Jan Christilaw

Fertility intentions of women of reproductive age living with HIV in British Columbia, Canada.

Background:We undertook a study to examine the fertility intentions and reproductive health issues of women living with HIV in a broad-based sample in British Columbia, Canada. Methods:Between November 2003 and December 2004, we invited women with HIV at all HIV clinics and AIDS service organizations in the province of British Columbia, Canada, to complete the survey instrument ‘Contraceptive Decisions of HIV-positive Women’. Logistic regression analysis was conducted to calculate adjusted odds ratios to identify factors that may be significant predictors of the intention of women living with HIV to have children. Results:Of the 230 surveys completed, 182 women (79.1%) were of reproductive age (≤ 44 years), and 25.8% of women living with HIV indicated an intention to have children. In multivariate modeling, non-aboriginal ethnicity, younger age and having a regular partner were associated with an increased likelihood of reporting the intention to have children in the future. Discussion:In this study, we found that the predictors of fertility intention of women with HIV were age, ethnicity and marital status. Women who were HIV-positive described an intention to have children at levels approaching those among the general population and regardless of their clinical HIV status. Public policy planners and health practitioners need to consider and plan for the implications of increased numbers of women with HIV who may choose to have children.

Female Genital Cosmetic Surgery

OBJECTIVE To provide Canadian gynaecologists with evidence-based direction for female genital cosmetic surgery in response to increasing requests for, and availability of, vaginal and vulvar surgeries that fall well outside the traditional realm of medically-indicated reconstructions. EVIDENCE Published literature was retrieved through searches of PubMed or MEDLINE, CINAHL, and The Cochrane Library in 2011 and 2012 using appropriate controlled vocabulary and key words (female genital cosmetic surgery). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to May 2012. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table). Recommendations 1. The obstetrician and gynaecologist should play an important role in helping women to understand their anatomy and to respect individual variations. (III-A) 2. For women who present with requests for vaginal cosmetic procedures, a complete medical, sexual, and gynaecologic history should be obtained and the absence of any major sexual or psychological dysfunction should be ascertained. Any possibility of coercion or exploitation should be ruled out. (III-B) 3. Counselling should be a priority for women requesting female genital cosmetic surgery. Topics should include normal variation and physiological changes over the lifespan, as well as the possibility of unintended consequences of cosmetic surgery to the genital area. The lack of evidence regarding outcomes and the lack of data on the impact of subsequent changes during pregnancy or menopause should also be discussed and considered part of the informed consent process. (III-L) 4. There is little evidence to support any of the female genital cosmetic surgeries in terms of improvement to sexual satisfaction or self-image. Physicians choosing to proceed with these cosmetic procedures should not promote these surgeries for the enhancement of sexual function and advertising of female genital cosmetic surgical procedures should be avoided (III-L) 5. Physicians who see adolescents requesting female genital cosmetic surgery require additional expertise in counselling adolescents. Such procedures should not be offered until complete maturity including genital maturity, and parental consent is not required at that time. (III-L) 6. Non-medical terms, including but not restricted to vaginal rejuvenation, clitoral resurfacing, and G-spot enhancement, should be recognized as marketing terms only, with no medical origin; therefore they cannot be scientifically evaluated. (III-L).

Caesarean Section on Maternal Request: Risks and Benefits in Healthy Nulliparous Women and Their Infants

OBJECTIVE To determine the risks and benefits of an elective Caesarean section (CS) at term in healthy nulliparous women. METHODS We conducted a population-based cohort study of deliveries between 1994 and 2002. Using bivariate and multivariable techniques, we compared maternal and neonatal outcomes in healthy nulliparous women who had undergone elective pre-labour CS (using breech presentation as a surrogate) with those in women who had undergone spontaneous labour with anticipated vaginal delivery (SL) at full term. RESULTS There were 1046 deliveries in the pre-labour CS group and 38 021 in the SL group. Life-threatening maternal morbidity was similar in each group. Life-threatening neonatal morbidity was decreased in the CS group (RR 0.34; 99% CI 0.12 to 0.97). Subgroup analysis of the SL group by mode of delivery demonstrated the increased neonatal risk was associated with operative vaginal delivery and intrapartum CS but not spontaneous vaginal delivery. CONCLUSION An elective pre-labour Caesarean section in a nulliparous woman at full term decreased the risk of life-threatening neonatal morbidity compared with spontaneous labour with anticipated vaginal delivery. However, the 63% of women with spontaneous labour who achieved a spontaneous vaginal delivery would not have benefited from delivery by Caesarean section. Further research is needed to better identify women with an increased likelihood of an operative vaginal or intrapartum Caesarean section, as this may assist maternity caregivers in decision-making about childbirth. Further research is also needed to determine if these findings can be confirmed in a prospective study.

Anaesthetic management of patients with placenta accreta

The management of a 28-year-old primigravida with placenta accreta diagnosed during Caesarean section is described. A hysterectomy was required to control massive haemorrhage, and the patient made a full recovery. The increased incidence of placenta accreta over the last three decades is thought to be associated with the concomitant increased frequency of Caesarean section, resulting in an increased incidence of placenta praevia (1.9 per cent to 3.9 per cent). Patients with placenta praevia who have had a previous Caesarean section have a remarkably increased risk of placenta accreta. Management of placenta accreta is primarily by control of haemorrhage on delivery of the placenta. Control can be assisted by infrarenal cross-clamping of the aorta and/or intra-myometrial injection of prostaglandin F2α which produces myometrial and vascular contraction. Identification of patients at increased risk, preparation for treatment and effective treatment of placenta accreta will minimize maternal morbidity and mortality.RésuméOn décrit la conduite thérapeutique chez une femme primigeste de 28 ans ayant un placenta accreta diagnostiqué durant une césarienne. On a dû pratiquer une hystérectomie afin de contrôler ľhémorrhagic massive et la patiente s’est rétablie complètement. On croit que ľaugmentation de ľincidence de placenta accreta au cours des trente dernières années est associée à ľaugmentation concomitante de la fréquence de césarienne, ayant pour résultat une incidence accrue de placenta praevia (1.9 à 3.9 pour cent). Les patients avec un placenta praevia, qui ont déjà subi une césarienne, sont à risque accru de placenta accreta. Le traitement du placenta accreta est ďabord le contrôle de ľhémorrhagie au moment où le placenta est libéré. On peut aider à contrôler cette hémorrhagie par le clampage infrarénal de ľaorte et/ou par ľinjection, dans la paroi utérine, de prostaglandine F2α qui produit des contractions myométriques et vasculaires. Ľidentification des patientes à risque accru, la préparation pour le traitement et un traitement efficace pour le placenta accreta minimiseront la morbidité et la mortalité maternelle.

Informed Consent to Donate Embryos for Research Purposes

OBJECTIVE To develop guidance for clinicians participating in the informed choice process with respect to the donation of human embryos for research purposes. RECOMMENDATIONS 1. As indicated in the Canadian Institutes of Health Research Guidelines and the Assisted Human Reproduction Act, specific consent from both the gamete and embryo providers is required before embryos can be used for research purposes. The gamete donors may be different individuals than the embryo providers when donated gametes are used to create embryos. 2. The consent process should inform potential donors of the possible types of (and for final consent, the specific) research project(s) for which the embryos will be used; the risks involved in donating embryos to research, such as not having these embryos available for their reproductive purposes; the fact that the woman/couple will not benefit personally from donating embryos to research; the potential for commercial gain by others; the possibility that they will be contacted in future about the disposition of the embryos; the fact that confidentiality cannot be absolutely guaranteed. 3. Designation of cryopreserved embryos no longer be required for reproductive purposes to be donated to research, donated to another couple, or discarded should be discussed prior to gamete retrieval and made at the time of cryopreservation, with the understanding that in the future, final consent will be requested. The final decision as to the donation of cryopreserved embryos research should not be made until after the woman/ couple decide they no longer require the embryos for their reproductive purposes. The decision to end cryopreservation should be made separately from the decision regarding disposition of the embryos. The woman/couple will have to be re-contacted regarding the final disposition of their embryos. 4. As a result of lack of scientific data regarding the predictability of microscopic characterization of embryos and potential for pregnancy, it is recommended that all women/couples be offered the opportunity to cryopreserve all embryos not transferred during the treatment cycle and be informed that a failure to cryopreserve all embryos may increase the chance of having to undergo an additional in vitro fertilization cycle to achieve reproductive goals. 5. Research participants should be informed that they may withdraw their consent at any time before the embryos are thawed for research purposes, or, in the case of stem cell research, before a stem cell line is created. 6. Potential donors should be informed that their medical care will not be affected by their decision regarding embryo donation.

Pelvic Examinations by Medical Students

Ensuring the quality of medical education is important to ensuring that all Canadians have access to good health care today and in the future; however, patient autonomy should be respected in all clinical and educational interactions. When a medical student is involved in patient care, patients should be told what the student’s roles will be, and patients must provide consent. Patient participation in any aspect of medical education should be voluntary and non-discriminatory. PREAMBLE

Self-collection based HPV testing for cervical cancer screening among women living with HIV in Uganda: a descriptive analysis of knowledge, intentions to screen and factors associated with HPV positivity

BackgroundWomen living with HIV (WHIV) are disproportionately impacted by cervical dysplasia and cancer. The burden is greatest in low-income countries where limited or no access to screening exists. The goal of this study was to describe knowledge and intentions of WHIV towards HPV self-collection for cervical cancer screening, and to report on factors related to HPV positivity among women who participated in testing.MethodsA validated survey was administered to 87 HIV positive women attending the Kisenyi Health Unit aged 30–69 years old, and data was abstracted from chart review. At a later date, self-collection based HPV testing was offered to all women. Specimens were tested for high risk HPV genotypes, and women were contacted with results and referred for care. Descriptive statistics, Chi Square and Fischer-exact statistical tests were performed.ResultsThe vast majority of WHIV (98.9%) women did not think it necessary to be screened for cervical cancer and the majority of women had never heard of HPV (96.4%). However, almost all WHIV found self-collection for cervical cancer screening to be acceptable. Of the 87 WHIV offered self-collection, 40 women agreed to provide a sample at the HIV clinic. Among women tested, 45% were oncogenic HPV positive, where HPV 16 or 18 positivity was 15% overall.ConclusionsIn this group of WHIV engaged in HIV care, there was a high prevalence of oncogenic HPV, a large proportion of which were HPV genotypes 16 or 18, in addition to low knowledge of HPV and cervical cancer screening. Improved education and cervical cancer screening for WHIV are sorely needed; self-collection based screening has the potential to be integrated with routine HIV care in this setting.

The Efficacy of the Quadrivalent Human Papillomavirus Vaccine in Girls and Women Living With Human Immunodeficiency Virus

BACKGROUND Human papillomavirus (HPV) vaccination is safe and efficacious in women without human immunodeficiency virus (HIV). Although good immunogenicity has been observed in women living with HIV (WLWH), efficacy data in this population are needed. METHODS We enrolled 420 females aged ≥9 years (range, 9-65) living with HIV. Participants were to receive 3 doses of qHPV vaccine (0/2/6 months). The main endpoint was vaccine failure (ie, incident persistent qHPV infection, cervical intraepithelial neoplasia of grade 2 or higher [CIN2+], or genital warts). We compared these rates to published rates in vaccinated and unvaccinated women without HIV as well as unvaccinated WLWH. RESULTS Among 279 eligible women, median follow-up was 2 years. In the intention-to-treat population, the incidence rate (IR) of persistent qHPV (HPV6/11/16/18) was 2.3 per 100 person-years (/100PY) (95% confidence interval [CI], 1.1-4.1), and IR of genital warts was 2.3/100PY (95% CI, 1.2-4.1). In the per-protocol efficacy population, IR of persistent qHPV was 1.0/100PY (95% CI, 0.3-2.6) and of genital warts was 1.0/100PY (95% CI, 0.3-2.5). No cases of CIN2+ occurred. Reported rates of qHPV-related infection and disease within vaccinated women without HIV, unvaccinated women without HIV, and vaccinated WLWH: 0.1 (95% CI, 0.02-0.03), 1.5 (95% CI, 1.1-2.0), and 1.2 (95% CI, 0.2-3.4) /100PY, respectively. The rate of persistent qHPV among vaccinated WLWH was lower than among unvaccinated WLWH (2.3 vs 6.0/100PY). CONCLUSIONS Vaccinated WLWH may be at higher risk for vaccine failure than vaccinated women without HIV. However, overall rates of vaccine failure were low, and rates of persistent qHPV were lower than in unvaccinated WLWH.

Cellules souches : Trois questions

Simone, collegue de confiance et amie de longue date, vient tout juste de feter son 42e anniversaire. Il y a quatre mois, a la suite de la reussite de la fecondation in vitro apres des annees d’essai, elle s’est soumise a la reimplantation de deux embryons. Elle dispose de cinq autres embryons qui sont maintenant congeles. Il y a deux semaines, apres environ 11 semaines de gestation, Simone a connu une effroyable fausse couche. Elle vient tout juste de nous confier qu’elle souhaite faire don de ses cinq embryons congeles aux fins de la recherche sur les cellules souches. « Je ne peux tout simplement pas revivre cette experience », affirme-t-elle. « Je ressens plus le besoin de voir cette experience aboutir a des resultats positifs, que de tenter le coup a nouveau. »

Stem Cells: Three Questions

Simone, a trusted colleague and dear friend, has just turned 42. Four months ago, after years of trying, and finally after successful in vitro fertilization, she had two embryos reimplanted. She has five other embryos that are now frozen. Two weeks ago, at about 11 weeks’ gestation, Simone had a gut-wrenching miscarriage. She has just told us that she wants to donate her remaining frozen embryos for stem cell research. “I just can’t go through it again,” she says. “I need to see something good come out of this more than I need to try again.”