Surgical techniques for excision of juvenile cystic adenomyoma.

OBJECTIVE: To review causes of pelvic pain among adolescents and discuss surgical techniques for safe and effective resection of juvenile cystic adenomyomas. DESIGN: Case report. SETTING: Academic medical center. PATIENTS: We present a 16-year-old patient with chronic pelvic pain and ultrasound evidence of a 2.4 cm adenomyoma. The lesion was thought specifically to represent a juvenile cystic adenomyoma, defined as a cystic lesion >1 cm occurring in women younger than 30 years with severe dysmenorrhea that is distinct from the uterine cavity and surrounded by hypertrophic myometrium. INTERVENTION: Given minimal relief from medical therapy and high suspicion for coexistent endometriosis, our patient elected to undergo laparoscopic resection of adenomyoma and excision of pelvic lesions. MAIN OUTCOME MEASURES: Preoperative considerations discussed in this video include imaging to identify the location of the lesion and adjacent structures, such as the uterine vessels, discontinuation of gonadotropin-releasing hormone agonist for adequate intraoperative visualization, and the high likelihood of encountering endometriosis at operation. RESULTS: We review the following surgical techniques: maximize visualization with the use of a uterine manipulator and temporary oophoropexy, optimize hemostasis via temporary uterine artery ligation and control of collateral blood vessels, complete ureterolysis, meticulous enucleation of adenomyoma, and excision of coexistent endometriotic lesions. Surgical findings demonstrated a 2 cm lesion along the left lower uterine segment and red-brown lesions along bilateral ovarian fossa, pathologically confirmed as adenomyoma and superficial endometriosis, respectively. CONCLUSION: This video presents strategies for safe and effective adenomyoma resection and treatment of refractory chronic pelvic pain in an adolescent.

ASRM müllerian anomalies classification 2021.

There are many proposed classification systems for müllerian anomalies. The American Fertility Society (AFS) Classification from 1988 has been the most recognized and utilized. The advantages of this iconic classification include its simplicity, recognizability, and correlation with clinical pregnancy outcomes. However, the AFS classification has been criticized for its focus primarily on uterine anomalies, with exclusion of those of the vagina and cervix, its lack of clear diagnostic criteria, and its inability to classify complex aberrations. Despite this classification and others, the wide range of müllerian anomalies is still largely unknown and confusing to many providers. Consequently, müllerian anomalies may go undiagnosed for extended periods, receive inappropriate or inadequate surgical interventions, and result in persistent issues such as pain or loss of reproductive function. The American Society for Reproductive Medicine Task Force on Müllerian Anomalies Classification was formed and charged with designing a new classification. The Task Force set goals for a new classification and chose to base it on the iconic AFS classification from 1988 because of its simplicity and recognizability, while expanding and updating it to include all categories of anomalies. In addition, this was recognized as an opportunity to raise awareness of this area of medicine, educate providers and learners, and promote patient advocacy. Presented here is the new American Society for Reproductive Medicine Müllerian Anomalies Classification 2021.

Delayed blastulation, multinucleation, and expansion grade are independently associated with live-birth rates in frozen blastocyst transfer cycles.

OBJECTIVE: To identify blastocyst features independently predictive of successful pregnancy and live births with vitrified-warmed blastocysts. DESIGN: Retrospective study. SETTING: Academic hospital. PATIENT(S): Women undergoing a cycle with transfer of blastocysts vitrified using the Rapid-i closed carrier (n = 358). INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Clinical pregnancy and live-birth rates analyzed using logistic regression analysis. RESULT(S): A total of 669 vitrified-warmed blastocysts were assessed. The survival rate was 95%. A mean of 1.7 ± 0.5 embryos were transferred. The clinical pregnancy, live-birth, and implantation rates were 55%, 46%, and 43%, respectively. The odds of clinical pregnancy (odds ratio [OR] 3.08; 95% confidence interval [CI], 1.88-5.12) and live birth (OR 2.93; 95% CI, 1.79-4.85) were three times higher with day-5 blastocysts versus slower-growing day-6 vitrified blastocysts, irrespective of patient age at cryopreservation. Blastocysts from multinucleated embryos were half as likely to result in a live birth (OR 0.46; 95% CI, 0.22-0.91). A four -fold increase in live birth was observed if an expanded blastocyst was available for transfer. The inner cell mass-trophectoderm score correlated to positive outcomes in the univariate analysis. The implantation rate was statistically significantly higher for day-5 versus day-6 vitrified blastocysts (50% vs. 29%, respectively). CONCLUSION(S): The blastocyst expansion grade after warming was predictive of successful outcomes independent of the inner cell mass or trophectoderm score. Delayed blastulation and multinucleation were independently associated with lower live-birth rates in frozen cycles. Implantation potential of the frozen blastocysts available should be included in the decision-making process regarding embryo number for transfer.

Residency training in pediatric and adolescent gynecology across obstetrics and gynecology residency programs: a cross-sectional study.

STUDY OBJECTIVE: To estimate the prevalence of Pediatric and Adolescent Gynecology formal training in the United States Obstetric and Gynecology residency programs. DESIGN: Prospective, anonymous, cross-sectional study. PARTICIPANTS: United States program directors of Obstetrics and Gynecology residency programs, N = 242; respondents 104 (43%). RESULTS: 104 residency programs responded to our survey. Among the 104 residency programs, 63% (n = 65) have no formal, dedicated Pediatric and Adolescent Gynecology clinic, while 83% (n = 87) have no outpatient Pediatric and Adolescent Gynecology rotation. There is no significant difference in the amount of time spent on a Pediatric and Adolescent Gynecology rotation among residents from institutions with a Pediatric and Adolescent Gynecology fellowship (P = .359), however, the number of surgeries performed is significantly higher than those without a Pediatric and Adolescent Gynecology fellowship (P = .0020). When investigating resident competency in Pediatric and Adolescent Gynecology, program directors reported that residents who were taught in a program with a fellowship-trained Pediatric and Adolescent Gynecology faculty were significantly more likely to be able to interpret results of selected tests used to evaluate precocious puberty than those without (P = .03). CONCLUSIONS: Residency programs without fellowship trained Pediatric and Adolescent Gynecology faculty or an established Pediatric and Adolescent Gynecology fellowship program may lack formal training and clinical exposure to Pediatric and Adolescent Gynecology. This information enables residency directors to identify deficiencies in their own residency programs and to seek improvement in resident clinical experience in Pediatric and Adolescent training.

In vitro fertilization update.

Success rates with in vitro fertilization (IVF) continue to improve as we gain insight into optimal culture conditions for gametes and embryos. New procedures such as in vitro egg maturation, preimplantation genetic testing, single embryo transfer, and oocyte freezing hold the promise of reducing the cost, inconvenience, and risks of IVF, as well as preserving future fertility. We provide an overview of the current and experimental assisted reproductive technology techniques.

Relationship between cytokines and the embryotoxicity of hydrosalpingeal fluid.

OBJECTIVE: The exact chemical composition of hydrosalpingeal fluid is unknown. The objective of this study was to characterize cytokines in hydrosalpingeal fluid (HSF) and examine their possible role in the embryo development. STUDY DESIGN: HSF was aspirated at laparoscopic salpingectomy in eight infertile women. Levels of IL-1beta, IL-13, IL-8, IL-6 and TNF-alpha in the HSF were determined by quantitative immunoassay kits. Two-cell mouse embryos were incubated with 0, 25, 50 and 75% concentrations of HSF. The blastocyst development rate (BDR) of mouse embryos was measured at each HSF concentration. RESULT(S): The embryotoxicity of HSF was concentration dependent. An increase in the HSF concentration resulted in significant decrease in % BDR (p < 0.01). IL-1beta was present in six of the eight HSF samples with a mean (+/-SD) concentration of 0.9 +/- 0.8 pg/mL. IL-13 was not detected in any of the HSF samples. IL-8, IL-6 and TNF-alpha were detected in all samples with a mean (+/-SD) concentration of 4741.2 +/- 6554.4 pg/mL, 204.8+/-132.8 pg/ml and 12 +/- 12.8 pg/mL respectively. IL-6 was positively correlated with BDR (r = 0.53; p < 0.04). CONCLUSION(S): We demonstrated for the first time the presence of IL-1beta, IL-8, IL-6 and TNF-alpha and the absence of IL-13 in human hydrosalpingeal fluid. IL-6 was positively related to the BDR.

Protein supplementation and the incidence of apoptosis and oxidative stress in mouse embryos.

OBJECTIVE: To estimate the effect of protein supplementation of culture media on reactive oxygen species production and incidence of apoptosis in preimplantation mouse embryos. METHODS: A total of 72 two-cell mouse embryos were cultured in human tubal fluid (HTF) alone (HTF-alone, control) and 71 embryos in HTF with protein supplementation (10% serum substitute supplement; HTF-SSS) for 72 hours. Total cell number per embryo was determined by staining with Hoechst 33258. Allocation of inner cell mass and trophectoderm in blastocysts and incidence of apoptosis were determined by confocal microscopy. Levels of reactive oxygen species in culture media were measured by chemiluminescence assay using luminol as probe. RESULTS: Blastocyst development, total cell number, and the inner cell mass/trophectoderm ratio were similar between the 2 groups. The blastocyst hatching rate was significantly higher in the HTF-SSS group than in the HTF-alone group (20% compared with 4%, P = .007). Level of reactive oxygen species was significantly higher in HTF-alone compared with HTF-SSS at 24 hours (median and interquartile range 28 [13, 43] compared with 0 [0, 1], P = .02), 48 hours (24 [21, 26] compared with 2 [1, 2], P = .02), and 72 hours (26 [9, 32] compared with 2 [2, 3], P = .03). The incidence of apoptosis in blastocysts cultured in HTF-SSS was significantly lower than those in HTF-alone group (mean +/- standard deviation 2.38 +/- 0.68 and 5.81 +/- 1.11, respectively, P = .001). CONCLUSION: Protein supplementation of culture media improves the hatching rate and reduces reactive oxygen species levels and the incidence of apoptosis in mouse preimplantation embryos.

Ovarian function preservation in the cancer patient.

OBJECTIVE: To review the clinical modalities that are available to women receiving potentially sterilizing cancer therapy. DESIGN: The MEDLINE database was reviewed for all publications on medication, surgery, or assisted reproductive technology that could potentially preserve fertility in women who are receiving cancer therapy. CONCLUSION(S): There are many options available to a patient undergoing a treatment that will negatively impact her fertility. Many procedures and medical interventions have been proven successful both in terms of ovarian function and pregnancy rates. Other techniques have great potential but do not have long-term clinical data. It is important that the patient's primary care physician understand the methods available to preserve fertility in cancer patients and communicate this information to the patient.

Adolescent endometriosis.

Endometriosis is a cause of chronic, pelvic pain in adolescents. Lack of response to NSAIDS and OCPs should prompt further investigation and subsequent treatment. The goal of therapy is to minimize pelvic pain and dysmenorrhea primarily through long-term, medical therapy. Surgical intervention is principally indicated to establish a diagnosis. The poor response to surgical therapy negates the need for repetitive or radical surgery. Much patience and care should be directed toward these patients to provide them with an understanding of their disease and to help enhance the quality of their life.

Laparoscopy for adnexal masses in the second trimester of pregnancy.

STUDY OBJECTIVE: To assess the safety of laparoscopic treatment of adnexal masses in the second trimester of pregnancy. DESIGN: Retrospective chart review (Canadian Task Force classification II-3. SETTING: Large tertiary care medical center. PATIENTS: Eleven women. INTERVENTION: Laparoscopic surgery. MEASUREMENTS AND MAIN RESULTS: All masses were identified by ultrasound. The average gestational age at the time of surgery was 17 weeks, 4 days. In seven women the primary cannula was inserted in the left upper quadrant of the abdomen. Procedures were eight ovarian cystectomies, two oophorectomies, and one exploratory laparoscopy. Average operating time was 135 minutes (range 95-195 min). Average time exposed to carbon dioxide was 78 minutes (range 59-135 min). None of the masses was malignant. There were no fetal complications or malformations. No patients had preterm labor and all delivered at term. CONCLUSIONS: The increasing number of reported cases and our experience suggest that laparoscopic treatment of adnexal masses in the second trimester is safe and effective, but the surgeon must be skilled in advanced techniques of laparoscopic surgery.

Vitamin C and vitamin E supplementation reduce oxidative stress-induced embryo toxicity and improve the blastocyst development rate.

To evaluate the adverse effects of exogenously induced reactive oxygen species (ROS) on mouse embryo development by using the 12-phorbol 13-myristate acetate (PMA)-activated leukocyte model as a source of ROS, and to examine the protective effect of antioxidant supplementation (vitamin C and vitamin E). Prospective study. Research laboratory. Effects of ROS on the blastocyst development rate in the presence and absence of antioxidant supplementation. After incubation with the PMA-activated leukocyte supernatant, the median (25th, 75th percentile) rate of blastocyst development significantly decreased from 73% (60%, 80%) after 3 hours to 30% (20%, 40%) after 6 hours compared with control reactions (86% [80%, 100%]). Co-incubating the embryos with vitamin C (50 microM) and the PMA-activated supernatant significantly increased the blastocyst development rate from 73% (60%, 80%) to 90% (80%, 91%) at 3 hours and from 30% (20%, 40%) to 91% (89%, 91%) at 6 hours-a level similar to that of control reactions. The blastocyst development rate increased after vitamin E supplementation (400 microM) at 6 hours, but not significantly and not by as much as after vitamin C supplementation. Exposure of mouse embryos to ROS for extended periods results in embryotoxicity. Vitamin C is more effective than vitamin E in reversing ROS-induced mouse embryo toxicity.

Endometriosis: still tough to diagnose and treat.

Endometriosis is a chronic disease that may have life-altering implications such as chronic pelvic pain and infertility. The following review will familiarize the practicing physician with available therapies to maintain and enhance reproductive potential and control pelvic pain in women with endometriosis.