Anusch Yazdani

Miscarriage karyotype and its relationship with maternal body mass index, age, and mode of conception.

This study investigated the association between miscarriage karyotype and body mass index, maternal age, and mode of conception. Miscarriages after IVF and/or intracytoplasmic sperm injection were less frequently aneuploid; advanced maternal age was associated with an increase in aneuploid products of conception; overweight and obese women aged <35 years were less likely to have aneuploid miscarriages than women in a healthy weight range, suggesting alternate mechanisms for miscarriage in this population.

Endometriosis and Infertility – a consensus statement from ACCEPT (Australasian CREI Consensus Expert Panel on Trial evidence)

Endometriosis is common in women with infertility but its management is controversial and varied. This article summarises the consensus developed by a group of Australasian subspecialists in reproductive endocrinology and infertility (the Australasian CREI Consensus Expert Panel on Trial evidence group) on the evidence concerning the management of endometriosis in infertility. Endometriosis impairs fertility by causing a local inflammatory state, inducing progesterone resistance, impairing oocyte release and reducing sperm and embryo transport. Medical treatments have a limited role, whereas surgical and assisted reproductive treatments improve pregnancy rates. The role of surgery for deep infiltrative endometriosis and repeat surgery requires further evaluation and there is insufficient evidence for the use of anti‐adhesives to improve fertility. Intrauterine insemination (IUI) and in vitro fertilisation (IVF) improve pregnancy rates but women with endometriosis have lower pregnancy rates than those with other causes of infertility. The decision about whether to operate or pursue assisted reproduction will depend on a variety of factors such as the patients symptoms, the presence of complex masses on ultrasound, ovarian reserve and ovarian access for IVF, risk of surgery and cost. Some women with infertility and endometriosis may benefit from a combination of assisted reproduction and surgery.

Sperm DNA fragmentation in men with malignancy

OBJECTIVE To determine if men with malignancy have increased sperm DNA fragmentation compared with men presenting for sperm donation. DESIGN Retrospective observational study. SETTING Tertiary-level fertility center. PATIENT(S) Eighty-nine men with cancer presenting for prophylactic semen cryopreservation and 35 men presenting for sperm donation. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Sperm DNA fragmentation index (DFI) measured by sperm chromatin assay. RESULT(S) The mean sperm DFI in men with a diagnosis of cancer, 9.88% (95% confidence interval [CI] 7.84%-12.44%), did not differ from that found in men presenting for sperm donation 10.46% (95% CI 8.68%-11.80%). There were no significant differences in mean sperm DFI within cancer subgroups or when comparing testicular and nontesticular cancers. Subgroup analysis lacked statistical power. Men with testicular cancer have significantly reduced sperm concentration compared with both control subjects and men with nontesticular cancer. CONCLUSION(S) In our study population there was no difference in sperm DFI between men undergoing prophylactic semen cryopreservation and men presenting for sperm donation. Sperm DFI assessment has limited utility in the routine evaluation of men presenting for semen cryopreservation.

Post-mortem sperm retrieval in Australasia

Post‐mortem Sperm Retrieval (PMSR) is seldom requested in Australasia. The retrieval of sperm is permitted only by prior written consent or by order of the court. Sperm should be retrieved within 24 h following death; however, collection within 36 h may still be successful. The clinical response to such a request must be mindful of complex ethical and legal considerations. Clear, accessible and consistent law in this area would benefit medical, legal and societal stakeholders.

Right of reply to: Surgical treatment is an excellent option for women with endometriosis and infertility

Professor Abbott presents an impassioned plea for the surgical treatment of endometriosis, and, for the management of pain, the role of surgery is undisputed. Unfortunately, the case for surgery falls short in the management of infertility. Despite the extensive research presented, there is only one prospective randomised controlled study of endometriosis in infertility that supports surgery. The Marcoux study,1 celebrating its 30th anniversary, remains the reference exemplar for the efficacy of surgery. Yet the absolute pregnancy rate of women with minimal and mild endometriosis remains disappointingly low six months after randomisation. Appropriately, health consumers are now much more critical of an intervention that purports a cumulative pregnancy rate of only 30% at six months. The Marcoux study was conducted at a time when women had different life balance expectations and limited effective alternatives. It is therefore timely to reassess the applicability of this study to a modern population. As gynaecological surgeons, we have the tendency to overestimate the magnitude of the treatment effect and underestimate the burden of intervention. And so, while Professor Abbott reiterates the reassuring mantra that women conceive following surgery, it is important to emphasise that many studies report on fertility outcomes in study populations who have never had infertility. It is therefore not surprising to achieve a 70% pregnancy rate in the year following surgery. More astounding is that these women have been able to conceive despite surgery. Finally, Professor Abbott fails to address the fundamental resource issue with the surgical management paradigm: only a handful of gynaecology units in Australia and New Zealand have the requisite infrastructure to be considered ‘Centres of Excellence for Endometriosis’ to effectively manage advanced disease. This is in stark contrast to the numerous fertility clinics that provide accessible and effective care. Appropriately, the consensus statement that forms the basis of the Australian and New Zealand guidelines for the management of infertility in endometriosis2 recommends that ‘surgical and assisted reproductive treatments do not need to occur in isolation, and many women may benefit from a combination of approaches.’ Ultimately, the decision rests with each individual woman in coordination with her specialist in a given resource setting.

Factors influencing women's decision making in hysterectomy

OBJECTIVE To explore factors influencing how well-informed women felt about hysterectomy, influences on their decision making, and on them receiving a less-invasive alternative to open surgery. METHODS Online questionnaire, conducted in 2015-2016, of women who had received a hysterectomy in Australia, in the preceding two years. RESULTS Questionnaires were completed by 2319/6000 women (39% response). Most women (n=2225; 96%) felt well-informed about hysterectomy. Women were more aware of the open abdominal approach (n=1798; 77%), than of less-invasive vaginal (n=1552; 67%), laparoscopic (n=1540; 66%), laparoscopic-assisted (n=1303; 56%), and robotic approaches (n=289; 12%). Most women (n=1435; 62%) reported their gynaecologist was the most influential information source. Women who received information about hysterectomy from a GP (OR=1.47; 95% CI 1.15-1.90), or from a gynaecologist (OR=1.3; 95% CI 1.06-1.58), were more likely to feel better informed (p<0.01). CONCLUSION This study is important because it helps clinicians, researchers and health policy makers to understand why many women still receive an open abdominal approach despite many learned societies recommending to avoid it if possible. PRACTICE IMPLICATIONS Additional information, or education about avoiding open abdominal approach where possible may lead to a greater number of women receiving less-invasive types of hysterectomy in the future.

Surgery or in vitro fertilization: The simplicity of this question belies its complexity

Unlike surgery, assisted reproduction, particularly in vitro fertilisation (IVF), requires a low skill base, is largely practitioner independent, is highly effective, quality controlled, reproducible and consistent in the management of endometriosis‐associated infertility. Ultimately, however, the decision to proceed to IVF or surgery is dependent on the woman, her reproductive expectations, her specific disease pattern, her support and family network and the resources available in a given health care setting.

Clomiphene ovulation induction and higher-order multiple pregnancy

Clomiphene citrate is a widely used treatment for ovulatory dysfunction in women seeking pregnancy. The major adverse consequence of clomiphene use is the increased risk of multiple and higher‐order multiple pregnancy. Mechanisms for multiple pregnancy include dosing variation, adjuvant therapies, pretreatment weight loss and a cumulative effect of multiple clomiphene cycles. It has been suggested that the risk of higher‐order multiple pregnancy may be reduced with ultrasound monitoring, although there is limited evidence to support this practice.

Surgical approach to hysterectomy and barriers to using minimally invasive methods

Minimally invasive approaches to hysterectomy have been shown to be safe, effective and have recovery advantages over open hysterectomy, yet in Australia 36% of hysterectomies are still conducted by open surgery. In 2006, a survey of Australian gynaecological specialists found the main impediment to increasing laparoscopic hysterectomy to be a lack of surgical skills training opportunities. We resurveyed specialists to explore contemporary factors influencing surgeons’ approaches to hysterectomy; 258 (estimated ~19%) provided analysable responses. Despite >50% of surveyed specialists wishing to practise laparoscopic hysterectomy in the future, lack of surgical skills, arising from the lack of training opportunities, remains the main impediment.

Assisted reproduction in a subfertile couple with serodiscordant HIV infection

Mrs. S. (31 years old) and Mr. S. (34 years old) were a Cambodian couple who presented with infertility at er a 2-year history of intermittent unprotected intercourse. Mr. S. had been diagnosed with human immunodei ciency virus type 1 infection (HIV) 8 years earlier. Aware of the risks of HIV transmission the couple had elected to time unprotected intercourse to the days around supposed ovulation, while at other times in the cycle they used condoms. He was on antiviral medication. Mrs. S. had regular HIV serology performed, which was consistently negative.