Assessment of operator performance during oocyte retrievals: residents' learning curve and continuous monitoring of senior physicians.

BACKGROUND: The learning curve cumulative summation test (LC CUSUM test) allows to define an individualized learning curve and determine the moment when clinical proficiency is attained. After acquisition of the skills, the cumulative summation test (CUSUM test) allows to monitor the maintenance of the required level over time. The LC CUSUM test has been frequently used in the field of Obstetrics and Gynecology (Ob/Gyn) for several procedures, but only once for OR. METHODS: We performed a retrospective study at Angers university hospital between May 2017 and September 2018. Seven Ob/Gyn residents and 5 senior physicians were included, and all OR performed during that time (n = 690) were analyzed. The performance index assessed was the oocyte retrieval rate (ORR), defined as the ratio of oocytes retrieved to follicles aspirated. We used the LC CUSUM test to analyze the learning curves of residents, and the CUSUM test to monitor the performance of senior physicians. An ORR ≥50% in 60% of retrievals was defined as the threshold for clinical proficiency. RESULTS: Six hundred seventy-four oocyte retrieval (OR) were included: 315 were performed by residents, 220 by senior physicians, and 139 by both residents and physicians (mixed retrievals). Four residents (57%) reached the threshold after aspirating 82, 67, 53 and 46 ovaries, respectively. The mean number of ovaries aspirated in order to reach clinical proficiency was 62, and the mean number of weeks needed was 21. The duration of the learning period varied between 26 and 80 days. Two senior physicians (40%) remained proficient across the duration of the study, while two physicians (40%) had one statistically "suboptimal" OR, and one physician (20%) had two suboptimal retrievals. CONCLUSION: There is a large variability in the duration of the learning period and the number of procedures needed for a resident to master OR. Senior physicians maintain an adequate performance.

Surgical treatment of septate uterus in cases of primary infertility and before assisted reproductive technologies.

Septate uterus is the most common congenital uterine malformation in women with infertility. Several criteria are available for the definition of septate uteri, such as the one proposed by the European Society of Human Reproduction and Embryology (ESHRE)/European Society for Gynecological Endoscopy (ESGE) (ESHRE/ESGE), or by the American Society for Reproductive Medicine (ASRM), with notable differences between the two. Recently, a simplified classification was proposed by the Congenital Uterine Malformations Experts (CUME), where a septum is defined as an internal indentation depth≥10mm. To date, there is no consensus on the management of women with a septate uterus and infertility. We have performed an extensive literature appraisal and reviewed all the available international guidelines in order to propose a management strategy for infertile patients with a uterine septum. Hysteroscopic septum incision seems to improve natural conception rates in the year following surgery. Moreover, it improves in vitro fertilization (IVF) outcomes when performed before the embryo transfer, by improving embryo implantation rates. On the other hand, for patients with an arcuate uterus (indentation<1.5cm according to the ASRM guidelines) and infertility, it seems that assisted reproductive technologies are the most appropriate first line treatment. However, in cases of recurrent implantation failure or recurrent pregnancy loss following IVF, hysteroscopic section could be proposed. Overall, we recommend hysteroscopic septum incision for patients with primary infertility, and for patients undergoing assisted reproductive technologies.

[Training of medical students for pelvic examination: Benefits of teaching on anatomic models]. / Formation des externes à l'examen gynécologique : intérêt de l'enseignement sur modèles anatomiques.

OBJECTIVES: To evaluate the benefits of training sessions for pelvic examination using anatomic models. MATERIAL AND METHODS: The medical students (MS) registered in their 5th year of medical studies at Angers University Hospital had to complete two anonymous questionnaires; one at the beginning of the workshop and one at the end. Every procedure which included pelvic exam (PE), vaginal sample (VS), smear test (ST), insertion of a speculum and insertion of intra-uterine device (IUD) was evaluated. RESULTS: Seventy-one MS answered both questionnaires. They were very satisfied or satisfied with the outcomes of the workshop in 91 % of the cases. At the beginning of the workshop, 28 %, 52 %, 30 %, 25 % and 3 % reported a low level of difficulty to carry out, respectively, a PE, VS, ST, insertion of a speculum, insertion of an IUD. At the end of the session, there were respectively 55 %, 83 %, 76 %, 66 % and 16 % of MS to report a low level of difficulty of these same procedures. For all of these procedures, there were a significant (P<0.05) number of MS who estimated the procedure's level of difficulty as being low at the end of the session. CONCLUSION: The level of technical difficulty of all procedures was significantly decreased at the end of the workshop.

[The influence of exogenous LH/hCG activity on serum progesterone levels on the day of hCG administration in in vitro fertilization]. / Influence de l'activité LH/hCG exogène sur le taux sérique de progestérone le jour de l'hCG en fécondation in vitro.

OBJECTIVES: Clarifying whether the addition of recombinant LH (rLH) to recombinant FSH (rFSH) leads to progesterone (P4) levels on dhCG comparable to those obtained with stimulation with FSH and hCG (HP-hMG) MATERIALS AND METHODS: Pituitary-desensitized patients, matched for age and follicle reserve, received rFSH+LH (n=729) or HP-hMG (n=729). In the rFSH+rLH group, rLH (75 UI/day) was started at day 6. To control for the influence of ovarian response on P4, we divided serum P4 levels by the number of growing follicles (13-22 mm; "per follicle" P4 levels) and performed a multivariate analysis. RESULTS: Serum P4 levels on dHCG were lower in the HP-hMG (median: 0.63 ng/mL, max-min: 0.10-2.97) than in the rFSH+rLH group (0.91 ng/mL; 0.10-4.65, P<0.0001), as well as "per-follicle" P4 levels (0.055 ng/mL/growing follicle, 0.006-0.284 vs 0.077 ng/mL/growing follicle, 0.003-0.336; P<0.0001). CONCLUSIONS: HP-hMG led to lower P4 levels on day hCG than rFSH+rLH irrespective of the intensity of the ovarian response and the adjunction of rLH (75 IU/day from day 6 onward).

[Awareness and knowledge about risks of drinking during pregnancy in pregnant Lebanese women]. / Les conduites d'alcoolisation des femmes enceintes libanaises et leurs connaissances sur les risques et répercussions sur l'enfant à naître.

OBJECTIVE: To assess the awareness and knowledge of pregnant Lebanese women about the risks of drinking during pregnancy and the factors that influence their drinking patterns. MATERIALS AND METHODS: A prospective study was conducted on a sample of 107 women consulting the gynecology outpatient department of Hôtel-Dieu de France in Beirut, Lebanon, who completed the T-ACE screening test included in a 21 multiple choice questionnaire which examine knowledge and beliefs about alcohol use during pregnancy, drinking patterns and awareness of fetal alcohol exposure. RESULTS: The 107 women of our sample were all married, between 20 and 41 years old and had mostly a high educational level (86%). Most of the women (47%) were at their first pregnancy. Of the 20 women who self-reported drinking during pregnancy, 60% obtained a positive score on the T-ACE questionnaire, which indicates that more than 11% of the women engaged with potentially high risk drinking for the baby. There is not a significant difference between the different age categories or educational levels. This proportion is lower than that found in international publications. However, the rate of excessive drinking (4 drinks or more on any one occasion in females) was higher and one woman in five reported excessive drinking in the previous year. There is a high level of knowledge that alcohol use during pregnancy is harmful to the child, and the more consumption the more harmful and likely the effects, but there is confusion about the safety of small amounts of alcohol. Women (37%) think that there is a safe level of drinking during pregnancy; 29% tolerate up to one drink a month, 9% tolerate up to one drink a week and one woman thinks having one drink a day is safe. Women who actually drink during pregnancy are more likely to think that alcohol consumption to a certain level is safe. Women (31%) think that beer and/or wine are safe alcohols to a certain level during pregnancy. When asked about the source of this belief, 22% mention a gynecologist but the majority (61%) says it is a personal belief. Women (65%) in our sample are aware that alcohol use during pregnancy can lead to life-long disabilities in a child, such as delayed development (36%), birth defects/deformities (35%) and mental retardation (32%). However, up to 33% of the respondents report having no information about the effects of alcohol on the fetus and two women believe alcohol is not harmful at all. Women with lower levels of education are somewhat less knowledgeable about the risks of alcohol use during pregnancy than those with higher levels of education. There is no association between the drinking patterns of the women with their age, their professional habits and the alcohol consumption of their husbands. The women in our sample seem to be more aware of the necessity to stop smoking rather than stop drinking during pregnancy. CONCLUSION: Lebanese women are not fully aware of the recommendations and risks related to drinking during pregnancy. This is the reason why action must be taken to ensure better diffusion of these recommendations and better assessment of alcohol intake during prenatal visits.