Bradley S. Hurst

Expanded polytetrafluoroethylene (Gore-Tex Surgical Membrane) is superior to oxidized regenerated cellulose (Interceed TC7 ) in preventing adhesions

OBJECTIVE To compare the impact of expanded polytetrafluoroethylene (PTFE; Gore-Tex Surgical Membrane; W. L. Gore & Associates, Inc., Flagstaff, AZ) and oxidized regenerated cellulose (Interceed TC7, Johnson & Johnson Medical, Inc., Arlington, TX) on the development of postsurgical adhesions. DESIGN A multicenter, nonblinded, randomized clinical trial. SETTING University medical centers. INTERVENTIONS Each barrier was allocated randomly to the left or right sidewall of every patient. PATIENTS Thirty-two women with bilateral pelvic sidewall adhesions undergoing reconstructive surgery and second-look laparoscopy. MAIN OUTCOME MEASURES Adhesion score (on a 0- to 11-point scale), the area of adhesion (cm2), and the likelihood of no adhesions. RESULTS The use of both barriers was associated with a lower adhesion score and area of adhesion postoperatively. However, those sidewalls covered with PTFE had a significantly lower adhesion score (0.97 +/- 0.30 versus 4.76 +/- 0.61 points, mean +/- SEM) and area of adhesion (0.95 +/- 0.35 versus 3.25 +/- 0.62 cm2). Overall, more sidewalls covered with PTFE had no adhesions (21 versus 7) and, when adhesions were present on the contralateral sidewall, the number of sidewalls covered with PTFE without adhesions was greater than those covered with oxidized regenerated cellulose (16 versus 2). CONCLUSION Expanded polytetrafluoroethylene was associated with fewer postsurgical adhesions to the pelvic sidewall than oxidized regenerated cellulose.

Uterine artery embolization for symptomatic uterine myomas

OBJECTIVE To evaluate the role of uterine artery embolization as treatment for symptomatic uterine myomas. DESIGN Medline literature review, cross-reference of published data, and review of selected meeting abstracts. RESULT(S) Results from clinical series have shown a consistent short-term reduction in uterine size, subjective improvement in uterine bleeding, and reduced pain following treatment. Posttreatment hospitalization and recovery tend to be shorter after uterine artery embolization compared with hysterectomy. Randomized controlled trials have not been conducted, and long-term efficacy has not been studied. A limited number of deliveries have been reported following uterine artery embolization for uterine myomas. CONCLUSION(S) Uterine artery embolization is a unique new treatment for symptomatic uterine myomas. Even without controlled studies, demand for this procedure has increased rapidly. Uterine artery embolization may be considered an alternative to hysterectomy, or perhaps myomectomy, in well-selected cases. At the present time, however, uterine artery embolization should not be routinely recommended for women who desire future fertility.

Comprehensive management of severe Asherman syndrome and amenorrhea

OBJECTIVE To describe a comprehensive approach to women with severe Asherman syndrome and amenorrhea, including preoperative, operative, and postoperative care and subsequent resumption menses, and pregnancy. DESIGN Retrospective case series. SETTING Tertiary care teaching hospital. PATIENT(S) Twelve women with severe Asherman syndrome and amenorrhea. INTERVENTION(S) Preoperative administration of prolonged preoperative and postoperative oral E(2) to enhance endometrial proliferation, intraoperative abdominal ultrasound-directed hysteroscopic lysis of uterine synechia to ensure that the dissection is performed in the proper tissue plane, placement of a triangular uterine balloon catheter during surgery, and postoperative removal with placement of a copper intrauterine device (IUD) to maintain separation of the cavity and mechanically lyse newly formed adhesions during removal. MAIN OUTCOME MEASURE(S) Resumption of menses, pregnancy, and delivery. RESULT(S) All women resumed menses, although 5 of 12 had a preoperative maximal endometrial thickness of 4 mm or less, with follow-up ranging from 6 months to 10 years. Six of nine women less than age 39 years (67%) became pregnant, and four of six achieved a term or near-term delivery. CONCLUSION(S) Comprehensive management provides the best possible outcomes in poor-prognosis women with severe Asherman syndrome.

Cancer, Fertility Preservation, and Future Pregnancy: A Comprehensive Review

Given the increases in 5-year cancer survival and recent advances in fertility preserving technologies, an increasing number of women with cancer are presenting for discussion of fertility preserving options. This review will summarize the risk of infertility secondary to cancer treatment, available treatment options for fertility preservation, and techniques to reduce future risks for patients. Concerns that will be addressed include the risk of the medications and procedures, the potential delay in cancer treatment, likelihood of pregnancy complications, as well as the impact of future pregnancy on the recurrence risk of cancer. Recent advances in oocyte cryopreservation and ovarian stimulation protocols will be discussed. Healthcare providers need to be informed of available treatment options including the risks, advantages, and disadvantages of fertility preserving options to properly counsel patients.

A short period of ejaculatory abstinence before intrauterine insemination is associated with higher pregnancy rates

An ejaculatory abstinence period of <or=2 days before IUI produced the highest pregnancy rates per cycle compared with longer intervals of ejaculatory abstinence. This higher conception rate occurred despite a lower total number of motile spermatozoa inseminated.

Obstetric and gynecologic challenges in women with Ehlers-Danlos syndrome.

OBJECTIVE: To determine how often women with Ehlers-Danlos syndrome experience obstetric and gynecologic issues both compared with the general population and within the three most common subtypes of Ehlers-Danlos syndrome. METHODS: An anonymous, prospective, online questionnaire in English was posted to the Ehlers-Danlos National Foundation web site (http://ednf.org). RESULTS: Of the 1,769 of those who completed the survey, 1,225 reported a typed diagnosis of Ehlers-Danlos syndrome. Further stratification to the three most common types and reproductive-aged women (n=775) allowed conclusions to be made about differences in rates of obstetric complications and gynecologic dysfunction compared with the general population and between types of Ehlers-Danlos syndrome. Rates of obstetric outcomes for women who reported at least one pregnancy included term pregnancy in 69.7%, preterm birth in 25.2%, spontaneous abortion in 57.2%, and ectopic pregnancy in 5.1%. Infertility was reported by 44.1% of survey respondents. Normal menstrual cycles were reported by only 32.8% with intermenstrual bleeding occurring in 18.6%. Heavy menstrual bleeding was reported by 32.9% survey participants. Gynecologic pain reported included dysmenorrhea by 92.5% and dyspareunia by 77.0%. CONCLUSION: There is a much greater prevalence of obstetric and gynecologic issues reported by women with Ehlers-Danlos syndrome than in the general population. Additionally, rates differed significantly among the three most common types of Ehlers-Danlos syndrome with vascular type having the highest rates of adverse pregnancy outcomes and menstrual abnormalities. Physician providers should be aware of these challenges and should counsel patients with Ehlers-Danlos syndrome about relevant options and risks. LEVEL OF EVIDENCE: III

Association of blood type and patient characteristics with ovarian reserve

OBJECTIVE To assess whether blood type was associated with diminished ovarian reserve (DOR) (day-3 follicle-stimulating hormone level >10 IU/L), controlling for history of tobacco smoking, body mass index (BMI), history of endometriosis, ovarian surgery, previous pregnancy, and maternal age. DESIGN Cross-sectional study. SETTING Academic medical center, Division of Reproductive Endocrinology and Infertility. PATIENT(S) Women undergoing in vitro fertilization (IVF) from 2006-2011 (n = 305). INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Presence of DOR in relation to a patients blood type. RESULT(S) Other investigators have reported an increased risk for DOR in patients with blood type O and a protective effect on ovarian reserve for blood type A. We observed no association between a womans blood type and DOR. We found an increased risk for DOR in patients aged 35 and older. Obesity (BMI ≥ 30 vs. BMI <25) was associated with lower odds of DOR. CONCLUSION(S) In comparison with blood type A, blood type O is not associated with an increase in DOR. We found no clinical implications for using blood type as a risk factor for DOR.

Molecular evaluation of proliferative-phase endometrium may provide insight about the underlying causes of infertility in women with endometriosis.

PurposeTo determine if endometrial gene expression is different in women with endometriosis-related infertility and fertile women.MethodsProspective study of mid-follicular phase endometrium in 47 subjects in two phases: microarray study of 10 infertile women with endometriosis and five fertile controls, and a quantitative real-time PCR (qRT-PCR) study of 27 infertile women with endometriosis and 15 fertile controls. Gene expression was determined by DNA microarray, and qRT-PCR used for 12 “promising” genes based on the microarray analysis.ResultsCompared to fertile controls, women with stage I–II endometriosis had 23, and women with stage III–IV had 35 genes that were significantly up- or down-regulated by microarray. However, using qRT-PCR, only chemokine ligand (CXCL) 13 was significantly down-regulated and somatostatin was significantly up-regulated with early endometriosis, and only CXCL 14 was significantly down-regulated with advanced endometriosis compared to fertile controls.ConclusionsOur findings indicate that the pattern of gene expression in proliferative-phase endometrium is different when comparing tissue from patients with endometriosis versus fertile controls. Recognition of these endometrial alterations could be helpful to diagnose and stage endometriosis, and may provide insight to explain why conception rates are low in women with endometriosis.

Sexual absorption of vaginal progesterone: a randomized control trial.

Objective. To determine if sexual intercourse reduces absorption of vaginal progesterone gel in women and to determine if progesterone is absorbed by the male during intercourse. Study Design. Prospective, randomized, cross over, controlled study of 20 reproductive-aged women and their male sexual partners randomized to receive vaginal progesterone gel (Crinone 8% gel, Actavis Inc., USA) or placebo cream. Serum progesterone for both male and female partners were measured 10 hours after intercourse. One week later, subjects were crossed over to receive the opposite formulation. In the third week, women used progesterone gel at night and abstained from intercourse. Results. Serum progesterone was significantly reduced with vaginal progesterone gel + intercourse compared with vaginal progesterone gel + abstinence (P = 0.0075). Men absorbed significant progesterone during intercourse with a female partner using vaginal progesterone gel compared to placebo (P = 0.0008). Conclusion(s). Vaginal progesterone gel is reduced in women after intercourse which may decrease drug efficacy during luteal phase support. Because men absorb low levels of progesterone during intercourse, exposure could cause adverse effects such as decreased libido. This study is registered under Clinical Trial number NCT01959464.

The effect of ketorolac on pregnancy rates when used immediately after oocyte retrieval.

OBJECTIVE To study the effect of ketorolac, a potent anti-inflammatory medication, on in vitro fertilization (IVF) pregnancy outcomes when used at the time of oocyte retrieval. DESIGN Retrospective review of 454 patients from 2003-2009. SETTING Tertiary hospital-affiliated fertility center. PATIENT(S) Consecutive subfertile women undergoing their first IVF cycle. INTERVENTION(S) Ketorolac administration immediately after oocyte retrieval. MAIN OUTCOME MEASURE(S) Pregnancy, implantation, live-birth, and miscarriage rates, and postsurgical visual analog pain score. RESULT(S) Of the 454 patients undergoing their first IVF cycle for all indications, 103 received intravenous ketorolac immediately after oocyte retrieval, based on anesthesiologist preference. Patient and procedural characteristics were similar between both groups. The use of ketorolac had no effect on the rates of implantation, miscarriage, pregnancy, live birth, or multiple pregnancy. The patients receiving ketorolac experienced statistically significantly less pain. CONCLUSION(S) This study suggests ketorolac has no apparent detrimental effect on IVF pregnancy outcomes when administered immediately after oocyte retrieval. Ketorolac appears to be a safe and effective analgesic to use at the time of oocyte retrieval.