Fertility preservation in patients undergoing gonadotoxic treatments: a Canadian Fertility and Andrology Society clinical practice guideline.

The management of young patients with cancer presents several unique challenges. In general, these patients are ill prepared for the diagnosis and the impact on their fertility. With the improved survival for all tumour types and stages, the need for adequate fertility counselling and a multidisciplinary approach in the reproductive care of these patients is paramount. Recent advances in cryopreservation techniques allow for the banking of spermatozoa, oocytes, embryos and ovarian tissue without compromising survival. This Canadian Fertility and Andrology Society (CFAS) guideline outlines the current understanding of social and medical issues associated with oncofertility, and the medical and surgical technologies available to optimize future fertility.

Residents as supervisors: How senior residents make ad hoc entrustment decisions.

BACKGROUND: As residency programmes transition to competency-based medical education, there has been substantial inquiry into understanding how ad hoc entrustment decisions are made by attending supervisors in the clinical context. However, although attendings are ultimately responsible for the decisions and actions of resident trainees, senior residents are often the ones directly supervising junior residents enrolled in competency-based training programmes. This clinical dynamic has been largely overlooked in the ad hoc entrustment literature. The purpose of this study was to explore the considerations senior residents entertain when making ad hoc entrustment decisions for their junior resident colleagues. METHODS: In semi-structured interviews, 11 senior resident supervisors (third, fourth and fifth year) in obstetrics and gynaecology described how they entrust junior residents with clinical activities in the moment. Following constructivist grounded theory methodology, data were iteratively collected and coded with constant comparison until theoretical sufficiency was determined. RESULTS: Senior residents described many similar considerations as attendings regarding ad hoc entrustment of junior residents, including patient safety, desire to optimise the learning environment, junior resident qualities (such as discernment and communication skills), learner handover from colleagues, and situational factors. Uniquely, senior residents discussed how their role as a middle manager and their desire to protect the junior resident (from burnout, becoming a second victim and from attendings) impacts their decisions. CONCLUSIONS: Although senior residents make ad hoc entrustment decisions with some similar considerations to attendings, they also seem to think about additional factors. It may be that these different considerations need to be accommodated in documentation of ad hoc entrustment decisions if these documents are to be used for high-stakes summative entrustment decisions made by competency committees.

Who Should be Following the Trans-Female Patient Pre and Post Vaginoplasty? An Argument for the Pediatric Gynaecologist.

Increasing numbers of transgender patients are opting for gender-affirming care. Since pediatric and adolescent gynaecology (PAG) providers perform the majority of vaginoplasty procedures for developmental anomalies of the female reproductive tract (such as vaginal agenesis), this commentary supports the position that PAG providers should be involved in the pre- and postoperative care of trans women.

Resident Perspectives on Competency-By-Design Curriculum.

OBJECTIVE: The Royal College of Physicians and Surgeons of Canada is implementing a competency-by-design (CBD) curriculum for residency training across Canada. Although praise and criticism have been published regarding competency-based residency training, little has been published from the resident perspective. The University of Calgary obstetrics and gynaecology residents were surveyed to gather information on their viewpoints and allow their expectations and concerns to be incorporated into the design and implementation process for the curriculum. METHODS: An anonymous survey was administered to residents from the University of Calgary obstetrics and gynaecology program. The survey contained a mixture of Likert-scale responses, multiple-choice questions, and free-text response questions. Summary statistics were used to analyze the Likert-scale and multiple-choice responses, and thematic analysis was performed on free-text responses (Canadian Task Force Classification Level III). RESULTS: The survey respondents identified several anticipated benefits and challenges regarding the CBD curriculum. Overall, resident respondents seemed optimistic about the curriculum redesign; however, many residents identified concerns, including potential impacts on work relationships, challenges with operating room and call scheduling given the less rigid structure of CBD, and the amount of time and effort that evaluation will require. CONCLUSION: Residents offer a valuable perspective on CBD curriculum redesign and implementation. Gathering their input and including it in the curriculum redesign and implementation process will only strengthen the new curriculum and resident buy-in.

No. 313-Menstrual Suppression in Special Circumstances.

OBJECTIVE: To provide a Canadian consensus document for health care providers with recommendations for menstrual suppression in patients with physical and/or cognitive challenges or those who are undergoing cancer treatment in whom menstruation may have a deleterious effect on their health. OPTIONS: This document reviews the options available for menstrual suppression, its specific indications, contraindications, and side effects, both immediate and long-term, and the investigations and monitoring necessary throughout suppression. OUTCOMES: Clinicians will be better informed about the options and indications for menstrual suppression in patients with cognitive and/or physical disabilities and patients undergoing chemotherapy, radiation, or other treatments for cancer. EVIDENCE: Published literature was retrieved through searches of Medline, EMBASE, OVID, and the Cochrane Library using appropriate controlled vocabulary and key words (heavy menstrual bleeding, menstrual suppression, chemotherapy/radiation, cognitive disability, physical disability, learning disability). Results were restricted to systematic reviews, randomized controlled trials, observation studies, and pilot studies. There were no language or date restrictions. Searches were updated on a regular basis and new material was incorporated into the guideline until September 2013. Grey (unpublished) literature was identified through searching websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES: The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). BENEFITS, HARMS, AND COSTS: There is a need for specific guidelines on menstrual suppression in at-risk populations for health care providers.

Fertility Preservation Toolkit: A Clinician Resource to Assist Clinical Discussion and Decision Making in Pediatric and Adolescent Oncology.

PURPOSE: Fertility preservation (FP) discussions in children with cancer presents unique challenges due to ethical considerations, lack of models-of-care, and the triadic nature of discussions. This study evaluated a fertility toolkit for clinicians involved in FP discussions with pediatric, adolescent, and young adult patients and parents. MATERIALS AND METHODS: A survey-based, longitudinal study of clinicians at The Royal Children's Hospital Melbourne involved in FP discussions undertaken at 3 time-points: 2014, alongside an education session for baseline assessment of oncofertility practices (survey 1); after each toolkit use to evaluate case-specific implementation (survey 2); 2016, to evaluate impact on clinical practice (survey 3). RESULTS: Fifty-nine clinicians completed survey 1. Over 66% reported baseline dissatisfaction with the existing FP system; 56.7% were not confident in providing up-to-date information. Only 34.5% "often" or "always" provided verbal information; 14.0% "often" or "always" provided written information. Survey 2 was completed after 11 consultations. All clinicians were satisfied with the discussions and outcomes using the toolkit. Thirty-nine clinicians completed survey 3. Over 70% felt confident providing up-to-date FP knowledge, 67.7% "often" or "always" provided verbal information, and 35.4% "often" or "always" provided written information. CONCLUSIONS: Clinicians desire improvement in FP practice. The toolkit provided significant perceived and actual benefits.

Audit of referrals for concern regarding labial appearance at the Royal Children's Hospital: 2000-2012.

AIM: To audit the clinical features and outcomes for all patients referred to our centre with concerns regarding labial appearance. METHODS: Young females referred to a paediatric/adolescent gynaecology tertiary centre between 2000 and 2012 with concerns regarding their labial appearance were retrospectively identified. Adolescents presenting with anomalies were excluded. Retrospective chart review was undertaken to identify reasons for referral, patient characteristics, outcome of referral and concurrent health problems. RESULTS: In total, 46 females presenting with concerns about labial appearance were identified. Five were excluded. Median age of the study population was 14.5 years (range 5-21 years). Only four (9.8%) underwent surgery after a minimum of five consultations each, with mental health review in three of four cases prior to surgery. None of the 41 patients had documented abnormal labia; however, 6 patients had asymmetry, and 3 had a labial width of >5 cm. Of mothers, 24% (n = 10) raised the initial concern regarding labial appearance to a physician, of whom, 50% of patients had a comorbid condition. In total, 70.7% initially reported interference with daily activities, and 87.8% were reassured following discussion. CONCLUSIONS: With appropriate education and counselling, the majority of girls with concerns regarding labial appearance can be managed without surgery. Overall, our data support current international policy that female cosmetic genital surgery not be performed in mature minors unless there are specific indications. More research about characteristics of patients referred with labial concerns, definition of labial size and long-term satisfaction of conservative versus surgical methods is necessary to determine the best approach.

Dilation and surgical management in vaginal agenesis: a systematic review.

INTRODUCTION: The management of vaginal agenesis is currently determined by geographical location and surgeon preference. The optimal treatment is unknown and the majority of articles on technique and outcome focus on personal case series with little standardisation of reporting and follow-up. METHODS: Six thousand six hundred and ninety-one articles concerning the management of vaginal agenesis were systematically reviewed, with 162 fitting the inclusion criteria. RESULTS: Only one randomised control trial was included with the remaining articles made up of case series or case reports. The bowel vaginoplasty method was most commonly reported historically with 945 patients and 45 articles included. The Vecchietti procedure had the shortest operative time, but the highest number of urological injuries (2.1 %). The split thickness procedure had the highest infection rate (4.2 %) and re-operation rate (7.84 %). CONCLUSION: Overall, the conservative method using dilation had the fewest complications, with an average vaginal length of 6.65 cm (± 1.39 cm). However, with an operative procedure full consent is imperative, as is an understanding of the need for postoperative dilation with the majority of techniques.

Systematic review of sexual function and satisfaction following the management of vaginal agenesis.

Historically, sexual satisfaction following the management of vaginal agenesis was assessed subjectively. Standardized sexual function questionnaires are being used more frequently as instruments to accurately and more objectively assess the subjective nature of sexual outcomes as part of a more holistic approach to the care of women with vaginal agenesis. Articles concerning the management of vaginal agenesis were systematically reviewed, with specific focus on those that discussed functional outcomes, sexual satisfaction and psychosomatic outcomes, and in particular attempted to measure these outcomes. A total of 6,691 articles on vaginal agenesis were identified, with 106 of these reporting sexual satisfaction and psychosomatic outcomes. Only 1 randomized control trial (RCT) was identified, the remaining articles being made up of case series or case reports. Only 17 articles used standardized objective assessment of sexual satisfaction. While the bowel technique had the longest vaginal length at 12.87 cm, it had the most number of complaints of dyspareunia (4.8%), stenosis (10.5%) and the lowest average subjective sexual satisfaction. The Davydov method used standardized sexual function assessments most frequently. This technique had a higher average score than both the bowel vaginoplasty technique in the only RCT and the Vecchietti method in a prospective assessment. Overall, the management of vaginal agenesis requires a multidisciplinary approach to fully support these patients from initial diagnosis, through management decision-making and long-term follow-up, through transition to adulthood.

Menstrual suppression in special circumstances.

OBJECTIVE: To provide a Canadian consensus document for health care providers with recommendations for menstrual suppression in patients with physical and/or cognitive challenges or those who are undergoing cancer treatment in whom menstruation may have a deleterious effect on their health. OPTIONS: This document reviews the options available for menstrual suppression, its specific indications, contraindications, and side effects, both immediate and long-term, and the investigations and monitoring necessary throughout suppression. OUTCOMES: Clinicians will be better informed about the options and indications for menstrual suppression in patients with cognitive and/or physical disabilities and patients undergoing chemotherapy, radiation, or other treatments for cancer. EVIDENCE: Published literature was retrieved through searches of Medline, EMBASE, OVID, and the Cochrane Library using appropriate controlled vocabulary and key words (heavy menstrual bleeding, menstrual suppression, chemotherapy/radiation, cognitive disability, physical disability, learning disability). Results were restricted to systematic reviews, randomized controlled trials, observation studies, and pilot studies. There were no language or date restrictions. Searches were updated on a regular basis and new material was incorporated into the guideline until September 2013. Grey (unpublished) literature was identified through searching websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES: The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). BENEFITS, HARMS, AND COSTS: There is a need for specific guidelines on menstrual suppression in at-risk populations for health care providers. Recommendations 1. Menstrual suppression and therapeutic amenorrhea should be considered safe and viable options for women who need or want to have fewer or no menses. (II-2A) 2. Menstrual suppression should not be initiated in young women with developmental disabilities until after the onset of menses. (II-2B) 3. Combined hormonal or progesterone-only products can be used in an extended or continuous manner to obtain menstrual suppression. (I-A) 4. Gynaecologic consultation should be considered prior to the initiation of treatment in all premenopausal women at risk for abnormal uterine bleeding from chemotherapy. (II-1A) 5. Leuprolide acetate or combined hormonal contraception should be considered highly effective in preventing abnormal uterine bleeding when initiated prior to cancer treatment in premenopausal women at risk for thrombocytopenia. (II-2A).

Objectif : Offrir, aux fournisseurs de soins de santé, un document de consensus canadien comptant des recommandations pour ce qui est de la suppression menstruelle chez les patientes qui font face à des obstacles physiques et/ou cognitifs ou chez les patientes qui font l'objet d'un traitement contre le cancer et pour lesquelles les règles pourraient exercer un effet délétère sur la santé. Options : Le présent document analyse les options disponibles aux fins de la suppression menstruelle, les indications, les contre-indications et les effets indésirables (tant immédiats qu'à long terme) propres à cette dernière, et les explorations et le monitorage nécessaires tout au long de la suppression. Issues : Les cliniciens seront mieux renseignés au sujet des options et des indications propres à la suppression menstruelle chez les patientes qui présentent des déficiences cognitives et/ou physiques et chez les patientes qui font l'objet d'une chimiothérapie, d'une radiothérapie ou d'autres traitements contre le cancer. Résultats : La littérature publiée a été récupérée par l'intermédiaire de recherches menées dans Medline, EMBASE, OVID et The Cochrane Library au moyen d'un vocabulaire contrôlé et de mots clés appropriés (p. ex. « heavy menstrual bleeding ¼, « menstrual suppression ¼, « chemotherapy/radiation ¼, « cognitive disability ¼, « physical disability ¼, « learning disability ¼). Les résultats ont été restreints aux analyses systématiques, aux essais comparatifs randomisés, aux études observationnelles et aux études pilotes. Aucune restriction n'a été imposée en matière de langue ou de date. Les recherches ont été mises à jour de façon régulière et du nouveau matériel a été intégré à la directive clinique jusqu'en septembre 2013. La littérature grise (non publiée) a été identifiée par l'intermédiaire de recherches menées dans les sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et auprès de sociétés de spécialité médicale nationales et internationales. Valeurs : La qualité des résultats est évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs (Tableau). Avantages, désavantages et coûts : La rédaction (à l'intention des fournisseurs de soins de santé) de lignes directrices traitant particulièrement de la suppression menstruelle au sein des populations exposées à des risques s'avère nécessaire. Recommandations 1. La suppression menstruelle et l'aménorrhée thérapeutique devraient être considérées comme étant des options sûres et viables pour les femmes qui doivent ou qui souhaitent obtenir une atténuation ou l'élimination de leurs règles. (II-2A) 2. Chez les jeunes femmes qui présentent des déficiences sur le plan du développement, la suppression menstruelle ne devrait être mise en œuvre qu'après l'apparition des premières règles. (II-2B) 3. Des agents hormonaux combinés ou ne contenant que de la progestérone peuvent être utilisés de façon prolongée ou continue aux fins de l'obtention d'une suppression menstruelle. (I-A) 4. La tenue d'une consultation en gynécologie devrait être envisagée avant la mise en œuvre d'un traitement chez toutes les femmes préménopausées qui sont exposées au risque de connaître des saignements utérins anormaux attribuables à la chimiothérapie. (II-1A) 5. L'acétate de leuprolide ou la contraception hormonale combinée devraient être considérés comme des moyens grandement efficaces d'assurer la prévention des saignements utérins anormaux, lorsqu'ils sont mis en œuvre avant l'administration d'un traitement anticancéreux chez des femmes préménopausées exposées à un risque de thrombocytopénie. (II-2A).

Pregnancy and Placenta Increta in a Noncommunicating Uterine Horn.

BACKGROUND: We present a rare case of pregnancy and invasive placentation in a unruptured, noncommunicating rudimentary uterine horn at 20 weeks' gestation. CASE: The patient was followed with ultrasound throughout early pregnancy and initial imaging for dating purposes showed a pregnancy within a communicating right horn of the uterus. At the 18-week anatomy ultrasound, the pregnancy was discovered to be within the noncommunicating, rudimentary left horn of the uterus. This was confirmed using pelvic magnetic resonance imaging. The patient opted for surgical management and subsequently underwent laparotomy and removal of the noncommunicating uterine horn and pregnancy. Placental tissue was adherent to the level of the serosa during surgery and pathologic diagnosis was significant for a placenta increta. SUMMARY AND CONCLUSION: The patient recovered well from surgery and subsequently went on to have a successful term pregnancy delivered via cesarean section for breech in the right horn 15 months later.

Difficulties in Transition of Care from Pediatric to Adult Gynecology Providers: Should We Maintain Care into Adulthood?

There is evidence that transfer of care for older adolescent patients to adult care is associated with a deterioration in health, especially in those with chronic conditions. Because several specific conditions in pediatric and adolescent gynecology continue into adulthood, it is important that patients have a seamless healthcare transition. In this commentary, it is argued that instead of arranging transfer, long-term retention of patients by the same physician or physician team may be the more caring, patient-centered approach.

Outcomes of renal transplant from donors with polycystic kidney disease.

INTRODUCTION: Kidneys from donors affected by autosomal-dominant polycystic kidney disease (ADPKD) are, in general, considered unsuitable for transplantation. However, some authors report cases of patients who received kidneys from a deceased ADPKD donor showing encouraging outcomes. Our aim is to provide our experience of a patient with end stage renal failure who received a deceased donor kidney from a 29-year-old who themselves had been diagnosed with ADPKD but well maintained renal function, and to provide a comprehensive review of all the published literature. METHODS: In addition to our case, a literature search (PubMed database, Embase, Cochrane Library) of articles published between 1980 and 2017 was performed. RESULTS: Sixteen cases were identified. Median donor age was 24 (range12-55) years old. Median recipient age was 46 (range 19-72) years old. Fifteen cases had a single kidney transplant and one case had a dual kidney transplant. 13/16 (81%) had immediate function, 2 patients (12.5%) had delayed graft function and one patient (6.25%) had primary non-function. Median graft follow up was 36 months (range 6-180). Median serum creatinine at last follow up was 124 µmol/L (range75-442). Thirteen patients (81%) were still alive with a working renal transplant at last follow up. CONCLUSION: The published literature is encouraging and supports the use of polycystic kidneys from younger deceased donors. Therefore, we believe that if kidneys from ADPKD donors are offered, they should have a full assessment and be considered acceptable for renal donation to recipients who may have a life expectancy of 10 years or less and who are fully informed and have the capacity to consent to receiving a polycystic kidney.