First live birth after deceased donor uterine transplant takes place at the Cleveland clinic

This June 18, 2019 photo provided by the Cleveland Clinic 

Cleveland Clinic in Ohio becomes the first hospital in North America to deliver a baby born out of uterus that was transplanted after the donor was deceased.

The mother, who is in her mid-30s, is part of a groundbreaking research trial involving 10 women with uterine factor infertility, who are all destined to receive uterus from deceased donors.  Since the start of the trial, the team has performed 5 uterine transplants, of which 3 were successful, including the one which resulted in a live birth. Two other women are waiting for embryo transfer.

The baby was delivered “en caul,” meaning the amniotic sac remained intact until after the delivery. This is an extremely rare but safe occurrence and happened spontaneously with this delivery, adding to the special occasion. The woman whose identity was not disclosed chose to remove the uterus after delivering the baby.

This is the second birth from a uterus from a deceased donor, the first occurred in 2017 in a Brazilian trial involving a 32-year-old woman born without a womb who received a uterine transplant from a 45-year-old woman who'd died of a stroke.

Here is the video from Cleveland Clinic

Hologic launches multipurpose Omni-Hysteroscope

Hologic announced the launch of its FDA cleared, innovative 3-in-1 Omni™ Hysteroscope equipped with advanced visualization capabilities to streamline the diagnostic and therapeutic procedures.

The scope comes with 3 interchangeable sheaths which eliminate the physician need to change the scope between diagnostic and treatment procedures. Additionally, the scope is armed with Premium MyoSure optics to ensure clarity and quality visualization throughout the procedure.

The patients experience less pain and discomfort because the scope can be easily inserted because of thin sheaths (3.7 mm diagnostic sheath; 5 mm operative sheath; 6 mm operative sheath). It also provides long 200 mm working length to efficiently work with obese patients.

The sheaths are compatible to use with Hologic’s Fluent™ hysteroscopic fluid management system and all MyoSure® tissue removal offerings including MyoSure REACH, MyoSure XL, MyoSure LITE, and MyoSure MANUAL devices.

“Experts agree that direct visualization of the uterine cavity in women with abnormal uterine bleeding is the gold standard that allows physicians to accurately identify and collect quality samples and remove pathology – in a safer and more effective manner than blind biopsy and curettage,” said Edward Evantash, M.D., Medical Director and Vice President of Global Medical Affairs, Hologic. 

“Featuring three easily interchangeable sheaths in one scope, our new Omni scope gives physicians excellent visualization capabilities with the convenience of seeing and treating pathology in a more streamlined procedure,” he added.  

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myLotus becomes the first and only quantitative fertility tracking home test to get clearance in Europe

Concepta Plc, a company based in Bedfordshire, UK, announced the approval of its breakthrough product, myLotus® in Europe. myLotus assists women to conceive naturally by quantitatively measuring the LH surge to pinpoint the day of ovulation. 

myLotus is scheduled to be launched this weekend at The Fertility Show in Olympia, London on November 3-4. The system consists of myLotus fertility monitor, ovulation test strips and pregnancy test strips and myLotus fertility App.

The woman must dip the ovulation strip into the urine sample and insert it into the fertility monitor. The monitor provides a “+” and “–” fertility test result and measures the levels of Luteinising Hormone (LH) present in your urine. This quantitative estimation of LH  makes it different from traditional (qualitative) ovulation tests. Women can continue to test throughout the menstrual cycle to know about the pattern of LH levels and surge.

The pregnancy test provided allows for easy testing for conception in the days following LH surge results.

The LH test results can be entered in the App and viewed in graphic form to know more about the fertile time for intimacy. The results are as accurate as the laboratory-based test without the hassle of leaving your home. Data can be shared with your healthcare provider to improve your chance of conception.

Matthew Walls, Chairman said: "The Fertility Show marks the UK launch of our myLotus® fertility product and the start of our roll-out across CE territories. Women attending the show can exclusively buy a Starter Pack, consisting of a myLotus® monitor, three packs of 20 Ovulation Tests (LH) and three packs of 3 Pregnancy Tests (hCG), at the 'Special Launch' price of £199. We look forward to an exciting Fertility Show and to welcoming women and couples to our stand.

Here is a simple animation video to know more about myLotus

Here is a video to know about how the fertility monitor works

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Conceptanews release

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ESHRE appeals to national societies to spread awareness about oocyte donation

The European Society of Human Reproduction and Embryology (ESHRE) has created an oocyte donation brochure DONATION OF OOCYTES in collaboration with the Council of Europe European Committee on Organ Transplantation (CD-P-TO).

ESHRE is encouraging national societies across Europe to translate the publication into their national languages. Composed by internationally recognized experts, the patient brochure on oocyte donation is a guide for women to support informed decisions about donating oocytes.

Many women are unsure whether it is safe or not to donate oocytes and are interested in knowing the future implications of such donations. This guide will provide clear, accurate and balances information about the cause.

To translate the guide into regional language first seek permission with the Council of Europe who holds the copyright of the publication. This can be done by sending an e-mail to publications.info@edqm.eu where you will have to specify your intention and the language of translation.

DONATION OF OOCYTES Brochure

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Novel microfluidic device quickly corrals vigorous motile sperms for IVF

Courtesy: Pixabay

Cornell University scientist has created an innovative microfluidic device that effectively separates the motile, highly energetic sperms; thereby increasing the chances of fertilization for couples undergoing IVF.

The current method of separating sperms for IVF is highly tedious, manual and can take hours for completion. Doctors and technicians spend hours to separate the motile, good quality sperms making the process expensive and time-consuming.

“With the new method, it’s 5 minutes instead of hours,” said Alireza Abbaspourrad, a researcher involved in the latest study.

The new device takes advantage of sperm’s ability of positive rheotaxis—natural tendency of the sperms to face against fluid flow after reaching a specific velocity. The researchers devised a microfluidic channel through which the semen sample flows to which the researchers added a “C” shaped corral and a retaining wall.

The structure creates interference to flow of sperms, and the highly motile, stronger sperm enter the corral only to be trapped by the retaining wall. “We could separate the good sperm from the not-so-strong in a reasonably elegant way. We are able to fine-tune our selection process,” said Soon Hon Cheong, another researcher involved in the study.

Meisam Zaferani, a doctoral student at the Cornell, said the device might find broader application beyond its uses in Assisted Reproductive Techniques, especially in dairy and livestock industries. “The unprecedented efficiency of our device in comparison to previous studies and its benign, passive nature makes it favorable for sperm separation,” he said.

The study, “Rheotaxis-Based Separation of Sperm with Progressive Motility Using a Microfluidic Corral System,” published in the Proceedings of the National Academy of Sciences July 30.

Cornell newsletter

Here is the short video of how the technique works

Hologic unveils Fluent fluid management system that simplifies and streamlines hysteroscopies

Hologic launches its new Fluent™ fluid management system to streamline the liquid distention of the uterus during diagnostic and operative hysteroscopy and measure the volume of irrigation fluid in and out of the uterus.

The system is easy to set-up and the user-friendly interface prompts the operator through all the steps to set-up and wraps the operation. The screen provides large visual and audible alerts during monitoring of fluid deficit, pressure, low fluid bags, and full waste bags to keep the procedure running smoothly.

The system is sensitive enough to detect a change in average intrauterine pressure of less than 1% and fluid deficit within +/- 50 mL when running the MyoSure® system. A single waste bag eliminates the need of multiple canisters.

"We developed the Fluent system with a deep understanding of the hectic workflow that often characterizes the patient and staff experience," said Sean Daugherty, President of GYN Surgical Solutions, Hologic. "This launch is a testament to how our strong customer partnerships and unique technological innovations enable us to provide healthcare professionals with the advanced equipment they need to improve lives."

"Fluid management plays a vital role in gynecological procedures, yet there have been few advances in the technology," said Edward Evantash, M.D., Medical Director and Vice President of Global Medical Affairs, Hologic. "The Fluent system is changing the game in fluid management. Developed in response to the challenges facing nurses and doctors performing hysteroscopies, it combines a streamlined design with innovative technology for more efficient fluid monitoring during procedures."

Here is a video about how the Fluent system untangles your fluid management experience

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Ten simple safety tips to avoid complications during hysteroscopy

Courtesy: Hysteroscopy newsletter

A series of precautions taken during before, during and after the hysteroscopic surgery can considerably reduce the risk of complications — reports Dr. Alice Rhoton-Vlasak, MD, Division of Reproductive Endocrinology & Infertility, from the University of Florida in the recent Hysteroscopy newsletter.

Hysteroscopy has evolved from merely a diagnostic procedure to method of choice for surgical treatment of intrauterine pathologies. Pantoleoni performed the first hysteroscopy using Desormeaux hysteroscope in 1869, and since then the development of hysteroscopy has flourished. 

With the increasing number of endometrial ablations, morcellation, electrosurgical procedures, and hysteroscopic sterilization performed worldwide, hysteroscopy has finally found its well-deserved niche in gynecological armamentarium.

It is generally a low-risk technique that utilizes the body’s natural passage to gain entry inside the uterine cavity. But like every surgical procedures complication are known to happen. These can be further reduced by taking simple precautions and being familiar with equipment and distention media.

Before the start of the procedure, the patient should be positioned appropriately to avoid nerve injury because the actual surgical time may be longer than the estimated time.

To avoid uterine perforation under challenging cases like Asherman’s syndrome or sizeable submucosal myoma, always use synchronous laparoscopic or ultrasound guidance.

The light source, suction and irrigation systems should be checked for smooth working before the start of the procedure. A backup set of instruments should be available in case of any intra-operative emergency.

Cervical dilatation should be cautiously performed, and precaution should be taken to avoid endometrial trauma and perforation. Hysteroscopic dilation of the cervix using the scope and hydrodistension is ideal.

Flushing air from tubes easily avoids air embolism, and it is always advisable to stop the procedure to purge the air out during the change of bags. The patient should not be put in Trendelenburg position during cervical dilatation and the hysteroscopic procedure to avoid a suction that may draw air into the uterine cavity.

Insert the hysteroscope cautiously inside the uterine cavity to avoid the formation of false passage in the cervix.

Hemorrhage during the hysteroscopic surgery is preventable with the use of electrosurgical coagulation, injection of vasopressin into the cervical stroma or the use of a Foley catheter balloon to exert intrauterine tamponade.

Avoid fluid overload by keeping a strict record of ins and out, limiting excess fluid absorption, and use of isotonic solutions in healthy individuals. Special precautions should be taken in older patients and those with heart failure or renal insufficiency.

A preoperative pelvic examination before the start of procedure gives a good idea of the uterine position. If the hysteroscope is in and the uterus fails to distend any time— a possibility of uterine perforation should be kept in mind. Stop the procedure immediately, and laparoscopy may be needed to assess the damage.

If any of the new morcellators or electrosurgical devices are introduced during a procedure, the entire surgical team should be aware of their functioning.

Following this simple safety tips can reduce the rate of hysteroscopic complications considerably. Besides, the patient should be made aware of all the risks before scheduling the procedure, and informed consent should be obtained.

Hysteroscopy Newsletter

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ACOG update: Letrozole is the first line therapy for ovulation induction in PCOS

The American College of Obstetricians and Gynecologists (ACOG) now recommends Letrozole (aromatase inhibitor) as the first-line treatment for ovulation induction in women with Polycystic Ovarian Syndrome (PCOS) due to data demonstrating increased ovulation rates, clinical pregnancy rates and live-birth rate vs clomiphene citrate. The guidelines are published as Practice Bulletin No. 194 in the June issue of Journal Obstetrics and Gynecology.

This replaces the Practice Bulletin Number 108, published October 2009, which recommends letrozole as first-line therapy for ovulation induction only in women with PCOS and a BMI greater than 30.

It is estimated that polycystic ovary syndrome (PCOS) affects 1 in 10 women of childbearing age and it is the most common cause of ovulatory infertility. If lifestyle modifications and weight loss are unable to achieve conception, currently clomiphene citrate (CC) is usually prescribed as the first-line treatment for ovulation induction.

  

The gonadotropin-stimulating action of letrozole has been used off-label in the treatment of patients with ovulatory dysfunction, such as polycystic ovary syndrome.

The results of recent double-blind, multicenter trial show that letrozole was associated with higher live-birth (27.5% vs 10.1%) and ovulation rates (61.7% vs 48.3%) among infertile women with the polycystic ovary syndrome as compared to CC.

Women on letrozole also had a 40% higher clinical pregnancy rate (OR 1.40 95% CI, 1.18-1.65) and 64% increased live birth rate (OR 1.64 (95% CI, 1.32-2.04) as compared to CC.

If prescribing letrozole, the starting dose is 2.5 mg/day for 5 days typically starting on day 3, 4, or 5 after a spontaneous menses or progestin-induced bleed. If ovulation does not occur, the dose can be increased to 5 mg/day for 5 days with a maximum dose of 7.5 mg/day. Doses higher than 7.5 mg/day have been associated with thinning of the endometrium as seen with clomiphene citrate.

Lifestyle modification and weight loss are strongly encouraged along with letrozole therapy.

Several studies have also shown that letrozole is also the drug of choice in clomiphene non-responders with 50–80% women ovulating on letrozole.

Letrozole and clomiphene citrate are pregnancy category X drugs, and studies have demonstrated similar rates of congenital malformation in mothers who achieved pregnancy because of ovulation induction using these drugs.

When prescribing letrozole for ovulation induction, patients should be counseled that unlike clomiphene citrate, letrozole is not approved by the U.S. Food and Drug Administration for ovulation induction.

More recent papers on PCOS:

Fresh or frozen-embryo transfer results in similar pregnancy rates in women without PCOS

The therapeutic dilemma in PCOS patients not desiring pregnancy: A systematic review and meta-analysis

Clomiphene compared with other drugs in terms of ovulation, EMT, pregnancy and live births: systematic review and meta-analysis

Stair-step clomiphene protocols shorten time to ovulation in women with PCOS

Preconception IGT in PCOS results in adverse pregnancy outcome, independent of BMI

New study quantifies the risk of developing type 2 Diabetes in women with PCOS

Polycystic ovarian syndrome increases the risk of subsequent early ovarian aging later in life

PCOS is often underdiagnosed as the common cause of Abnormal Uterine Bleeding in Adolescents

Letrozole does not increase the risk of adverse pregnancy or neonatal outcomes and major congenital anomalies in patients conceived by ARTs

ACOG calls upon all obstetrician-gynecologists to screen PCOS patients for metabolic abnormalities.

Current options for ovulation induction in Polycystic Ovarian Syndrome (PCOS)

PCOS and Infertility: Pretreatment Weight loss hikes the live birth and ovulation rate in overweight and obese patients. 

PracticeBulletin No. 194

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iFertracker- First Overnight Basal Body Temperature tracker to monitor the fertility

iFertracker™ by Raaing Medical is the first overnight fertility monitor that measures the core body temperature continuously throughout the night. It also simultaneously calculates and record the Basal Body Temperature (BBT) to predict the fertile window.

Usually, to measure the BBT a woman must use a special thermometer to record the temperature early morning each day at the same time before she gets out of bed. This task itself is tiresome and unreliable, sometimes a day is missed, or some error might occur.

iFertracker eliminates all this hassle and does all the work while the woman can sleep soundly throughout the night. It comes in beautifully packaged, with two CR2025 batteries (each battery is predicted to last for 45-60 days so the other is kept as spare one), a battery replacement tool, and 150 double-sided, single-use adhesive patches.

Setting up the iFertracker before the woman can start measuring the temperature is a very easy task. The woman has to simply download the free app to an Android or iOS cell phone and input all her menstrual cycle details along with her biometrics.

The device itself is very small and lightweight and has a very sleek, oblong design. It powers on automatically as soon as it comes in contact with body heat and a small blue light starts flashing indicating that Bluetooth capabilities are enabled. After once connected the iFertracker will recognize the user’s cell phone and will connect with it every time the app is opened.

To begin using, the woman places a new, double-sided adhesive patch on the oblong wearable thermometer and adhere it to the armpit. It is advisable to shave the area before putting on the device. The device turns on by itself and collects 20,000 data points in a single night, continuously monitoring the temperature as the user sleeps through the night. These are eventually uploaded to cloud and analyzed by an advanced algorithm to calculate the BBT.

The next morning, she removes the device and goes around with her morning routine. At her convenience, she opens the app on her smartphone and the device sync to it and starts downloading the temperature readings collected overnight.

In an event that internet connectivity is lost, or the user is very busy to open the app, the device has the ability to store data up to 10 days and it syncs with the app as soon as it is opened.

The iFertracker app displays the information collected in the form of graphs that are user-friendly and easy to understand. The graph color codes each phase of the cycle, including Menstruation, Follicular & Luteal phases, Fertile Window, and Ovulation day.

In addition to the display of last night’s BBT, the home screen informs the user about her fertility possibility and days until ovulation. The app also allows the user to input relevant event such as cervical mucus, mood, sexual activity, etc. The accuracy of prediction increase linearly with the duration of use as the tracker collects data over time and harness it to predict the fertility window and day of ovulation.

Besides getting pregnant this information can be used for natural family planning, hormone tracking during pregnancy or return to full fertility after delivery.

Raiing Medical also manufacture iThermonitor ™, the only wearable, wireless, clinically validated, and non-invasive core temperature thermometer.  It is worn similar to iFertracker and can be used in children and adults.

The iFertracker is available on Amazon or directly from Raiing Medical for $109. The adhesive patches are also available separately. 

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Here is a video about how to track your BBT using iFertracker

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Fresh or frozen-embryo transfer results in similar pregnancy rates in women without PCOS

Episona.com

Healthy infertile women with no polycystic ovarian syndrome have the same ongoing pregnancy and live birth rates from IVF irrespective of whether the embryo was fresh or frozen reports the results of two recent clinical trials published in JAMA. 

Recent clinical trials have documented higher pregnancy and live birth rates with the transfer of frozen embryos as compared to fresh ones. A clinical review published in the Journal of Human Reproduction Update also favored “elective frozen embryo transfer (eFET) not only in terms of achieving higher pregnancy rates but, more importantly, also in terms of lower maternal and infant morbidity and mortality.”

The two current studies were conducted to see whether fresh frozen embryo transfer resulted in higher birthrates in women who do not have PCOS.

The first multicenter, randomized trial recruited 2157 women who were scheduled to undergo their first IVF cycles. They were randomly assigned to undergo either fresh-embryo transfer or embryo cryopreservation followed by frozen-embryo transfer. The maximum embryo transferred in each participant was two with the live birth rate as the primary outcome after the first embryo transfer.

There was no significant difference in terms of live birth rates in the frozen-embryo group and the fresh-embryo group (48.7% and 50.2%; P=0.50) respectively. Both the groups were also similar in terms of risks of obstetrical and neonatal complications, rates of implantation, clinical pregnancy, overall pregnancy loss, and ongoing pregnancy.

But, frozen embryo transfer did result in a significantly lower risk of the ovarian hyperstimulation syndrome than fresh-embryo transfer (0.6% vs. 2.0%; P=0.005).

The second study randomly assigned 782 healthy infertile women with no PCOS to receive either a frozen embryo or a fresh embryo on day 3 during their first or second IVF. In this study also, the pregnancy rates were comparable in both the groups, 36.3% in the frozen-embryo group 34.5% in the fresh-embryo group (P = .65).

The authors concluded that in women who do not have PCOS, the pregnancy rates are similar with fresh or frozen embryos. In healthy infertile women, probably the uterine environment was favorable for fresh embryos transfer. 

Abstract-NEJM

Abstract-NEJM

Abstract-JAMA

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Photo of the day: Three-dimensional sonography-based automated follicle count (SonoAVC) in polycystic ovarian morphology

Automated Volume Count software in three-dimensional volume of left ovary, depicting 67 antral follicles

Three-dimensional Sonography-based Automated Volume Count, GE Medical Systems (SonoAVC) could be a useful adjunct for follicular monitoring in patients with Polycystic ovarian syndrome (PCOS), with a significant saving in time and an accurate prediction over manual counts. 

SonoAVC was introduced in 2008 (GE Medical Systems, Zipf, Austria), and automatically identifies and counts follicles in a given ovarian volume because of hypoechoic nature against hyperechoic ovarian tissue background.

SonoAVC software is either integrated into the ultrasound device or it can be installed separately on a PC for the offline analysis of data sets obtained using an ultrasound device from the same manufacturer. Each volume has its own color, making SonoAVC an ideal tool for studying follicular development within the ovary.

Here is a beautiful picture of the day published on January 3, 2018 in the Journal Ultrasound in Obstetrics and Gynecology, which depicts the stark contrast between Grayscale two-dimensional ultrasound images showing follicles vs. automated follicle counting using Sonography-based Automated Volume Count software in three-dimensional volume of left ovary, depicting 67 antral follicles.  

Grayscale two-dimensional ultrasound images showing follicles

automated follicle counting using Sonography-based Automated Volume Count software

Technique of using SonoAVC on the Voluson E8 ultrasound system:

• A transvaginal ultrasound is performed using a 3D imaging probe (RIC 5-9 or RIC 6-12)

• Optimize the gain and harmonics for optimum image quality

• Select 3D imaging mode, adjust quality settings

• Adjust volume angle to include entire ovary and acquire volume

• Adjust 3D box over area of interest

• Select SonoAVC to evaluate the ovarian follicles

• Increase or decrease growth or follicular separation

• Select follicles manually if they are not identified

• Display report and chart

Full-Text of Journal Article 

The International Glossary on Infertility and Fertility care updated

The International Committee for Monitoring Assisted Reproductive Technology(ICMART) along with 20 more organization notably ASRM, ESHRE, IFFS, MOD, AFS, GIERAF, ASPIRE, MEFS, REDLARA and FIGO has released a new evidence and consensus based updated document that includes the current definitions of 283 terms that are used in infertility and fertility care. 

The updated document was simultaneously published in Fertility and Sterility and Human Reproduction.

Earlier, the list contained 87 terms in 2009 and was developed to facilitate better communications between infertility professionals and researchers around the world.

Twenty-five Infertility professionals around the world grouped into 5 groups to work on adding more words and terms to the existing list, particularly in areas of male fertility, epidemiology and public health. The final list was reviewed by independent experts around the globe in particular category.

The definition of infertility was revised in the new glossary - “A disease characterized by the failure to establish a clinical pregnancy after 12 months of regular, unprotected sexual intercourse or due to an impairment of a person's capacity to reproduce either as an individual or with his/her partner. […] Infertility is a disease, which generates disability as an impairment of function.”

According to the new edition ‘subfertility’ and ‘infertility’ could be used interchangeably.

Richard J. Paulson, MD, ASRM President, said in a press release, “The new glossary is a great tool that will help us improve patient care as well as collaborative research.  Agreeing on standardized definitions and meanings that go beyond culture and context is essential for medical and scientific advancements. Everyone in the field of reproductive medicine and science will benefit from using the new glossary.” 

Here is the link to download the complete glossary in PDF format: Zegers-Hochschild et al, The International Glossary on Infertility and Fertility Care, 2017, Fertility and Sterility, in press.

Source: ASRM Bulletein.

News from ASRM 2017: Subfertility May be Harbinger of Disease Later in Life

The American Society for Reproductive Medicine (ASRM) 2017 Scientific Congress kicked of today morning by an opening keynote address from President Richard J. Paulson, M.D. at San Antonio, TX. The agenda ranges from the latest molecular and genetic technologies to advocacy for the patients with a focus on access to care.

Researchers from the University of Pennsylvania today presented research showing that women seeking infertility treatment have a shorter life span as compared to their parous counterparts. They have a higher risk of dying from endocrine related disorders such as diabetes and breast cancer than other women.

This retrospective cohort study examined  records of nearly 80,000 women and followed them for nearly 13 years, with an aim to determine the association of a history of infertility with all-cause mortality.

These women were enrolled in the Prostate Lung, Colorectal, and Ovarian (PLCO) Cancer screening trial from 1992-2001. Nearly 76,000 women had data on infertility.

It was seen that 14.5% (n=11,006) of women did not have any children. The average age at death for each cohort was similar (74 years) but women in infertile cohort had 10% greater chances of dying as compared to fertile cohort.  (HR1.10, 95%CI 1.03, 1.17, p=0.005).

Infertile women also face 69% increased chances of dying due to diabetes, 49% more chances of death due to breast cancer.

Ovarian cancer and Endometrial cancer did not increase the risk of death, although infertile women had marginally high risk of ovarian cancer.

This large retrospective study does show an association between endocrine related diseases and infertility but does not prove causation.It stresses the need of prospective studies and more research  in this area.

But, infertility can present an early opportunity to screen these women for chronic diseases and interventions.

Richard J. Paulson, MD, President of ASRM said in a News Release, “This is an intriguing and potentially very important study. More work is clearly needed to help us understand if, in some patients, there might be an underlying medical problem that presents as infertility during the reproductive years and then contributes to endocrine-related disease later in life. We also need to investigate if infertility treatments can counter some of this increased risk.”

The study is also published in Fertility and Sterility September supplement.

Endometriosis fertility index can accurately predict a women’s chances of conception after laparoscopy

courtesy:Can stock photos

The Endometriosis fertility index can accurately predict the possibility of non-ART conception or the need of ART for achieving pregnancy after surgical resection of moderate-severe (Stage III–IV) endometriosis reports the results of study published in Human Reproduction. The study confirmed that adnexal function is deciding factor in evaluation of fertility prognosis after the surgery.

There is no evidence based guidelines about post-surgery fertility management of women who have undergone surgery for severe endometriosis. Physicians differ in their approach about the length of conservative treatment and that sometimes add years and causes unnecessary delays.

The researchers in this study from Australia, led by Dr. Sarah Maheux-Lacroix of the Royal Hospital for Women in Randwick, looked into data of 279 women who had undergone laparoscopic surgery for stage III-IV and were trying to become pregnant.

Endometriosis fertility index was first published in 2010 and is a robust tool to predict fertility after surgical staging of endometriosis.

https://image.slidesharecdn.com/

The EFI is combines obstetrical and surgical factors to predict a woman’s chance of becoming pregnant. In addition to all the components of the revised-American Society of Reproductive Medicine score, it also includes a detailed evaluation of the fallopian tubes, fimbriae, and ovaries, and accounts for any adnexal dysfunction after surgery.

The researchers calculated EFI for all these women based on detailed operative reports and surgical images plus the obstetric history of women.

The average follow-up was 4 years during which 147 women (63%) gave birth, of which 94 conceived naturally without ART.

None of the women with EFI 0-2 conceived, while 91% women with EFI 9-10 had live births in 5 years period after surgery.

Similarly, women with EFI 0-2 had a success rate of 38% with ART, while those with EFI 9-10 had a success rate of 71%.

So, low EFI was significant in predicting failure to conceive (P = 0.003) in addition to other factors which adversely affected the pregnancy rates like being older than 40 years (P = 0.027), having uterine fibroids (P = 0.037) and history of previous resection (P = 0.019) or incomplete resection (P = 0.028).

The only drawback of the study was its retrospective nature.

The researchers concluded that the tool can be used to predict the fertility prognosis in women after surgery for endometriosis. Depending on the EFI score, the obstetrician can advise patients about timed intercourse or refer the patients  for ART, without wasting precious years.

Abstract

An effective, minimal invasive but “vastly underutilized” treatment option for fibroids: Uterine Fibroid Embolization

Statistics by National Institute of Health (NIH) indicate that nearly 3 in 4 women will develop fibroid by the time they reach age 50, but more than half of these women have never heard of Uterine Fibroid Embolization and 11% think that hysterectomy is the only treatment option available to them says the results of a Nationwide survey conducted by Harris Poll between June 23 and 27, 2017.

The survey was conducted on behalf of the Society of Interventional Radiology (SIR) and results were presented at the Society of Interventional Radiology’s 2017 Annual Scientific Meeting.

The survey of almost 1,200 women found that about one third of women did not know what fibroids are, 37% did not know anybody else with the diagnosis of fibroid, and nearly 60% did not think that they are at risk of developing fibroid.

Courtesy: Linkedin.com 

One in 5 women thought fibroids are cancerous and surgery is the only treatment option they have.

A majority of women (62%)have never heard of Uterine Fibroid Embolization, and 73% of women who knew about UFE reported that they got the information elsewhere, other than their Ob/Gyn.

As per National Uterine Foundation, nearly 600,000 hysterectomies performed annually in the United States out of which ~170,000 - ~300,000 are due to uterine fibroids. A review of published studies has shown that nearly 1 in 5 hysterectomy is unindicated and 40% of patient who have hysterectomy do not receive full information about other medical or less invasive procedures available to them. It appears that it was presented to them as the best treatment option available, says the SIR report.

James Spies, MD, MPH, a professor of radiology at Georgetown University Medical Center, Washington, DC, and the president-elect of SIR said, "Misperceptions about uterine fibroids and the treatments available often lead women to undergo invasive and potentially unnecessary surgery for their fibroids, despite more than 20 years of clinical use supporting uterine fibroid embolization.”

"Unfortunately, still many health care professionals start and end with hysterectomy as the recommendation for patients," he further added.

An NIH study showed that 165,000 more hysterectomies were performed than UFEs (167,650 vs. 2,470) nationwide, a difference of whopping 67% between the two procedures.

The study also reported that nine out of 10 women who have uterine fibroid embolization have significant improvement. Many women report their symptoms disappear completely.

UFE also helps women in getting back to normal lives quickly after the procedure, with no residual effects of early menopause and sexual dysfunction, as often experienced after hysterectomies.

It is also minimally invasive with a hospital stay of one day or less, cost effective, low rate of complications and few women require follow up treatment. If the fibroids recur, they can be again be treated: A second UFE is not contraindicated, said Dr Spies.

It’s also a great option for women desiring future pregnancies.  A study published in Radiology Journal showed a 41.5 percent pregnancy rate after an average follow-up of almost six years.

The ACOG has included UAE in its FAQs on Uterine Fibroids. The procedure was included as one of the treatment option in its 2008 bulletin, reaffirmed again in 2016. The bulletin concludes, "Based on long- and short-term outcomes, uterine artery embolization is a safe and effective option for appropriately selected women who wish to retain their uteri." 

Courtesy: SIR

UFE is performed by an interventional radiologist who inserts a thin catheter into the artery at the groin or wrist. The doctor guides the catheter to the fibroid’s blood supply where small particles, about the size of grains of sand, are released to float downstream and block the small blood vessels and deprive the fibroid of nutrients. This results in the fibroid softening, bleeding less, and shrinking in size.

Does  the push to promote UFE by SIR means promoting self-interest? No, it only means that women diagnosed with fibroids deserve to know about all the options they have and the clinicians should be able to inform them about it. 

Executive summary of survey, Full PDF, SIR news release
RCOG recommendations for UAE for Fibroids