MaterCare International in Mission.

MaterCare International (MCI) is an international group of Catholic obstetricians and gynecologists, which has adopted a preferential option for mothers and babies. MCI's mission is to carry out the work of Evangelium Vitae (the Gospel of Life) by improving the lives and health of mothers and babies, both born and unborn. This is achieved through new initiatives of service, training, research, and advocacy, which are designed to reduce the tragic levels of abortion world-wide, and maternal and perinatal morbidity and mortality in developing countries. This paper describes the history of MCI's formation, how it developed and applied a model of comprehensive rural maternity care for developing countries, and numerous other activities upholding the dignity of life and providing advocacy for women and their children. The future of MCI lies in our answer to the 2001 call of Saint Pope John Paul II to the medical profession to "commit whole-heartedly to the service of human life … promoting the ideal of unambiguous service to the miracle of life!"

Hormonally Active Contraceptives, Part II: Sociological, Environmental, and Economic Impact.

To investigate the sociological, environmental, and economic impact of hormonally active contraceptives, a series of comprehensive literature surveys were employed. Sociological effects are discussed including abortion, exploitation of women, a weakening of marriage, and an increase in divorce with deleterious effects on children such as child poverty, poorer health, lower educational achievement, suicide risks, drug and alcohol abuse, criminality, and incarceration, among others. The environmental impact is discussed briefly and includes the feminization and trans-gendering of male fish downstream from the effluent of city wastewater treatment plants with declining fish populations. The potential economic impact of most of these side effects is estimated based on epidemiologic data and published estimates of costs of caring for the diseases which are linked to the use of hormonally active contraceptives. Hormonally active contraceptives appear to have a deleterious impact on multiple aspects of women's health as well as negative economic and environmental impacts. These risks can be avoided through the use of nonhormonal methods and need to be more clearly conveyed to the public. SUMMARY: Hormonal contraceptives have wide-ranging effects.  The potential economic impact of the medical side effects is estimated. Sociological effects are discussed including abortion, exploitation of women, a weakening of marriage and an increase in divorce with negative effects on children such as child poverty, poorer health, lower educational achievement, suicide risks, drug and alcohol abuse, criminality and incarceration among others. The environmental impact includes hormonal effects on fish with declining fish populations. Women seeking birth control have a right to know about how to avoid these risks by using effective hormone-free methods like Fertility Awareness Methods.

Hormonally Active Contraceptives Part I: Risks Acknowledged and Unacknowledged.

Hormonal contraceptives have been on the market for over fifty years and, while their formulations have changed, the basic mechanism of action has remained the same. During this time, numerous studies have been performed documenting side effects, some of which appear over time, some within weeks or months, but all can have a serious impact on health and quality of life. An effort was made to perform a series of comprehensive literature surveys to better understand immediate and long-term side effects of these agents. The results of this literature review uncovered a number of potential side effects, some of which are acknowledged and many of which are not noted in the prescribing information for these agents. Among the unacknowledged side effects are: an increased risk of HIV transmission for depot medroxyprogesterone acetate (DMPA), and for combination contraceptives breast cancer, cervical cancer, Crohn's disease, ulcerative colitis, systemic lupus erythematosus, depression, mood disorders and suicides (especially among women twenty-five years of age and younger, in the first six months of use), multiple sclerosis, interstitial cystitis, female sexual dysfunction, osteoporotic bone fractures (especially for progesterone-only contraceptives), and fatty weight gain. Misleading prescribing information regarding cardiovascular and thrombotic risks are also noted. Women seeking birth control have a right to be informed and educated about risk avoidance through the use of effective nonhormonal methods like fertility awareness methods. In one case-that of DMPA-the increased risk of HIV acquisition has been conclusively demonstrated to be both real and unique to this drug. Considering the availability of numerous alternatives, there is no justification for the continued marketing of DMPA to the public. SUMMARY: We reviewed the effect of hormonal contraceptives on women's health. A number of potential side effects were noted including increased risks of breast cancer, cervical cancer, inflammatory bowel  disease, lupus, multiple sclerosis, cystitis, bone fractures, depression, mood disorders and suicides,  fatty weight gain, and female sexual dysfunction.  With the long-acting injectable contraceptives there is an increased risk of getting HIV.  Misleading prescribing information regarding the risks of heart attacks, strokes and blood clotting problems were also noted. Women seeking birth control have a right to know about how to avoid these risks by using effective hormone-free Fertility Awareness Methods.

COVID-19 Vaccination: Guidance for Ethical, Informed Consent in a National Context.

This Guidance addresses the essential elements of informed consent to novel, provisionally registered COVID-19 vaccines which conform to the current definition of an investigational vaccine namely, lacking requirements for approval for full registration. 1 First, it addresses the ethical obtaining of informed consent in a setting of short and long term knowns and unknowns, by structuring the personal nature of informed consent into its twelve component parts. Second, as a guidance for family physicians, it explores reasonable medical concerns arising for individuals from both knowns and unknowns about COVID-19 disease and vaccines.Where there are waves of pandemic pressure impelling political, economic, social and public health forces to promote vaccination to health care providers and their patients, the necessary constituents of valid informed consent can be sublimated and possibly forfeited. This context of informed consent for COVID-19 vaccines is not unique to Australia. The analysis and presentation of international data by Australian Government agencies is a process occurring in all countries. Therefore, the Australian experience of consenting for vaccination is relevant to informed consent across the globe.The purpose of this Guidance is to assist personalised risk-benefit assessment for the informed consent of the vaccinee. Its aim is not to give a therapeutic guide nor to draw conclusions which can only rightly be drawn pertaining to each individual recipient in discussion with a health care provider. This is especially true in the setting of incomplete research where the many unknowns may be more significant for some than others. Since data is changing over time, national tables have not been used for specifics which the vaccine provider should access at the time of consultation.While we recommend the Guidance be read in conjunction with Government issued information, this Guidance will address specific fields relevant to informed consent which may not be addressed in those communications, but which a consenting individual as a person with their own values and experiences may wish to know. Aim: To address the requirements of ethical informed consent of the individual adult in the context of reasonable concerns pertaining to the unknowns and incomplete research attending novel, provisionally registered COVID-19 vaccines. Methodology: To elucidate what might be reasonable concerns for individuals considering vaccination, Public Assessment Reports of regulatory authorities (Food and Drug Administration and Therapeutic Goods Administration) and published trials of currently available vaccines were reviewed. International Covid-19 vaccine safety discussions were observed for peer-reviewed and, if necessary, pre-print references base. These references were studied for potential relevance to vaccine recipients. Vaccine Development Guidelines were also reviewed for pre-clinical requirements and compared with pre-clinical data presented at licensing. Missing information was requested from the Therapeutic Goods Administration (TGA).Pertinent unknowns were thereby identified as issues potentially relevant to fully informed consent, and compared with the content of standard Government-issued vaccine consent advice forms. Disparities were selected as relevant unknowns or reflecting incomplete research.Pertinent issues were incorporated into a twelve point structure for reasonable consideration to guide ethical inform consent. Paediatric COVID disease and vaccination are mentioned briefly due to paediatric vaccination being unapproved in Australia at the time of writing in under 12-year-olds, and exclusion of minors from phase III safety and efficacy trials. Conclusion: The provision of ethically obtained, fully informed consent is very pertinent to an investigational vaccine notwithstanding the pandemic context. To ascertain informed consent to the best of our ability, the gap between officially delivered information and reasonable concerns generated by knowns and relevant unknowns, can be addressed in a structured manner by physicians. Consent should not be coerced but be free of inducements and reprisals, respecting declarations of human rights, particularly given the investigational nature of COVID-19 vaccines. Each recipient requires adequate information to make their own judgment. The process of validly informed consent will therefore include discussion of concerns and of relevant information we do and do not yet have. Ethical informed consent should address those concerns as best is possible.

Recent trends in the management of pelvic organ prolapse in Australia and New Zealand.

OBJECTIVE: To compare current practice in the management of female pelvic organ prolapse in Australia and New Zealand with that in 2007, and assess the impact on practice of the withdrawal of Prolift® and Prosima® mesh kits in 2015. MATERIALS AND METHODS: In early 2015, two invitations to participate in a survey, including a link to Surveymonkey, were emailed to 2506 Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) trainees and fellows. The online survey closely resembled a printed survey that was posted to RANZCOG trainees and fellows in 2007 and had additional questions relating to the impact of withdrawal of Prolift® and Prosima® products. RESULTS: Four-hundred-and-three doctors participated, giving a response rate of 16%. Native tissue repair was the procedure of choice for primary and recurrent prolapse of the anterior and posterior vaginal wall. An implant was used to treat 45% of anterior recurrences and 25% of posterior recurrences. Vaginal hysterectomy and repair were the procedures of choice for uterovaginal prolapse. Sacrospinous hysteropexy was the uterine preservation procedure of choice, preferred by 41%. For post-hysterectomy vault prolapse, sacrospinous colpopexy and vaginal repair was preferred by 65% of respondents. Between 2007 and 2015, there was a substantial decrease in respondents' usage of implants across all indications except for midurethral slings and sacrocolpo/hysteropexy. Forty-two percent of respondents changed their practice as a result of Prolift® and Prosima® being withdrawn. CONCLUSION: There is a trend toward increasing use of various native tissue prolapse repair procedures and midurethral slings, and less utilisation of transvaginal mesh for prolapse.

Long-term outcomes of laparoscopic repair of cystocoele.

BACKGROUND: There is little information on the effectiveness of laparoscopic techniques for native tissue repair of cystocoele. AIM: To assess the long-term outcome of laparoscopic cystocoele repair. METHODS: Two hundred and twenty-three women with symptomatic pelvic organ prolapse underwent laparoscopic paravaginal repair and treatment of associated conditions. Women were assessed pre-operatively and postoperatively at 6 weeks, 6 months, 12 months and then annually or biannually with pelvic organ prolapse quantification (POPQ) and subjective assessment at each visit. RESULTS: Median follow-up was 5.2 years (range: 1-12 years) with 140 women (63%) followed for at least 5 years. During follow-up, 79% of women developed prolapse of at least POPQ stage 2 in one or more compartments and 58% became symptomatic again. Overall, 48% underwent further prolapse surgery, but only 24% of women had an anterior prolapse beyond the hymen. Thirty per cent eventually had a further cystocoele repair. CONCLUSION: Long-term follow-up of laparoscopic cystocoele repair shows that cystocoeles are difficult to repair successfully.

Effect of uterine preservation on outcome of laparoscopic uterosacral suspension.

STUDY OBJECTIVE: To compare the objective outcome of laparoscopic uterosacral hysteropexy with that of hysterectomy combined with laparoscopic uterosacral colpopexy. DESIGN: Retrospective cohort study, 1999-2010 (Canadian Task Force classification II-2). SETTING: University hospital in South Australia. PATIENTS: Women with uterovaginal prolapse who had undergone laparoscopic uterosacral hysteropexy (n = 104) or laparovaginal hysterectomy with uterosacral colpopexy (n = 160). Apical suspension procedures were subdivided into prophylactic (Pelvic Organ Prolapse Quantification System [POP-Q] stage 1 apical descent, with stage ≥2 prolapse in an adjacent compartment) and therapeutic (POP-Q stage ≥2 apical descent, with or without adjacent compartment prolapse). INTERVENTIONS: All patients were assessed via POP-Q scoring preoperatively and postoperatively at 6 weeks, 6 months, annually, and then biannually. Recurrence of bulge symptoms and need for repeat treatment were recorded. MEASUREMENTS AND MAIN RESULTS: Demographic data, preoperative degree of prolapse, and percentages of prophylactic and therapeutic procedures were similar in both groups. With a median follow-up of 2.5 years, objective success rates (POP-Q stage <2 in all compartments) for uterosacral hysteropexy were 53% for prophylactic procedures and 41% for therapeutic procedures, and for hysterectomy with uterosacral colpopexy were 66% for prophylactic procedures and 59% for therapeutic procedures. Repeat operation rates overall were 28% for hysteropexy and 21% for hysterectomy with colpopexy. Failures at the apex specifically were 27% for hysteropexy and 11% for hysterectomy with colpopexy (p < .02). CONCLUSION: Hysterectomy with laparoscopic uterosacral colpopexy produced better objective success rates than did laparoscopic uterosacral hysteropexy; however, repeat operation rates were not significantly different.

Use of surgisis for treatment of anterior and posterior vaginal prolapse.

Aim. To evaluate the anatomical success and complication rate of Surgisis in the repair of anterior and posterior vaginal wall prolapse. Methods. A retrospective review of 65 consecutive Surgisis prolapse repairs, involving the anterior and/or posterior compartment, performed between 2003 and 2009, including their objective and subjective success rates using the pelvic organ prolapse quantification (POPQ) system. Results. The subjective success rate (no symptoms and no bulge beyond the hymen) was 92%, and the overall objective success rate (no subsequent prolapse in any compartment) was 66% (43 of 65). The overall reoperation rate for de novo and recurrent prolapse was 7.7% with 3 women undergoing repeat surgery at the same site (anterior compartment). No long-term complications occurred. Conclusions. Surgisis has a definite role in the surgical treatment of prolapse. It may decrease recurrences seen with native tissue repair and long-term complications of synthetic mesh. Its use in posterior compartment repair in particular is promising.

Laparoscopic supralevator repair for combined apical and posterior compartment prolapse.

STUDY OBJECTIVE: To analyze the objective outcome of laparoscopic supralevator repair in the treatment of rectoenterocele with the Pelvic Organ Prolapse Quantification (POPQ) system. STUDY DESIGN: Retrospective cohort study 1999-2009 (Canadian Taskforce Classification II-2). SETTING: University hospital in South Australia. PATIENTS: A total of 166 women with a median age of 63 years (range 36-89) who underwent laparoscopic supralevator repair for rectoenterocele and treatment of associated conditions over a 10-year period. INTERVENTIONS: All patients were assessed with the POPQ scoring system before surgery and at 6 weeks, 6 months, annually, and biannually after surgery. MEASUREMENTS AND MAIN RESULTS: The median operating time was 151 minutes (range 35-390); median blood loss was 50 mL (range 50-600); and median hospital stay was 4 days (range 1-14). Four women, 2 of whom required laparotomy, had a major complication. Ten women (6%) needed day surgery to treat vaginal granulations or suture exposure. With a median follow-up time of 45 months (interquartile range 16-67) the overall objective success rate was 63% according to National Institute of Health criteria. The median time to failure was 24 months. Of 61 objective failures, 23 required further prolapse surgery, representing a 14% reoperation rate. CONCLUSION: Laparoscopic supralevator repair is a safe and effective procedure for the treatment of rectoenterocele.

Laparoscopic paravaginal repair of anterior compartment prolapse.

STUDY OBJECTIVE: To assess the results of laparovaginal repair of anterior vaginal prolapse in terms of perioperative morbidity and repair durability. DESIGN: Longitudinal study of a consecutive series of women assessed with the pelvic organ prolapse quantification (POPQ) system before and after laparoscopic paravaginal repair of anterior vaginal prolapse (Canadian Task Force classification II-2). SETTING: University hospital in South Australia. PATIENTS: Two hundred twelve women undergoing laparoscopic paravaginal repair for anterior compartment prolapse, with average follow-up of 14.2 months and 10 (4.7%) lost to follow-up. INTERVENTIONS: All women underwent bilateral laparoscopic paravaginal repair that was combined with uterosacral hysteropexy or colpopexy in women with concomitant level I defects (n = 42) and supralevator repair in those with posterior fascia defects (n = 47). Recurrences were treated with graft-reinforced anterior colporrhaphy (n = 18). MEASUREMENTS AND MAIN RESULTS: Nine women (4.2%) had major complications, and there were 61 minor complications. The POPQ assessment on follow-up (mean 14.2 months) gave a prolapse cure of the laparoscopic repair of 76% (95% CI 70.7%-82.1%). Eighteen of 23 women with a residual central defect subsequently had a graft-reinforced anterior colporrhaphy, after a mean interval of 14 months, which increased the cure rate to 84% (95% CI 79.6%-89.3%). CONCLUSION: Laparoscopic paravaginal repair followed by graft-reinforced anterior colporrhaphy for central defects, when necessary, is associated with a low morbidity rate and achieves an anatomic cure rate greater than 80%.

Laparovaginal hysterectomy: a decade of evolution.

OBJECTIVE: To compare surgical outcomes for laparoscopically-assisted vaginal hysterectomy (LAVH) to total laparoscopic hysterectomy (TLH) and to document the modifications to the technique of laparovaginal hysterectomy which have occurred over the last decade at Flinders Endogynaecology, South Australia, Australia. The method of choice at the start of the decade was LAVH and by the end of the study period it had been superceded by TLH. SAMPLE: Seven hundred and ninety-four consecutive women underwent hysterectomy between January 1992 and December 2001 at Flinders Endogynaecology. This included 424 women who underwent TLH and 370 who underwent LAVH. METHODS: Retrospective review of case history notes and manual extraction of data. MAIN OUTCOME MEASURES: Demographic data including patient age, weight and parity were extracted. Intraoperative complications including ureteric injury, cystotomy, bowel damage or conversion to open procedure were recorded. The rate of non-autologous blood transfusion was recorded and miscellaneous data including length of procedure, estimated blood loss, length of hospitalisation, concomitant procedures carried out and re-admission rates were also recorded. RESULTS: There was a statistically significant reduction in major morbidity in the TLH group when compared to the LAVH group. The lower rate of conversion to laparotomy in the TLH group was statistically significant (3.0 vs 0.9%). A non-significantly higher rate of ureteric injury was observed in the TLH group (0.7 vs 0.3%). Other outcome measures showed a trend toward an improved outcome for TLH but were not statistically significant. This includes a lower rate of bowel injury in the TLH group (0 vs 0.3%), a lower rate of cystotomy in the TLH group (1.4 vs 3.0%) and lower rate in non-autologous blood transfusion in the TLH group (1.2 vs 3.0%). There was a statistically significant reduction in hospital stay from 4.5 days in the LAVH group to 3.4 days in the TLH group. CONCLUSION: The evolution of laparovaginal hysterectomy from LAVH to TLH over the last 13 years has resulted in improved patient outcomes. Ongoing modification of the technique to ensure ureteric protection must remain a priority.

Laparoscopic treatment of enterocele: a 3-year evaluation.

OBJECTIVE: To report the morbidity associated with the laparoscopic treatment of enteroceles and assess the durability of the repair. DESIGN: Prospective observational study. SETTING: University Teaching Hospital. POPULATION: Forty-five consecutive women with symptomatic enteroceles who underwent laparoscopic treatment of an enterocele. MAIN OUTCOME MEASURES: Objective urogynaecological assessment using the pelvic organ prolapse quantification system. RESULTS: The 11% incidence of anterior wall prolapse is lower than that associated with previous reports of surgical procedures to treat enterocele. There is a 4.4% incidence of major complications. The procedure has been demonstrated to have a 93% success rate at 3 years in treating enterocele. CONCLUSION: The laparoscopic enterocele sac excision and vaginal vault suspension fulfils Richardson's requirements for surgical correction of enterocele and provides an anatomic solution to the long-standing surgical dilemma of enterocele.

Pregnancy following endometrial ablation: case history and literature review.

UNLABELLED: A total of 43 pregnancies that occurred subsequent to endometrial ablation were reported to July 2002. Only 17 of these pregnancies had progressed beyond 20 weeks. We report a successful planned pregnancy following endometrial ablation and sterilization reversal, culminating in vaginal birth after a previous Caesarean section. The English literature has been reviewed to ascertain family planning practices, uterine cavity assessment and pregnancy outcomes after endometrial ablation/resection. Pregnancy management recommendations are provided. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader will be able to list the various pregnancy complications associated with a history of endometrial ablation, and to describe the changes in the endometrial cavity following endometrial ablation.

Two-year experience with laparoscopic pelvic floor repair.

STUDY OBJECTIVE: To evaluate the cumulative experience at our institution of laparoscopic pelvic floor repair to treat genital prolapse and associated symptoms. DESIGN: Retrospective analysis (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: Seventy-three consecutive women treated surgically for symptomatic genital prolapse. INTERVENTION: Surgical treatment was site specific depending on findings on physical examination. Anterior compartment defects were treated by laparoscopic paravaginal repair, laparoscopic Burch colposuspension, or transvaginal anterior vaginal repair. Defects in the posterior compartment were treated by a combination of laparoscopic supralevator repair, laparoscopic vaginal vault suspension, enterocele sac invagination or excision, and transvaginal posterior vaginal repair. Anatomic defects in the apical compartment were primarily treated by laparoscopic vaginal vault suspension and enterocele sac excision. Patients whose anatomic anomalies contained elements of anterior, posterior, and apical compartments were classified in a global group. MEASUREMENTS AND MAIN RESULTS: Preoperatively, prolapse was considered as an attachment or fascial defect at DeLancey level I, II, or III. Each was then quantified by the pelvic organ prolapse quantification (POPQ) system and compartmentalized according to site of the major defect. Women were assessed by physical examination and repeat POPQ staging 6 weeks postoperatively and every 6 months thereafter. A standard interview was administered to assess functional status. Major complications occurred in 4.1% of women. Objective and subjective cure rates were 90% at 2 years. CONCLUSIONS: Laparoscopic pelvic floor repair is an effective procedure with low morbidity. It should play a primary role in surgical management of DeLancey levels I and II attachment defects. For fascial defects, in particular DeLancey level II anteriorly and posteriorly, it should be complemented with vaginal repair.

Total laparoscopic hysterectomy: a new option for removal of the large myomatous uterus.

This is the first report of a series of women who underwent total laparoscopic hysterectomy (TLH) to remove a large myomatous uterus weighing more than 390 g. The case history notes of 21 women undergoing TLH in both the private and public sectors of Flinders Endogynaecology were studied. The mean uterine weight was 534.7 g (390-1,022 g). The mean operating time was 155.0 +/- 56.1 minutes and mean blood loss was 297.6 mL (50-1,000 mL). The mean hospital stay was 3.2 +/- 1.0 days. The two complications were a post-operative deep venous thrombosis (DVT) and an estimated blood loss of 1000 mL in separate cases. Total laparoscopic hysterectomy is a low morbidity procedure offering a new option for the removal of the large myomatous uterus and avoidance of abdominal hysterectomy