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.

Uterine factor in recurrent pregnancy loss.

OBJECTIVE: To review the current understanding of the role the uterus plays in recurrent pregnancy loss. FINDINGS: Congenital and acquired uterine abnormalities are associated with recurrent pregnancy loss in the first and second trimester. Relevant congenital Mullerian tract anomalies include unicornuate, didelphys, bicornuate and septate uteri. Pregnancy loss has also been associated with acquired uterine abnormalities that distort the uterine cavity such as intrauterine adhesions and submucosal myomas. Initial evaluation of women with recurrent pregnancy loss should include a uterine assessment such as a pelvic ultrasound or sonohysterography. Uterine abnormalities such as uterine septum, intrauterine adhesions and submucosal myomas may be managed surgically with operative hysteroscopy. CONCLUSION: Uterine abnormalities, both congenital and acquired, can be responsible for recurrent pregnancy loss.

Ovarian Morphology by Transabdominal Ultrasound Correlates With Reproductive and Metabolic Disturbance in Adolescents With PCOS.

PURPOSE: To determine whether ovarian morphology imaged using transabdominal ultrasonography reflects clinical and metabolic features in adolescents with polycystic ovary syndrome (PCOS). METHODS: A retrospective pilot study was conducted in 33 adolescents (12-18 years) with PCOS as defined by hyperandrogenism and irregular cycles. Adolescents underwent the following assessments at a random time during the menstrual cycle: transabdominal ultrasonography, physical examination (height, weight, and systolic and diastolic blood pressure), fasting hormonal tests (free, percent free, and total testosterone, androstenedione, follicle stimulating hormone, luteinizing hormone), and metabolic tests (including an oral glucose tolerance test, fasting and 2-hour insulin and glucose, homeostatic model assessment of insulin resistance, and whole-body insulin sensitivity index). Ultrasound images were analyzed offline for ovarian area (OA), ovarian volume (OV), follicle number per cross section (FNPS), and follicle distribution pattern. Associations among endocrine and metabolic variables with sonographic features were assessed by Spearman's rank correlation coefficients and stepwise multiple linear regression. RESULTS: Total testosterone and androstenedione, but not free testosterone, or percent free testosterone, positively correlated with OA (ρ = .515, ρ = .422, respectively), OV (ρ = .451, ρ = .382), and FNPS (ρ = .394, ρ = .474). Luteinizing hormone:follicle stimulating hormone ratio also positively correlated with ovarian size (OA, ρ = .520 and OV, ρ = .409). Unexpectedly, body mass index (ρ = -.503) and fasting glucose levels (ρ = -.393) were inversely correlated with FNPS. Total testosterone was an independent predictor of FNPS, OA, and OV as judged by stepwise multiple regression analyses. CONCLUSIONS: Some aspects of ovarian morphology in adolescents with PCOS using transabdominal ultrasonography associate with markers of reproductive dysfunction and provide rationale to further investigate how ovarian morphology may reflect concurrent metabolic dysfunction.

Acute portal vein thrombosis complicating in vitro fertilization.

OBJECTIVE: To describe a case of acute portal vein thrombosis after IVF treatment. DESIGN: Case report. SETTING: University teaching hospital. PATIENT(S): A 39-year-old woman experienced worsening, right upper quadrant pain several days after oocyte retrieval; ET was withheld. Imaging studies revealed acute portal vein thrombosis with extension into the splenic and superior mesenteric veins. INTERVENTION(S): Therapeutic anticoagulation; no ET was performed. MAIN OUTCOME MEASURE(S): Improvement in symptoms, accurate diagnosis of condition. RESULT(S): Decreased size of portal vein thrombosis and partial vessel recanalization. CONCLUSION(S): Thromboembolic events are a rare complication of assisted reproductive technology (ART). In women who present with upper abdominal pain during ART, portal vein thrombosis should be considered in the differential diagnosis.

Polycystic ovary syndrome in adolescents.

PURPOSE OF REVIEW: To highlight the new information in the field of polycystic ovary syndrome (PCOS) in adolescents and how it may pertain to current practice. RECENT FINDINGS: The diagnosis of adolescent PCOS remains controversial, and experts continue to debate the appropriate criteria to be used. There is growing support for using Rotterdam criteria, but requiring the presence of all three criteria (oligoovulation or anovulation, hyperandrogenism and polycystic ovaries on pelvic ultrasonography), as the standard 'two of three' criteria may overdiagnose PCOS in adolescents. As adolescent PCOS is better understood, a high rate of metabolic syndrome and sleep disorders is appreciated, which likely has implications on long-term health. The mainstay of PCOS treatment in adolescents should be lifestyle modification (diet, exercise and behavioral changes), and evidence exists that these interventions are beneficial. The use of insulin sensitizers to target PCOS-related insulin resistance and metabolic dysfunction is common, but further studies on its use and effectiveness are warranted. SUMMARY: As a better understanding of adolescent PCOS evolves, including appropriate diagnostic criteria, factors associated with concomitant metabolic disorders and effective treatment options, improved care for these adolescents will be achieved.

Deliberate practice improves obstetrics and gynecology residents' hysteroscopy skills.

INTRODUCTION: Development of surgical skills is an integral component of residency education in obstetrics and gynecology. OBJECTIVE: We report data from a supervised, deliberate, dry lab practice in hysteroscopy for junior obstetrics-gynecology residents, undertaken to evaluate whether simulation training improved hysteroscopy performance to a skill level similar to that of senior residents. METHODS: A prospective, comparative, multicenter trial compared Objective Structured Assessment Of Technical Skills (OSATS) performance of 2 groups: 19 postgraduate year (PGY)-1 and PGY-2 and 18 PGY-3 and PGY-4 Ob-Gyn residents. PGY-1 and PGY-2 participants underwent 4 sessions of brief, deliberate, focused training in hysteroscope assembly and operative hysteroscopic polypectomy using uterine models. Subsequently, all participants completed a simulated hysteroscopic polypectomy OSATS, and procedure times and structured assessment scores were compared among groups. RESULTS: PGY-1 and PGY-2 residents who had completed OSATS training performed at or above the level of untrained PGY-3 and PGY-4 residents. Junior residents had better assembly times and scores, resection scores, and global skills scores (P < .05). Resection times did not differ between groups but differed among institutions. DISCUSSION: Brief, hands-on training sessions, which were task-specific and repetitive facilitated short-term gains in learning operative hysteroscopy and increased the dry lab skill level of junior residents compared to that of senior residents. This curriculum was effectively implemented at 3 institutions and generated comparable results, suggesting generalizability.

Abnormal streak gonads in 46,XY complete gonadal dysgenesis.

OBJECTIVE: To describe the surgical findings in two adolescents with 46,XY complete gonadal dysgenesis. DESIGN: Report of two cases. SETTING: University teaching hospital. PATIENT(S): Two adolescents with 46,XY complete gonadal dysgenesis who underwent laparoscopic bilateral gonadectomy. INTERVENTION(S): Laparoscopic bilateral gonadectomy. MAIN OUTCOME MEASURE(S): Removal of dysgenetic gonads. RESULT(S): One benign fibrothecoma and one gonadoblastoma were identified upon pathologic evaluation of the streak gonads. CONCLUSION(S): Individuals with 46,XY complete gonadal dysgenesis are at risk for malignant transformation of the dysgenetic gonads. Because the risk of malignancy is approximately 30%, prompt gonadectomy should be performed after diagnosis of 46,XY complete gonadal dysgenesis.

Hysteroscopic resection of a symptomatic uterine leiomyoma in an adolescent.

BACKGROUND: Uterine leiomyomas or fibroids are rare in the adolescent population. Hysteroscopic resection is an ideal approach for adolescents with symptomatic intracavitary myomas. CASE: A 17-year-old female had a history of menometrorrhagia and symptomatic anemia, and had been hospitalized twice for acute management of heavy bleeding. On pelvic ultrasound and subsequent MRI, a 2 × 3 cm mass was visualized and appeared to distort the uterine cavity. Due to recurrent heavy bleeding, operative hysteroscopy was performed, and a 3-cm intracavitary mass was identified and resected; pathology evaluation confirmed a leiomyoma. SUMMARY AND CONCLUSION: Surgical intervention for abnormal bleeding due to a submucosal myoma was more successful than medical treatment. In adolescents, hysteroscopic resection of a symptomatic submucosal myoma is a reasonable minimally invasive management option.

Endometrial polyps affect uterine receptivity.

This case-control study evaluated the effect of hysteroscopically identified endometrial polyps on endometrium by means of HOXA10 and HOXA11, known molecular markers of endometrial receptivity. Uteri with endometrial polyps demonstrated a marked decrease in HOXA10 and HOXA11 messenger RNA levels, which may impair implantation. These findings suggest a molecular mechanism to support the clinical findings of diminished pregnancy rates in women with endometrial polyps.

Cesarean scar ectopic pregnancy: case series and review of the literature.

Cesarean scar ectopic pregnancy is becoming increasingly common at tertiary care hospitals around the world. It is a condition in which the embryo implants within the myometrium at the site of a previous cesarean hysterotomy, and it can occur in women with only one prior cesarean delivery. We present four cases of cesarean scar ectopic pregnancy diagnosed within a 6-month period between 2007 and 2008. Their initial presentations and management are discussed, followed by a review of the published literature summarizing both diagnostic and management recommendations.

Submucosal uterine leiomyomas have a global effect on molecular determinants of endometrial receptivity.

OBJECTIVE: To evaluate the effect of uterine leiomyomas on the endometrium using molecular markers of endometrial receptivity: HOXA10, HOXA11, LIF, and BTEB1. DESIGN: Case-control study. SETTING: University medical center. PATIENT(S): Thirty reproductive-aged women with submucosal, intramural, or no uterine myomas who underwent hysteroscopy or hysterectomy. INTERVENTION(S): Proliferative phase endometrial sampling was performed at the time of surgery. In uteri with a submucosal myoma, directed endometrial biopsies were obtained over the myoma and over normal myometrium. MAIN OUTCOME MEASURE(S): Endometrial HOXA10 expression was evaluated as a primary endpoint using quantitative real-time reverse transcriptase-polymerase chain reaction (RT-PCR) and immunohistochemistry. HOXA11, BTEB1, and LIF were evaluated using real-time RT-PCR. RESULT(S): Endometrial HOXA10 and HOXA11 messenger RNA (mRNA) expression were significantly decreased in uteri with submucosal myomas compared with controls and with uteri with intramural myomas. A similar trend was seen in BTEB1 mRNA expression; however, no difference was found in LIF mRNA expression. Immunohistochemistry localized the decrease in endometrial HOXA10 protein expression to stroma. In the presence of a submucosal myoma, there were no regional differences in gene expression. CONCLUSION(S): The molecular mechanism by which submucosal myomas adversely affect reproduction includes a global decrease in endometrial HOX gene expression, not simply a focal change over the myoma. This may explain the reproductive dysfunction observed with submucosal myomas.

Interstitial cystitis is an etiology of chronic pelvic pain in young women.

STUDY OBJECTIVE: The prevalence of interstitial cystitis (IC) in young women, especially in those 18 years old or younger, is not well defined. This case series was performed to investigate IC as a cause of chronic pelvic pain (CPP) in young women. DESIGN: Case series. SETTING: University medical center. PARTICIPANTS: Twenty-eight women with CPP, ages 13 to 25, who underwent concomitant laparoscopy and cystoscopy. INTERVENTIONS: All subjects underwent concomitant diagnostic laparoscopy and cystoscopy with hydrodistension for evaluation of CPP. Charts were reviewed to discern preoperative symptoms, operative findings, and postoperative diagnoses. MAIN OUTCOME MEASURE: Diagnosis of IC based on symptoms and cystoscopic findings. RESULTS: All 28 women had CPP, 23 (82%) had dysmenorrhea, and 12 of 25 (48%) sexually active subjects had dyspareunia. Twenty-six subjects (93%) had urinary symptoms including frequency (75%), nocturia (32%), urgency (25%), and dysuria (18%). Eleven (39%) subjects were diagnosed with IC and 18 (64%) with endometriosis, including 7 (25%) subjects with both IC and endometriosis. Laparoscopic findings were normal in 6 (21%) subjects. Of the 26 subjects with urinary symptoms, 21 (81%) had findings on laparoscopy or cystoscopy. In this cohort of young women with chronic pelvic pain, urinary frequency and dyspareunia were significantly associated with the diagnosis of IC. CONCLUSIONS: The results of this study suggest that interstitial cystitis is an etiology of CPP in young women. Evaluation of the bladder as an origin of pelvic pain is warranted in young women with CPP and urinary frequency or dyspareunia.

Training of residents in laparoscopic tubal sterilization: long-term failure rates.

OBJECTIVES: Laparoscopic tubal sterilization with bipolar coagulation is a common and effective method of contraception, and a procedure much used to teach laparoscopic surgical skills to Obstetrics and Gynaecology residents (trainees); but it has an inherent risk of failure. This study investigated the long-term failure rate of this procedure when performed by Obstetrics and Gynaecology residents on women treated in their teaching clinics. METHODS: From 1991 to 1994, Obstetrics and Gynaecology residents carried out 386 laparoscopic tubal sterilizations with bipolar coagulation at Yale-New Haven Hospital. Six to nine years after the procedure, the women concerned were contacted by telephone and data were collected about sterilization failure. RESULTS: Two failures of laparoscopic tubal sterilization with bipolar coagulation were identified: an ectopic pregnancy and a spontaneous abortion. For this time period, the long-term sterilization failure rate was 1.9% (0-4.4%). CONCLUSIONS: The long-term sterilization failure rate for laparoscopic tubal sterilization with bipolar coagulation performed by residents is comparable to the results of prior studies. These findings can be used to properly counsel women at a teaching clinic about the risks of sterilization failure with this procedure, and attest to the adequacy of residents' training and supervision.

GnRH antagonists may affect endometrial receptivity.

OBJECTIVE: HOXA10 is an essential regulator of endometrial receptivity. To determine the effect of GnRH antagonists on endometrial receptivity, we assessed endometrial HOXA10 expression in GnRH antagonist, GnRH agonist, and natural cycles. DESIGN: Prospective case-control study. SETTING: University academic medical center. PATIENT(S): Nineteen subjects were included: 12 subjects underwent controlled ovarian hyperstimulation with recombinant FSH and used either a GnRH antagonist or a GnRH agonist; seven control subjects underwent natural cycles. INTERVENTION(S): Pipelle endometrial biopsies were obtained 11 days after hCG administration or spontaneous LH surge in untreated cycles, respectively. Immunohistochemistry was used to assess HOXA10 protein expression in endometrial glands and stroma. MAIN OUTCOME MEASURE(S): Endometrial HOXA10 protein expression. RESULT(S): HOXA10 expression was significantly decreased in endometrial stromal cells in GnRH antagonist-treated cycles compared with GnRH agonist-treated cycles or natural cycle control subjects. There was no significant difference in glandular cell HOXA10 expression among the three groups. CONCLUSION(S): Use of GnRH antagonists may be associated with impaired HOXA10 expression in endometrial stromal cells and thus may affect endometrial receptivity.

Reproductive performance of women with müllerian anomalies.

PURPOSE OF REVIEW: This review discusses current diagnostic techniques for müllerian anomalies, reproductive outcome data, and management options in reproductive-age women. RECENT FINDINGS: Multiple retrospective studies have investigated reproductive outcomes with müllerian anomalies, but few current prospective studies exist. Uterine anomalies are associated with normal and adverse reproductive outcomes such as recurrent pregnancy loss and preterm delivery, but not infertility. Furthermore, unicornuate, didelphic, bicornuate, septate, arcuate, and diethylstilbestrol-exposed uteri have their own reproductive implications and associated abnormalities. Common presentations of müllerian anomalies and current diagnostic techniques are reviewed. Surgical intervention for müllerian anomalies is indicated in women with pelvic pain, endometriosis, obstructive anomalies, recurrent pregnancy loss, and preterm delivery. Although surgery for most uterine anomalies is a major intervention, the uterine septum is preferentially managed with a hysteroscopic procedure. Several recent studies and review articles discuss management of the septate uterus in asymptomatic women, infertile women, and women with a history of poor reproductive outcomes. Current assessment of reproductive outcomes with uterine anomalies and management techniques is warranted. SUMMARY: Müllerian anomalies, especially uterine anomalies, are associated with both normal and adverse reproductive outcomes, and management in infertile women remains controversial.

Successful pregnancy complicated by early and late adnexal torsion after in vitro fertilization.

OBJECTIVE: To report a case of unilateral adnexal torsion and subsequent contralateral adnexal torsion after in vitro fertilization. DESIGN: Case report and literature review. SETTING: Academic fertility center; university hospital. PATIENT(S): A 28-year-old woman with tubal factor infertility conceived with IVF and experienced mild-to-moderate ovarian hyperstimulation syndrome. Right adnexal torsion occurred at 7 weeks of gestation, and laparoscopic detorsion was performed. Subsequent contralateral adnexal torsion occurred at 19 weeks and was managed with laparotomy and salpingo-oophorectomy. INTERVENTION(S): Laparoscopic right adnexal detorsion and laparotomy with salpingo-oophorectomy for left adnexal torsion. MAIN OUTCOME MEASURE(S): Preservation of torsed adnexa and successful pregnancy. RESULT(S): Successful pregnancy and birth complicated by two episodes of adnexal torsion after IVF, and viable right adnexa after laparoscopic detorsion. CONCLUSION(S): Subsequent contralateral adnexal torsion is a rare complication of IVF and can occur in the second trimester. Data support preservation of the torsed adnexa despite the ovary's appearance.

Endometrial cancer and fertility.

PURPOSE OF REVIEW: Endometrial cancer can affect reproductive-age women who may desire fertility preservation. This article discusses the current, available data about conservative management of endometrial cancer in young women. RECENT FINDINGS: Reproductive-age women with well differentiated endometrial carcinoma have an overall favorable prognosis provided that the tumor is identified at an early, noninvasive stage; however, advanced disease can be present. This article discusses current modalities to evaluate and clinically stage endometrial cancer including hysteroscopy, dilation and curettage, pelvic ultrasound, abdominopelvic computed tomography scan, pelvic magnetic resonance imaging, tumor marker CA125 level, and surgical exploration with laparoscopy or laparotomy. Thorough evaluation is critical as 10 to 29% of young women with endometrial cancer have a synchronous ovarian malignancy. Detailed counseling about the risks and benefits of conservative management, and expectations for fertility after treatment, surveillance, and definitive surgical management is essential. Multiple effective protocols exist for conservative treatment of endometrial cancer, and the initial response rates are as high as 57 to 75%. Successful pregnancies have occurred after conservative management, spontaneously, and with assisted reproductive technologies. SUMMARY: There are no standard recommendations for selection of appropriate women, treatment protocols, or long-term surveillance for conservative management of clinical stage I endometrial adenocarcinoma, and larger prospective clinical studies are warranted.