National Canadian Survey on the Management of Noneuploid Embryos.

OBJECTIVE: To comprehensively describe current preimplantation genetic testing for aneuploidy (PGT-A) practices and management of non-euploid embryos in Canada. METHODS: This was a cross-sectional study utilizing an online survey distributed by email to all medical directors of fertility clinics with independent in vitro fertilization (IVF) embryology laboratories. The survey was designed to determine practice patterns regarding PGT-A usage; PGT-A reference laboratory, platform, and thresholds for classifying embryos; and management of embryos classified as mosaic, inconclusive, or aneuploid. RESULTS: Twenty-five medical directors (69%) participated in the survey. The majority of clinics (91%) offered PGT-A screening, with 45% of clinics offering PGT-A as routine screening. The majority of clinics (90%) that offered PGT-A received mosaicism data; 61% of these clinics had transferred mosaic embryos, and 94% would transfer mosaic embryos. Clinics that performed ≥1000 IVF cycles annually were more likely to have transferred mosaic embryos (100% vs. 45.5%; P = 0.043). The mean percentage of IVF cycles using PGT-A was lower in clinics that had transferred mosaic embryos (12.3% vs. 30.4%; P = 0.033). Only 1 clinic had transferred an aneuploid embryo, but 2 other clinics would consider this option. The majority of clinics (61%) that receive mosaicism data would recommend noninvasive prenatal testing (NIPT) following mosaic embryo transfer, with 22% of clinics indicating that this would be the only genetic test offered. CONCLUSION: We report significant practice variation in PGT-A and management of non-euploid embryos across Canada and highlight areas where consensus should be encouraged.

Assisted hatching of vitrified-warmed blastocysts prior to embryo transfer does not improve pregnancy outcomes.

OBJECTIVE: This study aims to determine the impact of assisted hatching (AH) on pregnancy outcomes in vitrified-warmed blastocyst transfers, and evaluate if embryo expansion or morphology influences outcomes. METHODS: A retrospective cohort study was performed including vitrified-warmed blastocyst transfers at our clinic between 2013 and 2017. Of the 2165 embryo transfers, 1986 underwent laser AH and 179 were non-assisted hatched (NAH). The primary outcome was live birth. Secondary outcomes included conception, implantation, clinical pregnancy, clinical pregnancy loss, and monozygotic twinning (MZT). RESULTS: AH and NAH groups had similar rates of conception (38.7% vs 42.1%), implantation (26.2% vs 27.3%), clinical pregnancy (29.1% vs 30.3%), clinical pregnancy loss (24.0% vs 17.8%), live birth (19.9% vs 20.5%), and MZT (2.08% vs 2.86%). Five pairs of dichorionic/diamniotic twins resulted from single embryo transfers. AH of embryos with expansion grades ≤3 was associated with lower rates of conception (32.5% vs 44.3%%, p < 0.05) and clinical pregnancy (24.0% vs 32.8%, p < 0.05). CONCLUSION: AH prior to transfer of vitrified-warmed blastocysts was not associated with improved pregnancy outcomes. The identification of dichorionic/diamniotic twins from single blastocyst transfers challenges the previously held notion that dichorionic/diamniotic MZTs can only occur from division prior to the blastocyst stage. Prospective studies are needed to validate the novel finding of lower rates of conception and clinical pregnancy after AH in embryos with lower expansion grade.

A Multicenter Study Evaluating the Effect of Ulipristal Acetate during Myomectomy.

STUDY OBJECTIVE: To compare surgical experience at myomectomy between patients with myomas pretreated with ulipristal acetate versus no pretreatment. DESIGN: A prospective, observational, multicenter study of myomectomy procedures by any route (hysteroscopic, laparoscopic, or laparotomy) (Canadian Task Force classification II-2). SETTING: Five university-affiliated hospitals including tertiary care and community sites. PATIENTS: Any patient who underwent hysteroscopic, laparotomic, or laparoscopic myomectomy regardless of medical pretreatment. INTERVENTIONS: Surgeons completed a Web-based questionnaire after each myomectomy procedure. Surgeons evaluated visualization, the myoma-myometrium relationship, extrusion, fluid deficit, blood loss, and overall ease of hysteroscopic myomectomies. For laparotomic/laparoscopic myomectomies, plane delineation, myoma separation, blood loss, and overall ease were assessed. The total surgical experience score was calculated by summing the values for each subscale. MEASUREMENTS AND MAIN RESULTS: A total of 309 myomectomies were evaluated by 52 surgeons (response rate = 83%) at 5 institutions. Of 140 hysteroscopic myomectomies, 84 (60%) were performed without pretreatment, 29 (21%) after ulipristal acetate pretreatment, and 27 (19%) after pretreatment with gonadotropin-releasing hormone agonist/other. Of 169 laparotomic/laparoscopic myomectomies, 104 (62%) were performed without pretreatment, 46 (27%) after ulipristal acetate, and 19 (11%) after gonadotropin-releasing hormone agonist/other. The mean surgical experience score (±standard deviation) was comparable between the no pretreatment and ulipristal acetate groups for hysteroscopic myomectomies (13.8 ± 2.2 vs 13.3 ± 2.2, p = .35) and laparotomic/laparoscopic myomectomies (12.9 ± 4.1 vs 12.1 ± 4.2, p = .30). Compared with no pretreatment, more laparotomic/laparoscopic myomectomies after ulipristal acetate pretreatment were associated with difficult delineation of surgical planes (22 [47.8%] vs 23 [22.1%], p = .002) and difficult myoma separation (20 [43.5%] vs 21 [20.2%], p = .003). More myomas were described as soft with ulipristal acetate pretreatment (14 [30.4%] vs 17 [16.4%], p = .049). The rates of profuse/abundant endometrium during hysteroscopy were similar between the no pretreatment (21 [25.0%]) and ulipristal acetate (7 [24.1%], p = .93) groups. CONCLUSION: Despite differences in surgical nuances, the overall myomectomy experience was not negatively affected by ulipristal acetate pretreatment.

Massive Vaginal Hematoma - A Complication of In Vitro Fertilization.

BACKGROUND: The rates of serious complications from IVF with transvaginal oocyte retrieval are low. However, as the usage of IVF continues to increase, more complications are presenting to acute care and physicians should be aware of management issues. CASE: A 36-year-old, gravida 4, para 1 woman presented to the emergency department with significant vaginal hemorrhage and severe abdominal pain after undergoing a routine transvaginal oocyte retrieval. She was taken to the operating room and found to have extensive lacerations of the posterior vaginal mucosa and a large vaginal hematoma tracking to the retroperitoneal space. CONCLUSION: This case represents a previously unreported but possible complication of oocyte retrieval. Although oocyte retrieval complications are not frequently reported, significant vaginal and pelvic vascular injury and hemorrhage can occur. Physicians should be cognizant of trauma that can occur secondary to vaginal instruments and not just intraperitoneal injuries.

A Multicentre Retrospective Review of Clinical Characteristics of Uterine Sarcoma.

OBJECTIVE: Professional societies have recently urged gynaecologists to counsel patients about the risks of encountering uterine sarcoma at fibroid surgery especially when morcellation is used. Our objective was to learn the preoperative and postoperative characteristics of patients with uterine sarcoma to better counsel patients undergoing surgery for presumably benign fibroids. METHODS: This is a multicentre, retrospective cohort study. Three academic tertiary cancer centres in Southern Ontario over a 13-year period (2001-2014). Patients diagnosed with leiomyosarcoma or endometrial stromal sarcoma were included after identification using pathology databases. A retrospective chart review was conducted to determine clinical characteristics and survival data. RESULTS: The study included 302 patients with uterine sarcomas (221 leiomyosarcomas, 81 endometrial stromal sarcomas). Mean age at diagnosis was 55 years, and 59% were postmenopausal. Sarcoma diagnosis was made following endometrial sampling (25%), hysterectomy (69% laparotomy, 2.7% laparoscopic/vaginal), and myomectomy (3.3%). Of all the patients who underwent endometrial sampling, 65% were diagnosed with a uterine sarcoma in this manner. A general gynaecologist performed the primary surgical procedure in 166 of 302 patients (55%). Tumour disruption at the time of primary surgery occurred in 57 of 295 patients (19%): subtotal hysterectomy (21), myomectomy (10), dissection of adherent tumour (17), and morcellation (9). Morcellation, to facilitate a minimally invasive approach, was performed with scalpel (2 at laparotomy, 5 vaginally) and with a laparoscopic electro-mechanical morcellator (2). At a median follow-up of 2.9 years, there was no significant difference in survival for stage I and II patients with tumour disruption (n = 32) compared with those without tumour disruption (n = 143), regardless of sarcoma type (P = 0.6). CONCLUSION: The majority of patients with uterine sarcomas were postmenopausal. Many can be diagnosed preoperatively with endometrial sampling. Forty-one percent of patients with uterine sarcomas had a high preoperative index of suspicion, resulting in intervention by an oncologist. Morcellation with laparoscopic electro-mechanical morcellator was rare.

The effect of low-fidelity endoscopic sinus surgery simulators on surgical skill.

BACKGROUND: Surgical training models are being increasingly used to provide an environment for surgical trainees to improve their skills without risk to patients. This study uses previously validated, inexpensive, low-fidelity training models to determine how pretraining affects endoscopic sinus surgery (ESS) skills. METHODS: Fourteen Otolaryngology residents were randomized to 1 of 2 groups that were stratified for training level. The first group took part in a pretraining session where they practiced on all 5 different modules whereas the second group did not receive any pretraining. The following day, all participants took part in a cadaveric ESS course. Participants were instructed to complete a set of tasks and their performances were videotaped. The videos were then evaluated using a Global Rating Scale (GRS) and a Task-Specific Checklist (TSC). The performances of those who trained using the models were compared to the performances of those who did not. RESULTS: The intervention (pretraining) group performed better than the nonintervention (no pretraining) group on the cadaveric ESS tasks (p < 0.05). As well, there was a statistical difference between the senior residents who had the pretraining with the simulator models performing better than those who did not. CONCLUSION: The modules appear to have made a positive impact on ESS skills. These low-cost, easily-constructed training modules have the potential to be integrated into Otolaryngology-Head and Neck Surgery resident training. Assessment of long-term training effects with a larger number of participants is planned for future studies.

An improved screw-free method for electrode implantation and intracranial electroencephalographic recordings in mice.

We recently developed a glue-based method for the implantation of intracranial electrodes in mice. Our approach is to secure a preconstructed electrode array using a cyanoacrylate-based glue (similar to Krazy Glue). This method is applicable to both young and aging mice and is suitable for long-term electroencephalographic recordings. In the present experiment, we explored whether the glue-based method is capable of securing individual electrodes in addition to securing the electrode array. C57 black mice aged 25-35 days or 13-19 months were operated on under isoflurane anesthesia. Monopolar or bipolar electrodes were inserted independently in the ipsilateral hippocampal CA3 and entorhinal cortical areas, and they were fixed onto the skull using the glue together with dental acrylic, but without anchoring screws. We found that the implanted electrodes were stable and allowed repeat intracranial recordings and electrical stimulation in freely moving mice.

A glue-based, screw-free method for implantation of intra-cranial electrodes in young mice.

Intra-cranial electroencephalographic recordings are increasingly employed in mice because of the availability of genetically manipulated mouse models. Currently, dental acrylic and anchoring screws are used to cement implanted electrodes. This technique works well for adult animals but often encounters difficulty when employed in young mice because their skulls are not strong enough to bear the anchoring screws. Here we describe a novel method favorable for implantation of intra-cranial electrodes in mice as young as postnatal 18 days and suitable for long-term intra-cranial electroencephalographic recordings. Our approach is to construct a multi-electrode assembly according to the desired stereotaxic coordinates of intra-cranial recordings and to secure the implanted electrode assembly to the skull via glue rather than dental acrylic/anchoring screws. The surgical operation for such electrode implantation is relatively quick and rarely associated with complications such as infection, bleeding, neurological deficits, spontaneous seizures or behavioral disturbances. The implanted electrodes are stable, allowing repeated monitoring for several months. Data obtained by simultaneous intra-hippocampal and intra-cortical recordings indicate that our method is suitable for the examination of behaviorally related electroencephalographic activities and experimentally induced seizures. Technical aspects of our methods are discussed, and the procedures for constructing the electrode assembly are presented in detail.