Evaluation of endometrial receptivity and implantation failure.

PURPOSE OF REVIEW: To succinctly review the basic mechanisms of implantation and luteal phase endometrial differentiation, the etiologies of impaired endometrial function and receptivity, and the current methods that exist to evaluate and treat impaired endometrial receptivity. RECENT FINDINGS: Human embryo implantation requires bidirectional communication between blastocyst and a receptive endometrium. Etiologies of impaired endometrial receptivity are varied. Some of these include delayed endometrial maturation, structural abnormalities, inflammation, and progesterone resistance. Current methods to evaluate endometrial receptivity include ultrasonography, hysteroscopy, and endometrial biopsy. Treatments are limited, but include operative hysteroscopy, treatment of endometriosis, and personalized timing of embryo transfer. SUMMARY: Although some mechanisms of impaired endometrial receptivity are well understood, treatment options remain limited. Future efforts should be directed towards developing interventions targeted towards the known mediators of impaired endometrial receptivity.

Risk factors for perioperative blood transfusion in patients undergoing hysterectomy for benign disease in a teaching institution.

PURPOSE: The purpose is to identify risk factors for perioperative blood transfusion in patients undergoing hysterectomy for benign disease. METHODS: This study is a retrospective chart review including all the patients who underwent hysterectomy for benign disease between January 1st 2018 and December 31st 2019. Patients who received perioperative blood transfusion were identified and compared to those who did not. The following risk factors for blood transfusion were analyzed: route of hysterectomy, BMI, presence of adhesions, history of cesarean section, uterine weight. Descriptive statistics was used to analyze the data. RESULTS: A total of 517 patients were identified and included in the study. Forty-seven patients (9.09%) received a perioperative blood transfusion. The abdominal hysterectomy route (TAH) was a significant risk factor for receiving blood transfusion (p = 0.012). Other identified risk factors for blood transfusion included: Body mass index above 33.0 (p = 0.002), and uterine weight (p = 0.002). There was no association between the presence of pelvic adhesions (p = 0.91) or a personal history of cesarean section (p = 0.89) and receiving perioperative blood transfusion. When analyzing only the patients who underwent TLH, the presence of pelvic adhesion was found as a risk factor for perioperative blood transfusion (p = 0.024). CONCLUSION: The abdominal hysterectomy route, the presence of a large uterus, and obesity are risk factors for receiving a blood transfusion. Early identification of the patient at risk of requiring perioperative blood transfusion provides better patient counseling and surgical preparation.

Enlargement of the genital hiatus is associated with prolapse recurrence in patients undergoing sacrospinous ligament fixation.

OBJECTIVE: To correlate genital hiatus (GH) size with surgical failures in patients undergoing sacrospinous ligament fixation (SSLF) and compare anatomic outcomes after classification based on GH size. METHODS: A retrospective review of 81 patients who underwent SSLF for apical prolapse from 2010 to 2016 at a teaching hospital. Anatomical outcome is reported using the Pelvic Organ Prolapse Quantifications System. A comparison of parametric continuous variables was performed using unpaired Student t test. Categorical variables were evaluated using Pearson's χ2 test and Fisher's exact test. A P value <0.05 was considered significant. RESULTS: Among the 81 patients, no difference in age, parity, body mass index, preoperative prolapse stage or follow-up time was noted between those whose surgery succeeded and those with failed surgery. Postoperatively, a widened GH was significantly associated with recurrent prolapse (P < 0.001). When the preoperative size of the GH was dichotomized into widened (≥4 cm) or normal (<4 cm), there was a non-significant (P = 0.444) trend of more failures in the widened GH group. A posterior colporrhaphy did not improve success. CONCLUSION: Both preoperative and postoperative widened GH correlated with having more surgical failures following SSLF. Importantly, postoperatively a normal size GH was significantly associated with more surgical success.

Factors Predicting Type II Histology in Endometrial Biopsies Among Postmenopausal Minority Women at a Safety-Net Hospital.

Background: Rates of type II endometrial cancers (EC) are increasing in the United States, especially in minority women. The purpose of this project was to examine a primarily minority and low socioeconomic status patient population in a public hospital to identify risk factors associated with the finding of type II histology in endometrial biopsies (EMBs). Materials and Methods: A retrospective chart review was performed of patients who underwent an EMB between 2010 and 2016. Included patients were postmenopausal women older than 50 years with biopsy-proven EC. Basic demographic data were analyzed, along with indication for EMB and ultrasound findings. Statistics were completed using analysis of variance and logistic regression with significance set at p < 0.05. Results: Four hundred sixty-one EMB results were reviewed. Around 17.4% (n = 80) resulted in a diagnosis of EC, with 45% (n = 36) being type II histology. Average age was 62.5 (standard deviation [SD] = 7.63), and the majority (64%) were Hispanic. Type II malignancies were diagnosed in 17% of Caucasians, 41% of Hispanics, and 61% of blacks/Haitians (p = 0.03). Factors associated with type II tumors in univariable models included older age (odds ratio [OR] 1.10 [confidence interval; CI 1.03-1.18], p = 0.007), black/Haitian (vs. Caucasian) race (OR 8.75 [CI 0.86-88.70], p = 0.066), obesity (OR 0.39 [0.15-0.98], p = 0.044), and number of years since menopause (OR 1.06 [CI 1.01-1.12], p = 0.027), although none remained independently predictive in the multivariable analysis. Conclusion: This minority population of postmenopausal women with EC had a greater prevalence of type II histologies. Understanding this pattern may be helpful in expediting the workup for abnormal symptoms in these women and prompt a higher level of suspicion for EC.

Impact of physician attire on patients' impression of their gynecologist: Results from a large single-center survey analysis.

OBJECTIVE: To assess the impact of physician attire in a gynecology office setting on a patient's level of trust and perception regarding medical advice, performing vaginal exams, and physician's ability to perform major and minor procedures. STUDY DESIGN: Cross sectional anonymous survey at a large academic medical center. The survey was distributed to 200 patients of a single-physician gynecology office, between January 1st 2018 and March 31st 2018. The survey contained an image depicting a hypothetical gynecologist and hypothetical questions regarding clinical situations. Participants were asked to answer which doctor from the image shown they preferred for a given scenario. RESULTS: White coat was reported to be preferred physician attire in almost every clinical situation (p < 0.05). There were only two clinical scenarios, a gynecologic emergency (p < 0.01) and in the setting of major surgery (p < 0.07), in which patients did not have a preference for the gynecologist wearing a white coat. Attire did not have a significant effect on respondent's perception of the gynecologist's knowledge, level of compassion, authority, or ability to communicate. CONCLUSION: The majority of patients preferred a physician wearing a white coat in the presented gynecologic scenarios, with the exception of gynecologic emergencies and gynecologic surgery, in which surgical scrubs were preferred.

Endometriosis Presenting as Recurrent Haemorrhagic Ascites: A Case Report and Literature Review.

Endometriosis is a common condition that occurs in 6-10% of all reproductive age women. This number increases to approximately 40% in women with infertility and nearly 75% in women with complaints of chronic pelvic pain. Endometriosis is characterized by the presence of endometrial glands and stroma outside the uterine cavity. The most common complaints associated with endometriosis are dysmenorrhea and pelvic pain; however, patients often present with a variety of symptoms and on occasion are asymptomatic. When presenting with haemorrhagic ascites, endometriosis mimics ovarian malignancy. Conservative medical treatment is a feasible management option, especially in young patients who desire to preserve fertility. This article aims to present an extremely rare presentation of endometriosis, haemorrhagic ascites, and a review of the associated literature.

Impact of using words with unpleasant emotional connotations on perceived patient discomfort during vaginal speculum examinations: A randomized controlled trial.

OBJECTIVES: Many providers often use terms such as "this might hurt", or "you might feel pressure" during exams with the intention to be compassionate and to help decrease discomfort. No evidence exists to support this practice. Our objective was to evaluate the impact of the use of words with unpleasant emotional connotation on perceived discomfort at the time of vaginal speculum examination. STUDY DESIGN: A randomized trial was performed on premenopausal women undergoing a routine well-woman speculum exam. 120 total patients were included and randomized into one of two groups; phrases with unpleasant connotation (n = 60) vs. objective phrases (n = 60). During the speculum exam, the provider used either phrases with unpleasant connotation (i.e., "You are going to feel a lot of pressure"), or objective phrases (i.e., "I am going to introduce the speculum"). Following the exam, patients were asked to rate the level of discomfort/pain experienced during the exam and to compare their actual experience to their anticipated experience. Descriptive statistics were performed. Chi-square and independent samples t-test were used with a significance of p < 0.05. RESULTS: Patients in the phrases with unpleasant connotation group had significantly higher pain scores than the objective phrases group (2.9 ± 1.5 vs. 0.8 ± 0.8 (p < .01)). The majority of the patients in the phrases with unpleasant connotation group reported the exam "as painful as anticipated" or "more painful than anticipated" whereas the majority of the patients in the objective phrases group reported the exam as "pain free" or "less painful than anticipated". CONCLUSION: Healthcare providers performing speculum examinations should use objective statements and avoid the use of phrases with unpleasant connotation with the intention to minimize perceived pain during exams.

Ovarian hyperstimulation syndrome: A review for emergency clinicians.

INTRODUCTION: A great deal of literature has recently evaluated the prevention and management of ovarian hyperstimulation syndrome (OHSS) in the outpatient setting, but there remains a dearth of research evaluating OHSS in the emergency department (ED) and its management. OBJECTIVE: This narrative review evaluates the underlying pathophysiology and clinical manifestations of OHSS and discusses approaches to patient care in the ED based on current literature. DISCUSSION: OHSS is an iatrogenic complication caused by an excessive response to controlled ovarian stimulation during assisted reproductive cycles (ART). OHSS complicates up to 30% of ART cycles, and many of these patients seek initial care in the ED. Risk factors for the development of OHSS include age < 35, history of polycystic ovarian syndrome or previous OHSS, and pregnancy. Emergency physicians will be faced with several complications including ascites, abdominal compartment syndrome, renal dysfunction, acute respiratory distress syndrome, thromboembolic disease, and hemodynamic instability. Critical patients should be evaluated in the resuscitation bay, and consultation with the primary obstetrics/gynecology team is needed, which improves patient outcomes. This review provides several guiding principles for management of OHSS and associated complications. CONCLUSIONS: OHSS occurs in up to 30% of IVF cycles and carries a high morbidity. Effective care of the OHSS patient begins with early diagnosis while evaluating for other diseases and complications. Understanding these complications and an approach to the management of OHSS is essential to optimizing patient care.