Optical coherence tomography evaluation of vaginal epithelial thickness during CO2 laser treatment: A pilot study.

Genitourinary syndrome of menopause (GSM) negatively affects more than half of postmenopausal women. Energy-based therapy has been explored as a minimally invasive treatment for GSM; however, its mechanism of action and efficacy is controversial. Here, we report on a pilot imaging study conducted on a small group of menopause patients undergoing laser treatment. Intravaginal optical coherence tomography (OCT) endoscope was used to quantitatively monitor the changes in the vaginal epithelial thickness (VET) during fractional-pixel CO2 laser treatment. Eleven patients with natural menopause and one surgically induced menopause patient were recruited in this clinical study. Following the laser treatment, 6 out of 11 natural menopause patient showed increase in both proximal and distal VET, while two natural menopause patient showed increase in VET in only one side of vaginal tract. Furthermore, the patient group that showed increased VET had thinner baseline VET compared to the patients that showed decrease in VET after laser treatment. These results demonstrate the potential utility of intravaginal OCT endoscope in evaluating the vaginal tissue integrity and tailoring vaginal laser treatment on a per-person basis, with the potential to monitor other treatment procedures.

Reducing day 3 baseline monitoring bloodwork and ultrasound for patients undergoing timed intercourse and intrauterine insemination treatment cycles.

BACKGROUND: In the current context of a global pandemic it is imperative for fertility clinics to consider the necessity of individual tests and eliminate those that have limited utility and may impose unnecessary risk of exposure. The purpose of this study was to implement and evaluate a multi-modal quality improvement (QI) strategy to promote resource stewardship by reducing routine day 3 (d3) bloodwork and transvaginal ultrasound (TVUS) for patients undergoing intrauterine insemination (IUI) and timed intercourse (IC) treatment cycles. METHODS: After literature review, clinic stakeholders at an academic fertility centre met to discuss d3 testing utility and factors contributing to d3 bloodwork/TVUS in IC/IUI treatment cycles. Consensus was reached that it was unnecessary in patients taking oral/no medications. The primary intervention changed the default setting on the electronic order set to exclude d3 testing for IC/IUI cycles with oral/no medications. Exceptions required active test selection. Protocols were updated and education sessions were held. The main outcome measure was the proportion of cycles receiving d3 bloodwork/TVUS during the 8-week post-intervention period compared with the 8-week pre-intervention period. Balancing measures included provider satisfaction, pregnancy rates, and incidence of cycle cancellation. RESULTS: A significant reduction in the proportion of cycles receiving d3 TVUS (57.2% vs 20.8%, p < 0.001) and ≥ 1 blood test (58.6% vs 22.8%, p < 0.001) was observed post-intervention. There was no significant difference in cycle cancellation or pregnancy rates pre- and post-intervention (p = 0.86). Treatment with medications, cyst history, prescribing physician, and treatment centre were associated with receiving d3 bloodwork/TVUS. 74% of providers were satisfied with the intervention. CONCLUSION: A significant reduction in IC/IUI treatment cycles that received d3 bloodwork/TVUS was achieved without measured negative treatment impacts. During a pandemic, eliminating routine d3 bloodwork/TVUS represents a safe way to reduce monitoring appointments and exposure.

Safety and Assisted Reproductive Technology Outcomes of Hysteroscopic Tubal Microinserts Versus Laparoscopic Proximal Tubal Occlusion or Salpingectomy for Hydrosalpinges Treatment.

OBJECTIVE: This study sought to answer the following question: What are the complications and assisted reproductive technology outcomes among women with hydrosalpinges managed by hysteroscopic microinsert tubal occlusion compared with women with hydrosalpinges managed by laparoscopic proximal tubal occlusion or salpingectomy? METHODS: This was a retrospective cohort study conducted from January 2009 to December 2014 at two academic, tertiary care, in vitro fertilization centres in Toronto, Ontario. All patients (n = 52) who underwent hysteroscopic tubal occlusion for hydrosalpinges were identified. Patients who proceeded with embryo transfer cycles after hysteroscopic microinsert (n = 33) were further age matched to a cohort of patients who underwent embryo transfer after laparoscopic proximal tubal occlusion or salpingectomy (n = 33). Main outcome measures were clinical pregnancy rate per patient and per embryo transfer cycle. RESULTS: Among 33 patients, there were 39 fresh and 37 frozen embryo transfer cycles in the hysteroscopic group (group A); among 33 patients in the laparoscopic group (group B), there were 42 fresh and 29 frozen embryo transfer cycles. The cumulative clinical pregnancy rate in group A and group B was similar (66.7% vs. 69.7%, respectively; P = 0.8). The clinical pregnancy rate per embryo transfer cycle was also similar in both groups (28.9% in group A vs. 32.4% in group B; P = 0.6). There were two incidents of ectopic pregnancy in the laparoscopic group and no ectopic pregnancy in the hysteroscopic group. There were three major complications: tubo-ovarian abscess, distal migration of the coil after microinsert placement, and an acute abdomen following the hysteroscopic procedure. CONCLUSION: Pregnancy outcomes after hysteroscopic placement of a microinsert for hydrosalpinx management before embryo transfer were comparable to those following laparoscopic proximal tubal occlusion or salpingectomy. However, caution is advised regarding microinsert placement for hydrosalpinges before proceeding with assisted reproductive technology.

A Quality Improvement Initiative: Using Lean Methodology to Improve Efficiency of the Morning Cycle Monitoring at an Ambulatory Academic Fertility Clinic.

OBJECTIVE: Patients receiving fertility treatments require near-daily blood work and ultrasound for cycle monitoring. Patient volumes at an academic hospital-based ambulatory clinic were expected to increase with expanded provincial funding. The aim of this quality improvement project was for 85% of cycle monitoring patients to have a turnaround time (TAT) of 20 minutes or less from arrival until checkout. METHODS: This is a time series study analyzed with statistical process control methodology. A baseline survey was conducted to understand patient priorities. Multiple site-specific change ideas were developed by front-line staff using lean methodology including standard processes, standard work, supportive tools, visual management, and staffing and scheduling to meet Takt time. Patient and staff satisfaction surveys were conducted after implementation (Canadian Task Force Classification II-2). RESULTS: With the start of funding in December 2015 the clinic accommodated a 17% increase in daily patient volumes and increased the proportion of patients receiving education at each visit from 50% to 100%. Despite increased patient volumes and added education time, the control chart showed special cause variation with decreased TATs from 38.2 to 34.7 minutes. Patient surveys showed that their priorities were being met or exceeded, and all staff reported increased satisfaction with the new process. CONCLUSION: By using lean methodology in an ambulatory fertility setting, the clinic was able to improve efficiency in the morning monitoring process to decrease patient TATs while accommodating increased patient volumes and improving the quality of patient care.

PGD for a carrier of an intrachromosomal insertion using aCGH.

Intrachromosomal insertions are rare and difficult to diagnose. However, making the correct diagnosis is critical for genetic risk assessment, and prenatal and preimplantation genetic diagnosis outcomes. We present a case of preimplantation genetic diagnosis (PGD) using array comparative genomic hybridization (aCGH) following trophectoderm biopsy of embryos created after in vitro fertilization for a carrier of an intrachromosomal insertion on chromosome 1 [46,XX, ins(1)(q44q23q32.1)]. The PGD analysis of 6 blastocysts demonstrated 67% unbalanced embryos. No pregnancy was achieved after the transfer of 2 euploid embryos. To the best of our knowledge, this is the first reported case of PGD using aCGH following trophectoderm biopsy for a carrier of an intrachromosomal insertion.

Laparoscopic myomectomy versus uterine artery embolization: long-term impact on markers of ovarian reserve.

OBJECTIVE: To compare the relative long-term effects on ovarian reserve of treating fibroids in reproductive-aged women with uterine artery embolization (UAE) versus laparoscopic myomectomy (LM), using sensitive measures including antral follicle count (AFC) and serum anti-Müllerian hormone (AMH). METHODS: We undertook a retrospective cohort pilot study to evaluate the utility and feasibility of carrying out a larger prospective trial. Thirteen women were evaluated in this study, including eight in the UAE group and five in the LM group. They were identified from a larger group of 125 women who had undergone LM and 200 women who had undergone UAE at a participating institution at least 12 months previously; of these, 32 who had UAE and 27 who had LM were of reproductive age and eligible to participate. Participants had an assessment of ovarian reserve including measurements of serum AMH, estradiol, and FSH, and ultrasound assessment of AFC and ovarian volume. RESULTS: Median serum AMH levels were significantly lower in women who had undergone UAE at least 12 months previously than in women who had undergone LM (0.78 ng/mL [range 0.67 to 1.28] vs. 2.17 ng/mL [range 1.17 to 2.38], P = 0.01). Median AFC per ovary was also significantly lower in women who had UAE than in those who had LM (3.5 [range 2 to 7] vs. 7 [range 6 to 11], P = 0.03). Median levels of FSH and E2 and of ovarian volume were not significantly different between the two groups. CONCLUSION: Reproductive-aged women who have undergone treatment of fibroids with UAE may have lower ovarian reserve over the long term (> 12 months) than women with fibroids treated with LM. This could have an adverse impact on future response to fertility treatment and/or fecundity. This finding may inform the choice of minimally invasive treatment for fibroids in reproductive-aged women who have not completed childbearing. It suggests that further study in this area is warranted before the application of UAE is expanded to young reproductive-aged women.

Objectif : Comparer, chez des femmes en âge de procréer, la prise en charge de fibromes par embolisation de l'artère utérine (EAU) à leur prise en charge au moyen d'une myomectomie par laparoscopie (ML), pour ce qui est des effets relatifs à long terme sur la réserve ovarienne (déterminés au moyen de mesures sensibles, dont la numération des follicules antraux [NFA] et le taux sérique d'hormone antimüllérienne [HAM]). Méthodes : Nous avons mené une étude de cohorte rétrospective pilote afin d'évaluer l'utilité et la faisabilité de mener un essai prospectif de plus grande envergure. Treize femmes ont été évaluées dans le cadre de cette étude (huit dans le groupe EAU et cinq dans le groupe ML). Elles ont été identifiées à partir d'un groupe plus étendu comprenant 125 femmes qui avaient subi une ML et 200 femmes qui avaient subi une EAU au sein d'un établissement participant au moins 12 mois au préalable; de ces femmes, 32 de celles qui avaient subi une EAU et 27 de celles qui avaient subi une ML étaient en âge de procréer et admissibles à l'étude. Les participantes ont été soumises à une évaluation de leur réserve ovarienne (mesures des taux sériques d'HAM, d'estradiol et de FSH, et évaluation échographique de la NFA et du volume ovarien). Résultats : Les taux sériques médians d'HAM étaient considérablement moins élevés chez les femmes qui avaient subi une EAU au moins 12 mois au préalable que chez les femmes qui avaient subi une ML (0,78 ng/ml [plage : 0,67 - 1,28] vs 2,17 ng/ml [plage : 1,17 - 2,38], P = 0,01). La NFA médiane par ovaire était également considérablement moins élevée chez les femmes qui avaient subi une EAU que chez celles qui avaient subi une ML (3,5 [plage : 2 - 7] vs 7 [plage : 6 - 11], P = 0,03). Le volume ovarien et les taux médians de FSH et d'E2 n'étaient pas considérablement différents d'un groupe à l'autre. Conclusion : Les femmes en âge de procréer qui ont fait l'objet d'une EAU visant la prise en charge de leurs fibromes pourraient présenter, à long terme (> 12 mois), une réserve ovarienne moins élevée que celle des femmes ayant vu leurs fibromes être pris en charge au moyen d'une ML, ce qui pourrait exercer un effet indésirable sur la fertilité et/ou sur la réaction à de futurs traitements de procréation assistée. Cette constatation pourrait éclairer la décision quant au recours à un traitement à effraction minimale pour assurer la prise en charge des fibromes chez les femmes en âge de procréer qui souhaitent encore connaître une ou des grossesses. Elle laisse également entendre que la tenue d'autres études dans ce domaine s'avère justifiée avant que le recours à l'EAU ne soit élargi aux jeunes femmes en âge de procréer.

Does surgical "warming up" improve laparoscopic simulator performance?

INTRODUCTION: The objective of this study was to determine if preoperative warming up by obstetrics and gynecology trainees, using a validated bench model for intracorporeal suturing, improves efficiency, precision, and quality of laparoscopic suturing. METHODS: A randomized crossover design was used. Fourteen obstetrics and gynecology residents were randomized [3 junior (year 2) and 11 senior (years 3-5) residents]. Participants were randomized to warm-up or no warm-up and then acted as their own controls at least 2 weeks later. Warm-up consisted of the use of a laparoscopic bench model to practice intracorporeal suturing for 15 minutes. All participants performed a prevalidated intracorporeal suturing task (after either warm-up or no warm-up), which was scored based on time, precision, and knot strength. Each participant also completed a questionnaire anonymously to determine if they believed that warming up improved their performance, regardless of the score they received. RESULTS: Thirteen participants completed the study. There was no difference in score when warm-up was compared with no warm-up for the group as a whole. When the junior residents were excluded from the analysis, however, analysis of variance showed a significant improvement in score only when a warm-up was completed in the second session (P = 0.022). The questionnaire revealed that 81.8% of participants felt that warming up subjectively improved their ability, independent of their actual score. CONCLUSIONS: This study demonstrates that a preoperative warm-up, combined with repetition, is beneficial in improving senior obstetrics and gynecology residents' laparoscopic suturing performance. This demonstrates a novel approach to resident education for teaching advanced laparoscopic skills.

Maturation and long-term hypoxia-induced acclimatization responses in PKC-mediated signaling pathways in ovine cerebral arterial contractility.

In the developing fetus, cerebral arteries (CA) show striking differences in signal transduction mechanisms compared with the adult, and these differences are magnified in response to high-altitude long-term hypoxia (LTH). In addition, in the mature organism, cerebrovascular acclimatization to LTH may be associated with several clinical problems, the mechanisms of which are unknown. Because PKC plays a key role in regulating CA contractility, in fetal and adult cerebral arteries, we tested the hypothesis that LTH differentially regulates the PKC-mediated Ca(2+) sensitization pathways and contractility. In four groups of sheep [fetal normoxic (FN), fetal hypoxic (FH), adult normoxic (AN), and adult hypoxic (AH)], we examined, simultaneously, responses of CA tension and intracellular Ca(2+) concentration and measured CA levels of PKC, ERK1/2, RhoA, 20-kDa myosin light chain, and the 17-kDa PKC-potentiated myosin phosphatase inhibitor CPI-17. The PKC activator phorbol 12,13-dibutyrate (PDBu) produced robust contractions in all four groups. However, PDBu-induced contractions were significantly greater in AH CA than in the other groups. In all CA groups except AH, in the presence of MEK inhibitor (U-0126), the PDBu-induced contractions were increased a further 20-30%. Furthermore, in adult CA, PDBu led to increased phosphorylation of ERK1, but not ERK2; in fetal CA, the reverse was the case. PDBu-stimulated ERK2 phosphorylation also was significantly greater in FH than FN CA. Also, although RhoA/Rho kinase played a significant role in PDBu-mediated contractions of FN CA, this was not the case in FH or either adult group. Also, whereas CPI-17 had a significant role in adult CA contractility, this was not the case for the fetus. Overall, in ovine CA, the present study demonstrates several important maturational and LTH acclimatization changes in PKC-induced contractile responses and downstream pathways. The latter may play a key role in the pathophysiologic disorders associated with acclimatization to high altitude.

Unexplained amenorrhea in a patient taking methotrexate for the treatment of rheumatoid arthritis.

BACKGROUND: The cause of secondary amenorrhea in the following case cannot be explained by traditional etiologies. We therefore questioned whether long-term methotrexate treatment played a role as an endometrial inhibitor. CASE: A 44-year-old G4P2, with a 5-year history of rheumatoid arthritis, presented with a 2-year history of secondary amenorrhea. The patient took methotrexate since diagnosis. Her FSH, estrogen, prolactin, TSH and T4 levels were normal, her B-HCG was negative, her BMI was 22 and she had no history of Asherman's syndrome. CONCLUSION: There is no information, based on our search, on whether long-term methotrexate treatment has an effect on the menstrual cycle. This case highlights the need for the elucidation of the effects of long-term methotrexate treatment on the menstrual cycle in patients with rheumatoid arthritis.

The glucose intolerance induced by caffeinated coffee ingestion is less pronounced than that due to alkaloid caffeine in men.

Although acute alkaloid caffeine (CAF) ingestion results in an impaired glucose tolerance, chronic coffee (RCOF) ingestion decreases the risk of developing type 2 diabetes. This study examines the hypothesis that CAF ingestion impairs glucose tolerance to a greater extent than RCOF and that the ingestion of decaffeinated coffee (DECAF) results in a positive effect. Eleven healthy males underwent 4 double-blinded randomized trials. Each trial included the ingestion of either: 1) CAF in capsule form (4.45 mg/kg body weight), 2) RCOF (4.45 mg/kg body weight caffeine), 3) dextrose (placebo, PL) in capsule form, or 4) DECAF (equal in volume to the RCOF trial), followed 1-h later by a 2-h oral glucose tolerance test. Blood samples were collected at baseline (-30), 0 (time of treatment ingestion), 60 (initiation of oral glucose tolerance test), 75, 90, 120, 150, and 180 min. Area under the curve for glucose and insulin were higher (P < or = 0.05) following CAF than both PL and DECAF and, although a similar trend (P = 0.07) was observed following RCOF compared with DECAF, the effect was less pronounced. Interestingly, DECAF resulted in a 50% lower glucose response (P < or = 0.05) than PL, suggesting that the effects of PL and DECAF on glucose tolerance are not the same. These findings suggest that the effects of CAF and RCOF are not identical and may provide a partial explanation as to why acute CAF ingestion impairs glucose tolerance while chronic RCOF ingestion protects against type 2 diabetes.