging, ectopic/drug therapy, ectopic/epidemiology, ectopic/mortality, ectopic/surgery, heterotopic, interstitial, isthmo-cervical, ovarian, tubal, unknown location), recurrence, risk factors, salpingectomy, salpingostomy, tubal pregnancy, ultrasonography, doppler ultrasonography, and prenatal. Articles included were randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Additional publications were identified from the bibliographies of these articles. Only English-language articles were reviewed. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE: Obstetrician-gynaecologists, family physicians, emergency physicians, midwives, registered nurses, nurse practitioners, medical students, and residents and fellows. SUMMARY STATEMENTS (GRADE RATINGS IN PARENTHESES): RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

Influence of stage and grade of breast cancer on fertility preservation outcome in reproductive-aged women.

RESEARCH QUESTION: Does breast cancer spread and aggressiveness affect fertility-preservation results? DESIGN: Retrospective cohort study of women with breast cancer undergoing fertility-preservation treatment. INCLUSION CRITERIA: age 18-38 years and use of gonadotrophin releasing hormone antagonist protocol; exclusion criteria: recurrent cancer, previous oncological treatment, previous ovarian surgery and known ovarian pathology. Stimulation cycle outcomes of women with low-stage breast cancer were compared with those with high-stage disease. Patients with low-grade (G1-2) were compared with those with high-grade (G3) malignancies. PRIMARY OUTCOME: total number of mature oocytes; secondary outcomes: oestradiol level and number of follicles wider than 14 mm on the day of trigger, number of retrieved oocytes and cryopreserved embryos. RESULTS: The final analysis included 155 patients. Patients with high-grade tumours (n = 80; age 32 years [28-35]) had significantly lower number of mature oocytes compared with patients with low-grade cancer (n = 75; age 32 years [28-35]; seven mature oocytes [4-10] versus 13 mature oocytes [7-17]; P = 0.0002). The number of cryopreserved embryos was also lower in the high-grade group (three [2-5] versus five [3-9]; P = 0.02). Stage-based analysis revealed a similar number of mature oocytes in high-stage (n = 73; age 32 years [28-35]) compared with low-stage group (n = 82; age 33 years [28-35]; eight mature oocytes [4-13] versus nine mature oocytes [7-15]; P = 0.06). CONCLUSIONS: High-grade breast cancer has a negative effect on total number of mature oocytes and cryopreserved embryos.

Diagnosis and Treatment of Catamenial Pneumothorax: A Systematic Review.

OBJECTIVES: This study aimed to better characterize the phenomenon of catamenial pneumothorax; evaluate the risk factors, symptoms, and diagnostic modalities; and recommend treatment protocol. DATA SOURCES: We conducted an electronic-based search using PubMed, EMBASE, Ovid MEDLINE, Google Scholar, and Cochrane Central Register of Controlled Trials. METHODS OF STUDY SELECTION: The following medical subject heading terms, keywords, and their combinations were used: "catamenial pneumothorax; thoracic endometriosis; pulmonary endometriosis; and pleural endometriosis." TABULATION, INTEGRATION, AND RESULTS: Individual study results were tabulated in each table by outcome of interest. The search produced an initial 404 results. We excluded studies that did not contain cases with catamenial pneumothorax, case studies, and videos. Eighteen studies met our inclusion criteria and were selected, with a total of 490 patients. The prevalence of catamenial pneumothorax of all cases of pneumothorax in women of reproductive age ranges from 7.3% to 36.7%. The diagnosis was made at an older age than that of pelvic endometriosis. The presence of pelvic endometriosis was reported in only 55% of patients with catamenial pneumothorax. Previous pelvic surgeries were mentioned in only a few of the studies, and 52 of 104 cases (50%) had some kind of previous pelvic intervention. Diagnosis was mostly made clinically, with the patients complaining of the typical symptoms of shortness of breath and recurrent chest pain or shoulder pain a day before to 72 hours after menses. Pneumothorax was found mainly in the right lung (456 of 490 cases, 93%). Diaphragmatic endometriosis and/or nodules were observed in 265 of 297 cases (89%). Recurrence rate varied from 14.3% to 55%. CONCLUSION: The possibility of endometriosis should be considered in reproductive-aged women with catamenial symptoms of chest pain or shortness of breath. Right pneumothorax and diaphragmatic endometriosis are found in most patients.

Chronic Endometritis in Fertile and Infertile Women Who Underwent Hysteroscopic Polypectomy.

STUDY OBJECTIVE: To evaluate the prevalence of chronic endometritis (CE) among fertile and infertile women who underwent hysteroscopic polypectomy. DESIGN: A retrospective cohort study. SETTING: University-affiliated tertiary hospital. PATIENTS: A total of 277 women who underwent hysteroscopic polypectomy in the period from 2015 to 2018. INTERVENTIONS: Endometrial polyp samples were obtained after hysteroscopy for histopathologic analysis using hematoxylin-eosin and immunohistochemistry staining with CD138 antibodies for plasma cell detection. All infertile women diagnosed with CE were treated with oral doxycycline 100 mg twice daily for 14 days before infertility treatment. MEASUREMENTS AND MAIN RESULTS: The prevalence of CE in infertile women (n = 137) was significantly higher than in those with no history of infertility (n = 140) (22.6% vs 8.6%; p = .001). The prevalence of CE between women with primary infertility and those with secondary infertility was similar (25.0% vs 19.3%; p = .43). Clinical pregnancy (32.3% vs 41.5%; p = .35), live birth (29.0% vs 38.7%; p = .33), and miscarriage (10.0% vs 6.8%; p = .73) rates were similar between infertile women with treated CE and those without CE. A multivariate model showed that diagnosis of infertility was significantly associated with the diagnosis of CE (odds ratio, 3.16; 95% confidence interval, 1.53-6.49). CONCLUSION: In women with endometrial polyps, the prevalence of CE in infertile women is higher than that in fertile women. Pregnancy outcome in infertile women with treated CE was similar to those who were infertile and without CE.