Sleeve gastrectomy as a bridge to maternity in a patient with obesity, infertility and tetraplegia. A case report.

Traumatic spinal cord injury (SCI) is a major cause of severe and permanent disability in young adults. Overweight and obesity are commonly observed among patients affected with SCI, with reports of a prevalence of over 60 and 30% respectively. Case report: A 34 year-old woman suffering from tetraplegia after sustaining a traumatic injury to C5-C6 at age 23 as a result of a motor vehicle accident was presented to our hospital's multidisciplinary bariatric team due to class II obesity. At the time of presentation to the team, eleven years after the accident, her BMI was calculated to be 39 Kg/m2 (weight 97 kg, height 1.57 meters). She was diagnosed with infertility while seeking pregnancy, and referred to our bariatric unit for weight loss. In addition, she had overcome the physical limitations of her injury, had a regular job and was engaged in regular physical activities such as swimming. In May 2017, she underwent laparoscopic sleeve gastrectomy (LSG) without complications and was discharged on postoperative day 2. 17 months following LSG, with a normal BMI, she became naturally pregnant. She had emergency cesarean at 35 weeks due to pneumonia but both patient and child recovered without sequelae. Currently, 4 years after surgery she maintains 37.11% total weight loss (weight 61 kg). She reports having a better quality of life with fewer medical intercurrencies. Conclusions: Patients with SCI and obesity, particularly women seeking to conceive, may be benefited by being referred to bariatric teams for assessment and treatment to improve results associated with sustained weight reduction.

Bliss procedure for undescended ovaries.

OBJECTIVE: To highlight a novel surgical approach for the management of undescended ovaries in those presenting with infertility, to allow for potential transvaginal egg retrieval. The video demonstrates a novel surgical approach for mobilization and oophoropexy of undescended ovaries to allow for future transvaginal egg retrieval in the context of artificial reproductive technology (ART). DESIGN: Case report. Institutional Review Board approval is not required because this was not a human study. Patient consent was obtained for video footage. SETTING: Hospital. PATIENTS: We present a 26-year-old nulligravid woman with a unicornuate uterus, a high riding-right ovary, and an undescended left ovary with prior laparoscopic remnant uterine horn resection. Because of her 9 years of infertility and a prior unsuccessful ovarian mobilization and oophoropexy, she was referred for consideration of a repeat laparoscopic bilateral ovarian mobilization and oophoropexy. INTERVENTION: Surgical intervention for undescended ovaries. MAIN OUTCOME MEASURES: Postoperative ovarian location and postoperative pain. RESULTS: The patient reported minimal pain postoperatively at 6 weeks. Multiple follow-up imaging revealed both ovaries behind the uterus (antral follicle counts 15), with easy transvaginal access for future ART. CONCLUSION: Undescended ovary is uncommon and usually requires no treatment. However, intervention may be required in the context of infertility and ART, where transvaginal egg retrieval is impossible because of the location of the ovaries. This is the first educational video to our knowledge highlighting a novel surgical approach for the management of undescended ovaries.

An atypical erectile dysfunction patient with infertility treated with penile prosthesis implantation and testicular epididymal sperm aspiration (TESA)-intracytoplasmic sperm injection (ICSI): A case report.

RATIONALE: Erectile dysfunction (ED) is common in middle-aged and elderly men, affecting more than 100 million males worldwide. Most ED cases can be attributed to organic and/or psychological factors. Here we report an atypical ED case with no clear manifestation fitting the diagnosis for recognized types of ED. PATIENT CONCERNS: The 35-year-old male is unable to have normal erection since puberty, and unable to complete intercourse with his wife. He had no history of trauma, surgery or psychiatric/psychological disease. The patient has a normal male karyotype. There is no significant finding in physical examination, nocturnal penile tumescence test, and ultrasound measurement of penis vascular functions. The serum levels of major hormones are all in normal ranges. DIAGNOSES: Atypical ED, psychogenic ED not excluded; infertility. INTERVENTIONS: Oral phosphodiesterase inhibitors Tadalafil (20 mg, BIW) or Sildenafil (50 mg, BIW) had no effect in this patient. Penile prosthesis implantation helped the patient to acquire normal sexual life, but did solve the ejaculation failure and infertility. Motile sperms were obtained by testicular epididymal sperm aspiration under the guidance of ultrasound, and intracytoplasmic sperm injection was performed with occytes retrieved from his wife. OUTCOMES: The patient sexual life was significantly improved after penile prosthesis implantation; the patient wife is currently in the first trimester of pregnancy as the result of in vitro fertilization. CONCLUSIONS: The no response to phosphodiesterase type 5 inhibitors (PDE5) treatment may suggest an impediment of PDE5-related pharmacological pathways or the presence of defect/injury in the neural system. This special case raises a question if some patients with persistent ED may have similar manifestations and can be treated with the same procedures.

Laparoscopic Diagnosis and Treatment of an Isolated Cervical Diverticulum.

BACKGROUND: Congenital müllerian anomalies are found in 8.0% of women with infertility and up to 5.5% of women in a general population. Cervical diverticulum is a type of cervical malformation that can be congenital or acquired, with only select cases documented in the literature. Cervical diverticulum can be asymptomatic or present with abnormal uterine bleeding, pelvic pain, or infertility. Previously described management options are largely limited to observation or exploratory laparotomy. CASE: A 35-year-old woman, gravida 2 para 2, presented with persistent menorrhagia, pelvic pain, and abdominal bloating and was found to have an 8-cm right adnexal mass on pelvic ultrasonography. Magnetic resonance imaging showed a hemorrhagic cervical mass communicating with the uterine cavity. The mass was resected laparoscopically, and pathology revealed fibromuscular tissue with endocervical epithelium consistent with a cervical diverticulum. CONCLUSION: Isolated cervical diverticula are rare but should be considered in the differential diagnosis of adnexal masses. Laparoscopic surgery is a safe, minimally invasive approach for evaluation and repair of cervical diverticula.

Guidelines for Wide-Awake Local Anesthesia Surgery with No Tourniquet in the Office Setting Using Field Preparation Sterility.

SUMMARY: Wide-awake local anesthesia surgery with no tourniquet, or WALANT, has become popular in surgery, especially among hand surgeons. With the increasing number of surgeons performing office-based procedures, this article provides guidelines that may be used in the office setting to help transition more traditional hospital operating room-based procedures to the office setting. This article outlines the benefits of performing office-based wide-awake local anesthesia surgery with no tourniquet and provides a step-by-step guide to performing procedures that can be easily incorporated into any hand surgeon's practice successfully and safely.

A step-by-step approach to a frozen pelvis.

OBJECTIVE: To demonstrate a step-by-step approach for restoration of pelvic anatomy in frozen pelvis using a systematic approach to make the steps reproducible, safe, and time efficient. DESIGN: Video presentation. SETTING: Academic medical center. PATIENT(S): A 30-year-old nulliparous woman with lifelong dysmenorrhea and 4 years of infertility who presented for the surgical management of stage IV endometriosis. INTERVENTION(S): An abdominopelvic survey was first in a systematic fashion to assess the extent of adhesive disease and evalaute for normal anatomy. Dissection was then started on the patient's left side to mobilize the sigmoid colon at the pelvic brim. Subsequently, the ureters were identified and bilateral ureterolysis was performed as the retroperitoneal spaces were explored. Once the ureters were safely dissected, the adnexa were mobilized bilaterally. Attention was then turned to the dissection of the medial pararectal spaces (Okabayashi's space) before the dissection of the rectovaginal space. With the restoration of anatomy, the remaining planned surgery was completed. MAIN OUTCOMES MEASURE(S): Restoration of pelvic anatomy, excision of endometriosis, and resolution of symptoms. RESULT(S): The patient had an uncomplicated procedure with complete excision of endometriosis and an estimated blood loss of 45 mL. She was discharged on the same day and had an uneventful postoperative period. At her follow-up appointment, she had resolution of symptoms and was initiated on medical hormone suppression therapy until ready for in vitro fertilization. CONCLUSION(S): A frozen pelvis is a condition in which the pelvic organs are distorted and tethered to each other as a result of adhesive processes. This can obscure normal anatomical landmarks and surgical planes making dissection extremely difficult, thus increasing the risk of interoperative and postoperative complications. Although an uncommon surgical condition, it is not rare to come across in clinical practices, thus creating a challenge to reproductive surgeons as it is commonly seen with endometriosis-associated infertility. It is important for surgeons to be able to recognize the relevant anatomy and have the knowledge to open proper pelvic avascular spaces in the pelvis to mitigate these risks. Following this video's step-by-step approach can help restore pelvic anatomy for planned surgical procedures.

Reproductive outcomes of natural pregnancy after hysteroscopic septum resection in patients with a septate uterus: a systematic review and meta-analysis.

OBJECTIVE: The aim of this systematic review and meta-analysis was to analyze the reproductive outcomes of natural pregnancy after hysteroscopic septum resection in patients with recurrent miscarriage, primary infertility, or secondary infertility. DATA SOURCES: The PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), Wanfang Data Knowledge Service Platform, VIP Database, and Chinese Biomedical Literature Database (CBM) databases were electronically searched. The search time frame was from inception up to July 2021. The English search terms were (arcuate* and uter*), (sept* and uter*), (subseptate* and uter*), metroplast*, septoplast*, and resect*. STUDY ELIGIBILITY CRITERIA: Selection criteria included randomized controlled trials, cohort studies, and case series that explored reproductive outcomes after hysteroscopic septum resection in patients with recurrent miscarriage, primary infertility, or secondary infertility with or without a control group. METHODS: The primary outcomes were the live birth rate and eventual postoperative live birth rate after hysteroscopic septum resection. The secondary outcomes were the clinical pregnancy rate, preterm birth rate, and miscarriage rate. Study-level proportions of outcomes were transformed using the Freeman-Tukey double-arcsine transformation to calculate pooled values for the postoperative rates; the counted data were analyzed using relative risk as the effect analysis statistic, and each effect size was provided with its 95% confidence interval. Heterogeneity between the results of the included studies was analyzed using the I2 test. RESULTS: Overall, 5 cohort studies and 22 case series involving 1506 patients were included. In patients with a septate uterus and recurrent miscarriage, hysteroscopic septum resection was associated with an increased live birth rate (relative risk, 1.77; 95% confidence interval, 1.26-2.49; P=.001; I2=0%), resulting in a postoperative live birth rate of 66% (95% confidence interval, 59-72), and septum resection was associated with a reduced preterm birth rate (relative risk, 0.15; 95% confidence interval, 0.04-0.53; P=.003; I2=0%) and miscarriage rate (relative risk, 0.36; 95% confidence interval, 0.20-0.66; P=.0009; I2=0%). In patients with a septate uterus and primary infertility, hysteroscopic septum resection was associated with an increased live birth rate (relative risk, 4.12; 95% confidence interval, 1.19-14.29; P=.03; I2=0%) and clinical pregnancy rate (relative risk, 2.28; 95% confidence interval, 1.04-4.98; P=.04; I2=0%). The postoperative live birth rate was 37% (95% confidence interval, 30-44), and the miscarriage rate of patients with primary infertility was reduced (relative risk, 0.19; 95% confidence interval, 0.06-0.56; P=.003). The efficacy of hysteroscopic septum resection in patients with secondary infertility was unclear. However, their postoperative live birth rate was found to be 41% (95% confidence interval, 2-88). CONCLUSION: Hysteroscopic septum resection is associated with an increased live birth rate and a reduced miscarriage rate in patients with recurrent miscarriage or primary infertility, indicating that septum resection may improve the reproductive outcomes of these patients. The effectiveness of septum resection was unclear for patients with secondary infertility. These findings are limited by the quality of the included studies, warranting further randomized controlled trials, including only patients with recurrent miscarriage or primary infertility.

The undescended testis in children and adolescents part 2: evaluation and therapeutic approach.

Undescended testis (UDT) is defined as failure of a testis to descend into the scrotum and it is a common reason for consultation in pediatric urology. As extensively discussed in "The undescended testis in children and adolescents: part 1", the failure of a testis to descend alters testicular germ-cells development, increasing the risk of infertility and testicular cancer in adulthood. Here, we present the second part of our review and analysis of this topic with the aim to propose an updated and well-informed approach to UDT together with a treatment flow chart that may be useful to guide pediatric surgeons and urologists in the care of these patients. The main goal of the management of patients with UDT is to diminish the risk of infertility and tumor development and is based on the clinical findings at the time of diagnosis.

The impact of the ileoanal pouch on female fertility in ulcerative colitis: A systematic review and meta-analysis.

AIM: Ileal pouch-anal anastomosis is a restorative option for patients with ulcerative colitis (UC) requiring surgery. The primary outcome of this study was the relative risk of infertility in women with UC undergoing restorative proctocolectomy (RPC) compared to the same patients before undergoing RPC. Infertility was defined as the inability to conceive after 1 year of regular sexual intercourse without contraception. METHODS: A systematic review and meta-analysis were performed to include all relevant articles from 1946 from MEDLINE, Embase and Cochrane Central Register of Controlled Trials. Studies included reported on the fertility rate of a cohort with UC and also reported the rate after RPC in those within the cohort who underwent surgery. This study was registered on PROSPERO (CRD42021259745). RESULTS: Thirteen studies met the inclusion criteria and accounted for 793 patients pre-pouch and 802 post-pouch. The mean and median age of the patients at analysis was 36.8 and 32.7 years respectively; and the median duration of follow-up following ileal pouch-anal anastomosis was 110.4 (68-139) months. Our results highlight that following RPC the relative risk of infertility is 4.17 (95% CI 1.99, 8.74) compared with patients before RPC who had UC. CONCLUSIONS: The findings of this meta-analysis provide an update on a previous meta-analysis published over a decade ago and results remain congruent. This suggests that despite advancements in surgical techniques the risk to fertility remains similar to a decade ago. However, further high quality studies are needed to try and decipher independent risk factors associated with a decrease in infertility.

Comparison of Antisperm Antibody levels following totally extraperitoneal inguinal hernia repair and Lichtenstein hernia repair. A randomized controlled trial.

The study was supported by TUEK (Board of Education and Expertise in Medicine - grant number 2016-1201). Funding source had no involvement in conducting or reporting process of this study. Comparison of Antisperm Antibody level following extraperitoneal inguinal hernia repair and Lichenstein hernia >A randomzed rial PURPOSE: We compared laparoscopic totally extraperitoneal (TEP) hernia repair and open Lichtenstein hernia repair (LHR) in terms of Antisperm Antibody Levels (ASA), pain, operative times, return to work times, hernia recurrence, and postsurgery complications. METHODS: The patients were randomly divided into two groups as LHR and TEP. Blood samples were obtained for analysis of levels of ASA. Postoperative pain scores were assessed on the first day after repair using the Visual Analog Scale (VAS), and hernia recurrence, operation times, return to work times, and early and late postoperative complications were recorded. RESULTS: Sixty male patients enrolled in the study. All patients were negative for ASA presurgery. ASA were detected in two patients in the LHR group postsurgery. The VAS score of the patients in the TEP repair group was significantly lower than that in the LHR group (median: 4.0 vs. 6.0) (p <0.001). The mean operation time in the TEP hernia repair group (50 min) was significantly longer than that in the LHR group (40 min) (40.0) (p <0.011). The median return to work time in the TEP hernia repair group (7 d) was significantly shorter than that in the LHR group (15 d)(p <0.001). There was no statistically significant difference between the two methods in terms of ASA,recurrence, or postoperative complications (p> 0.05). DISCUSSION: Many studies have compared the superiority of different inguinal hernia repair methods. Which CONCLUSION: It is not possible to determine the superiority of concerning technics in reducing infertility after surgery. TEP inguinal hernia repair is superior to LHR in in terms of postoperative pain and return to work times. KEY WORDS: Lichtenstein, Antisperm antibody, Infertility, Inguinal hernia, Totally extra peritoneal repair.

Syndrome of inappropriate secretion of thyroid-stimulating hormone in a subject with galactorrhea and menstrual disorder and undergoing infertility treatment: Case report.

RATIONALE: Syndrome of inappropriate secretion of thyroid-stimulating hormone (SITSH) is a rare cause of hyperthyroidism. Thyroid-stimulating hormone (TSH) levels are usually normal or high, and triiodothyronine (FT3) and free thyroxine (FT4) levels are usually high in subjects with SITSH. PATIENT CONCERN: A 37-year-old woman had experienced galactorrhea and menstrual disorder for a couple of years before. She had undergone infertility treatment in 1 year before, hyperthyroidism was detected and she was referred to our institution. DIAGNOSIS: She was suspected of having SITSH and was hospitalized at our institution for further examination. The data on admission were as follows: FT3, 4.62 pg/mL; FT4, 1.86 ng/dL; TSH, 2.55 µIU/mL. Although both FT3 and FT4 levels were high, TSH levels were not suppressed, which is compatible with SITSH. In addition, in brain contrast-enhanced magnetic resonance imaging, nodular lesions were observed in the pituitary gland with a diameter of approximately 10 mm. In the thyrotropin-releasing hormone load test, TSH did not increase at all, which was also compatible with TSH-secreting pituitary adenoma. In the octreotide load test, the TSH levels were suppressed. Based on these findings, we diagnosed this subject as SITSH. INTERVENTIONS: Hardy surgery was performed after the final diagnosis. In TSH staining of the resected pituitary adenoma, many TSH-producing cells were observed. These findings further confirmed the diagnosis of pituitary adenoma producing TSH. OUTCOMES: Approximately 2 months after the operation, TSH, FT3, and FT4 levels were normalized. Approximately 3 months after the operation, she became pregnant without any difficulty. LESSONS: We should consider the possibility of SITSH in subjects with galactorrhea, menstrual disorders, or infertility. In addition, we should recognize that it is very important to repeatedly examine thyroid function in subjects with galactorrhea, menstrual disorder, or infertility.

Reproductive Outcomes Following Surgical Management for Isthmoceles: A Systematic Review.

OBJECTIVE: To evaluate the efficacy of surgical management for isthmoceles in patients presenting with secondary infertility. DATA SOURCES: A systematic search was performed in MEDLINE, EMBASE, and Cochrane Library databases from inception to May 2020. The search was limited to studies published in English. METHODS OF STUDY SELECTION: After the removal of duplicates, 3380 articles were screened for inclusion independently by 2 authors. These 2 authors assessed for studies which focused on women of reproductive age with a diagnosed isthmocele and secondary infertility who underwent any surgical intervention for defect repair with at least 1 of the goals being fertility restoration. TABULATION, INTEGRATION, AND RESULTS: A total of 13 studies, comprising of 1 randomized controlled trial, 6 prospective case series, and 6 retrospective case series describing 234 patients who underwent surgical management for an isthmocele and secondary infertility were included. The methodologic quality of the included studies was assessed independently by both reviewers. Next, the data extraction was performed independently and then compared to ensure no discrepancies. A total of 188 patients were treated by hysteroscopy, 36 by laparoscopy, 7 by laparotomy, and 3 through a vaginal approach. In total, 153 of the 234 patients (65.4%) achieved pregnancy across all studies within their respective study periods. Pregnancy rates in the randomized controlled trial were 21 of 28 (75%) for those treated by hysteroscopy compared with 9 of 28 (32%) for those untreated. Among the studies reporting pregnancy outcomes, 101 of 116 (87.1%) pregnancies resulted in a live birth. The incidence of adverse events was 2%, including the risk of reoperation. CONCLUSION: The results of this systematic review suggest that the surgical treatment of an isthmocele, particularly through hysteroscopy, in patients with residual myometrial thickness of at least 2.5 mm, may be effective in treating isthmocele-associated secondary infertility with a relatively low complication rate. Further high-quality studies are needed because of the small sample sizes and observational nature of most available data.

Oocyte ability to repair sperm DNA fragmentation: the impact of maternal age on intracytoplasmic sperm injection outcomes.

OBJECTIVE: To study the impact of sperm DNA fragmentation (SDF) on clinical outcomes of assisted reproductive technology in women with different age ranges. DESIGN: Historical cohort study. SETTING: Private university-affiliated in vitro fertilization center. PATIENT(S): Five hundred forty couples undergoing intracytoplasmic sperm injection cycles. INTERVENTION(S): Cycles were split into three groups according to maternal age: ≤36 years old (n = 285), 37-40 years old (n = 147), and >40 years old (n = 108). Semen samples were evaluated for SDF using the Sperm Chromatin Dispersion test and, for each age group, the cycles were subdivided according to SDF index: low fragmentation index (<30% SDF) and high fragmentation index (≥30% SDF). MAIN OUTCOME MEASURE(S): Implantation, pregnancy, and miscarriage rates. RESULT(S): For younger patients (≤36 years old) and those between 37 and 40 years of age, no significant differences were noted in laboratory and clinical outcomes for cycles with <30% SDF or ≥30% SDF. When maternal age was >40 years of age, significantly lower high-quality day-3 embryos (54.4% vs. 33.1% and blastocyst development rates (49.6% vs. 30.2%), lower pregnancy (20.0% vs. 7.7%) and implantation rates (19.7% vs. 11.9%), and increased miscarriage rate (12.5% vs. 100.0%) were observed for cycles with ≥30% SDF compared with <30% SDF, respectively. CONCLUSION(S): Older oocytes, when injected with sperm derived from samples with high SDF index, develop into embryos of poor quality that lead consequently to lower implantation and pregnancy rates and higher miscarriage rates, in intracytoplasmic sperm injection cycles from women with advanced maternal age.

A new approach to avoid ovarian failure as well function-impairing adhesion formation in endometrioma infertility surgery.

PURPOSE: Deep ovarian endometriosis surgery is likely to be associated with diffuse bleeding, intraoperative ovarian tissue destruction and perioperative adhesion formation. A new surgical approach is hereby proposed to avoid the negative short-term impact of classic laparoscopic cystectomy on ovarian reserve. RESULTS: The need for intraoperative periovarian coagulation after endometrioma excision was avoided by combining the gold standard minimal-access endometrioma stripping technique with a purely plant-based medical product with high-hemostatic and antiadhesion barrier properties. CONCLUSION: Endometrioma stripping followed by the application of a polysaccharide agent could avoid ovarian failure and at same time could reduce adhesion formation, thereby preserving tubo-ovarian function in endometrioma surgery. We encourage other surgically working groups to investigate middle- and long-term effects of this combined technique.

A comparison of reproductive outcomes of patients with adenomyosis and infertility treated with High-Intensity focused ultrasound and laparoscopic excision.

Objective: The aim of this study was to compare the treatment effects of high-intensity focused ultrasound (HIFU) and laparoscopic excision (LE) in patients with adenomyosis and infertility.Materials and methods: A total of 93 patients with adenomyosis and infertility who were treated with HIFU (50 patients) or LE (43 patients) from January 2012 to January 2017 at the Third Xiangya Hospital of Central South University were retrospectively analyzed. Clinical characteristics including dysmenorrhea severity pain score, menorrhagia severity scores, reproductive outcomes, complications during pregnancy and delivery, adverse effects, surgical complications, and other clinical variables were compared between the HIFU and LE groups.Results: Of the total 93 patients with adenomyosis and infertility, 50 were treated with HIFU and 43 underwent LE. Both HIFU and LE treatments achieved significant relief of dysmenorrhea and menorrhagia. The total hospital stay was shorter in patients treated with HIFU than in those who underwent LE surgery. Neither HIFU nor LE treatment led to severe complications after treatment. Most importantly, patients treated with HIFU showed significantly higher pregnancy rates and natural conception rates than those who underwent LE surgery. Notably, in the HIFU treatment group, those with diffuse adenomyotic lesions had significantly lower postoperative pregnancy rates than those with focal adenomyosis.Conclusion: HIFU showed a safe and effective profile as a therapeutic management option for patients with adenomyosis. In comparison with LE, HIFU treatment achieved better postoperative reproductive outcomes. HIFU treatment should be encouraged and implemented in clinical practice.

Clinical Success Rate of Extensive Hysteroscopic Cesarean Scar Defect Excision and Correlation to Histologic Findings.

STUDY OBJECTIVE: Cesarean scar defect (CSD) is often associated with postmenstrual bleeding, infertility, and pain. Hysteroscopic CSD repair was described in the past, mainly as excision of the proximal edge of the defect to allow continuous blood flow during menstruation. In this study we aimed to evaluate the efficacy of extensive hysteroscopic cesarean scar niche excision in symptomatic patients. DESIGN: A retrospective cohort study. PATIENTS: Symptomatic patients treated with hysteroscopic CSD excision who were considered eligible for the procedure when myometrial thickness of 2 mm or more was observed on sonohysterography. SETTING: Tertiary referral center. INTERVENTIONS: Extensive CSD excision was performed using a cutting loop and pure cutting current. The proximal and distal edges of the defect were resected. This was followed by resection of tissue at the base of the niche, until underling muscular tissue was evident. Tissue sampled from the base of the CSD was collected for histologic examination. Patients were followed for a minimum of 1 year after hysteroscopic CSD excision. Clinical information obtained included detailed obstetric history and preoperative and postoperative menstruation pattern. MEASUREMENTS AND MAIN RESULTS: Between 2011 and 2016, 95 patients underwent extensive hysteroscopic niche excision; 67 were included in the study, whereas the remaining were lost to follow-up. Patient mean age at the time of the procedure was 38 ± 5.5 years. Twenty-nine patients (43%) had a history of high-order repeat cesarean surgeries. Sixty-six patients (98.5%) presented with postmenstrual bleeding, 26 with secondary infertility (38.8%), and 2 with pelvic pain (2.9%). After hysteroscopic niche excision, 63.4% of patients reported significant improvement or resolution of postmenstrual bleeding. A statistically significant reduction in number of bleeding days per cycle (15.5 ± 4.8 vs 9.8 ± 4.7, p < .001) was also noted. Histologic evidence for myometrial tissue within the obtained samples was associated with better outcomes. A histologic specimen from patients who experienced significant improvement or resolution of postmenstrual bleeding was more likely to reveal myometrial tissue (p = .04). Of the 26 patients who suffered from infertility, 19 attempted to conceive spontaneously after CSD excision. Of those, 10 patients (52.6%) conceived and 9 delivered at least once (47.36%). CONCLUSION: Extensive hysteroscopic surgical excision of cesarean scar niche should be considered in symptomatic patients suffering from irregular menstrual bleeding. The quality of the excision at the apex of the niche could be associated with a higher success rate. The role of niche excision to overcome secondary infertility should be further evaluated.

A Systematic Review of Tissue Sampling Techniques for the Diagnosis of Adenomyosis.

OBJECTIVE: Evaluate the accuracy of tissue sampling techniques for the diagnosis of adenomyosis. DATA SOURCES: Systematic Review via MEDLINE and the Cochrane Library searches. METHODS OF STUDY SELECTION: Review performed utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, utilizing MeSH terms and keywords including "Adenomyosis/diagnosis" or "Adenomyosis/pathology" or "Myometrium/pathology" and "Biopsy" or "Hysteroscopy" or "Laparoscopy." Articles initially screened by title and abstract to include relevant studies with reference lists cross-referenced to find additional studies. Articles related to the diagnosis of uterine malignancy or studies in which tissue sampling was obtained through excisional surgical procedures were excluded from the review. TABULATION, INTEGRATION, AND RESULTS: Fourteen studies were identified describing tissue sampling techniques to diagnose adenomyosis, with a total of 1909 patients, from 12 different countries, involving 6 different continents. Tissue sampling techniques were categorized based on (1) biopsy approach as either intrauterine and extrauterine and (2) techniques that were validated or not validated with a confirmatory hysterectomy pathology. Overall, there was significant heterogeneity in the tissue sampling techniques including intrauterine sampling obtained through hysteroscopic biopsy or resection and extrauterine tissue sampling obtained with needle biopsy by a percutaneous, transvaginal, laparoscopic, or ex-vivo approach. Sensitivity of these techniques varied significantly based on technique, tissue sampling location and the number of biopsies obtained, and was as low as 22.2% for an ultrasound-guided transvaginal biopsy of suspicious uterine lesions (4 biopsies per patient) and was as high as 97.8% for a laparoscopic guided myometrial biopsy of suspicious uterine lesions (10 biopsies per patient). Specificity for the identified tissue sampling techniques was more homogeneous ranging from 78.5% to 100% for all methods identified. The positive predictive value and negative predictive value ranges were 75.9% to 100% and 46.4% to 80% respectively among all tissue sampling techniques identified with confirmatory hysterectomy pathology. CONCLUSION: Because of the heterogeneity of the tissue sampling techniques, diverse patient populations, and significant conflicting recommendations, no conclusive recommendation on the optimal tissue sampling technique can be made. However, it would be reasonable to limit uterine tissue sampling for confirmatory diagnosis of adenomyosis in patients with a suspicion of adenomyosis based on both symptom profile and pelvic ultrasound, where a planned diagnostic laparoscopy for either infertility or pelvic pain has already been contemplated and scheduled, and where the confirmatory results may be of clinical benefit in discussing the prognosis of recurrent postoperative symptoms and guide any future treatment recommendations.

When to Do Surgery and When Not to Do Surgery for Endometriosis: A Systematic Review and Meta-analysis.

OBJECTIVE: We performed a systematic review and meta-analysis with the aim to answer whether operative laparoscopy is an effective treatment in a woman with demonstrated endometriosis compared with alternative treatments. Moreover, we aimed to assess the risks of operative laparoscopy compared with those of alternatives. In addition, we aimed to systematically review the literature on the impact of patient preference on decision making around surgery. DATA SOURCES: We searched MEDLINE, Embase, PsycINFO, ClinicalTrials.gov, CINAHL, Scopus, OpenGrey, and Web of Science from inception through May 2019. In addition, a manual search of reference lists of relevant studies was conducted. METHODS OF STUDY SELECTION: Published and unpublished randomized controlled trials (RCTs) in any language describing a comparison between surgery and any other intervention were included, with particular reference to timing and its impact on pain and fertility. Studies reporting on keywords including, but not limited to, endometriosis, laparoscopy, pelvic pain, and infertility were included. In the anticipated absence of RCTs on patient preference, all original research on this topic was considered eligible. TABULATION, INTEGRATION, AND RESULTS: In total, 1990 studies were reviewed. Twelve studies were identified as being eligible for inclusion to assess outcomes of pain (n = 6), fertility (n = 7), quality of life (n = 1), and disease progression (n = 3). Seven studies of interest were identified to evaluate patient preferences. There is evidence that operative laparoscopy may improve overall pain levels at 6 months compared with diagnostic laparoscopy (risk ratio [RR], 2.65; 95% confidence interval [CI], 1.61-4.34; p <.001; 2 RCTs, 102 participants; low-quality evidence). Because the quality of the evidence was very low, it is uncertain if operative laparoscopy improves live birth rates. Operative laparoscopy probably yields little or no difference regarding clinical pregnancy rates compared with diagnostic laparoscopy (RR, 1.29; 95% CI, 0.99-1.92; p = .06; 4 RCTs, 624 participants; moderate-quality evidence). It is uncertain if operative laparoscopy yields a difference in adverse outcomes when compared with diagnostic laparoscopy (RR, 1.98; 95% CI, 0.84-4.65; p = .12; 5 RCTs, 554 participants; very-low-quality evidence). No studies reported on the progression of endometriosis to a symptomatic state or progression of extent of disease in terms of volume of lesions and locations in asymptomatic women with endometriosis. We found no studies that reported on the timing of surgery. No quantitative or qualitative studies specifically aimed at elucidating the factors informing a woman's choice for surgery were identified. CONCLUSION: Operative laparoscopy may improve overall pain levels but may have little or no difference with respect to fertility-related or adverse outcomes when compared with diagnostic laparoscopy. Additional high-quality RCTs, including comparing surgery to medical management, are needed, and these should report adverse events as an outcome. Studies on patient preference in surgical decision making are needed (International Prospective Register of Systematic Review registration number: CRD42019135167).

Introduction: Reproductive surgery: glimpses into the past and thoughts for the future (part 1).

This month's Views and Reviews sets the stage for a two part series regarding reproductive surgery. The development, importance, and implications for reproductive surgery in the setting of assisted reproductive technology is discussed. Images and videos augment the authors' reflections of the past, present, and/or future. This series will not include a focus on uterine transplantation as this will be a future topic of its own.

Reproductive surgery and in vitro fertilization: the future reevaluated.

A crisis is occurring in that reproductive endocrinologists are not doing the surgeries that are a part of their discipline. We list those procedures as a blueprint for training reproductive endocrinologists.