Search

Objective This study sought to answer the following question: What are the complications and assisted reproductive technology outcomes among women with hydrosalpinges managed by hysteroscopic microinsert tubal occlusion compared with women with hydrosalpinges managed by laparoscopic proximal tubal occlusion or salpingectomy? Methods This was a retrospective cohort study conducted from January 2009 to December 2014 at two academic, tertiary care, in vitro fertilization centres in Toronto, Ontario. All patients (n = 52) who underwent hysteroscopic tubal occlusion for hydrosalpinges were identified. Patients who proceeded with embryo transfer cycles after hysteroscopic microinsert (n = 33) were further age matched to a cohort of patients who underwent embryo transfer after laparoscopic proximal tubal occlusion or salpingectomy (n = 33). Main outcome measures were clinical pregnancy rate per patient and per embryo transfer cycle. Results Among 33 patients, there were 39 fresh and 37 frozen embryo transfer cycles in the hysteroscopic group (group A); among 33 patients in the laparoscopic group (group B), there were 42 fresh and 29 frozen embryo transfer cycles. The cumulative clinical pregnancy rate in group A and group B was similar (66.7% vs. 69.7%, respectively; P = 0.8). The clinical pregnancy rate per embryo transfer cycle was also similar in both groups (28.9% in group A vs. 32.4% in group B; P = 0.6). There were two incidents of ectopic pregnancy in the laparoscopic group and no ectopic pregnancy in the hysteroscopic group. There were three major complications: tubo-ovarian abscess, distal migration of the coil after microinsert placement, and an acute abdomen following the hysteroscopic procedure. Conclusion Pregnancy outcomes after hysteroscopic placement of a microinsert for hydrosalpinx management before embryo transfer were comparable to those following laparoscopic proximal tubal occlusion or salpingectomy. However, caution is advised regarding microinsert placement for hydrosalpinges before proceeding with assisted reproductive technology.

This clinical practice guide has been developed to support human immunodeficiency virus (HIV) care providers' use of the 2018 Canadian HIV Pregnancy Planning Guidelines (CHPPG) in their work with people and couples affected by HIV. HIV pregnancy planning has changed considerably in the last decade and requires a multidisciplinary team, and HIV care providers are often at the forefront of the team. It is, therefore, important to have clear guidance on how to provide HIV pregnancy planning care. This Clinical Practice Guide is intended for both primary and specialty HIV care providers, including doctors, nurses, and nurse practitioners. We have repackaged the 2018 CHPPG's 36 recommendations into five standards of care for ease of use. We have also included an initial algorithm that can be used with each patient to direct discussions about their reproductive goals. Pregnancy and parenting are increasingly normalized experiences in the lives of people and couples affected by HIV. While conception used to be a complicated decision, often heavily focused on minimizing the risk of HIV transmission, the current evidence supports more universal counselling and supports for HIV pregnancy planning. HIV care providers have a responsibility to be familiar with the unique considerations for pregnancy planning when supporting their patients. This counselling is critical to optimizing reproductive health outcomes for all people affected by HIV, including those who wish to prevent pregnancy.Les présentes directives de pratique clinique visent à soutenir l’utilisation des

To comprehensively describe current preimplantation genetic testing for aneuploidy (PGT-A) practices and management of non-euploid embryos in Canada.This was a cross-sectional study utilizing an online survey distributed by email to all medical directors of fertility clinics with independent in vitro fertilization (IVF) embryology laboratories. The survey was designed to determine practice patterns regarding PGT-A usage; PGT-A reference laboratory, platform, and thresholds for classifying embryos; and management of embryos classified as mosaic, inconclusive, or aneuploid.Twenty-five medical directors (69%) participated in the survey. The majority of clinics (91%) offered PGT-A screening, with 45% of clinics offering PGT-A as routine screening. The majority of clinics (90%) that offered PGT-A received mosaicism data; 61% of these clinics had transferred mosaic embryos, and 94% would transfer mosaic embryos. Clinics that performed ≥1000 IVF cycles annually were more likely to have transferred mosaic embryos (100% vs. 45.5%; P = 0.043). The mean percentage of IVF cycles using PGT-A was lower in clinics that had transferred mosaic embryos (12.3% vs. 30.4%; P = 0.033). Only 1 clinic had transferred an aneuploid embryo, but 2 other clinics would consider this option. The majority of clinics (61%) that receive mosaicism data would recommend noninvasive prenatal testing (NIPT) following mosaic embryo transfer, with 22% of clinics indicating that this would be the only genetic test offered.We report significant practice variation in PGT-A and management of non-euploid embryos across Canada and highlight areas where consensus should be encouraged.

Fertility care providers have an obligation to provide safe and effective care to patients. When a user of assisted reproductive technology (ART) is living with a blood-borne viral infection (BBVI: HIV, hepatitis C or hepatitis B), physicians and ART laboratory personnel need to know the requirements for providing quality care. Recent developments in the treatment of BBVI and understanding of transmission have changed these requirements. This guideline from the Canadian Fertility and Andrology Society (CFAS) provides comprehensive, evidence-based guidelines for reducing horizontal transmission and cross-contamination in the ART setting.

In the modern era of HIV care, a multitude of clinical needs have emerged; one such need is the growing sub-specialty of HIV and reproductive health. In 2007, a study surveying Canadian fertility clinics found limited access to fertility services for HIV-positive patients. Given the extensive efforts made to address this lack of services, a follow-up assessment was warranted. This study aimed to compare the access to Canadian fertility clinics and services for HIV-positive individuals and couples in 2014 and 2007. Surveys were sent to medical or laboratory directors of assisted reproductive technology (ART) clinics in 2014 and results were compared to those sent in 2007. Main outcome measures included: the proportion of fertility clinics willing to provide ART to people with HIV, the specific services offered, and whether the 2012 Canadian HIV Pregnancy Planning Guidelines were implemented to inform practice. Across Canadian provinces, 20/34 (59%) clinics completed the survey. Ninety-five percent (19/20) of clinics accepted HIV-positive patients for consultation. Only 50% (10/20) of clinics in four provinces offered a full range of ART (defined as including in vitro fertilization [IVF]). Ten clinics (50%) in five provinces were aware that guidelines exist; half (n = 5) having read them and four reporting implementation of all the guidelines' recommendations in their practice. Compared to 2007, more clinics had implemented separate facilities (p = 0.028) to treat HIV-positive individuals, offered IVF (p = 0.013) for HIV-positive female partners, sperm washing (p = 0.033) for HIV-positive male partners, and risk reduction techniques to couples with HIV-positive men and women (p = 0.006). Access to fertility clinics for people with HIV has improved over time but is still regionally dependent and access to full ART remains limited. These findings suggest the need for advocacy targeted towards geographical-specific areas and optimizing access to comprehensive services.

STUDY QUESTIONAre data accurately documented in the Canadian Assisted Reproductive Technologies Register (CARTR) Plus database?SUMMARY ANSWERMeasures of validity were strong for the majority of variables evaluated while those with moderate agreement were FSH levels, oocyte origin and elective single embryo transfer.WHAT IS KNOWN ALREADYHealth databases and registries are excellent sources of data. However, as these databases are typically not established for the primary purpose of performing research, they should be evaluated prior to utilization for research both to inform the study design and to determine the extent to which key study variables, such as patient characteristics or therapies provided, are accurately documented in the database. CARTR Plus is Canada’s national register for collecting extensive information on IVF and corresponding pregnancy outcomes, and it has yet to be validated.STUDY DESIGN, SIZE, DURATIONThis study evaluating the data translation CARTR Plus database examined IVF cycles performed in 2015 using data directly from patient charts. Six clinics across Canada were recruited to participate, using a purposive sampling strategy. Fixed random sampling was employed to select 146 patient cycles at each clinic, representing unique patients. Only a single treatment cycle record from a unique patient at each clinic was considered during chart selection.PARTICIPANTS/MATERIALS, SETTING, METHODSTwenty-five data elements (patient characteristics, treatments and outcomes) were reabstracted from patient charts, which were declared the reference standard. Data were reabstracted by two independent auditors with relevant clinical knowledge after confirming inter-rater reliability. These data elements from the chart were then compared to those in CARTR Plus. To determine the validity of these variables, we calculated kappa coefficients, sensitivity, specificity, positive predictive value and negative predictive value with 95% CI for categorical variables and calculated median differences and intraclass correlation coefficients (ICC) for continuous variables.MAIN RESULTS AND THE ROLE OF CHANCESix clinics agreed to participate in this study representing five Canadian provinces. The mean age of patients was 35.5 years, which was similar between the two data sources, resulting in a near perfect level of agreement (ICC = 0.99; 95% CI: 0.99, 0.99). The agreement for FSH was moderate, ICC = 0.68 (95% CI: 0.64, 0.72). There was nearly perfect agreement for cycle type, kappa = 0.99 (95% CI: 0.98, 1.00). Over 90% of the cycles in the reabstracted charts used autologous oocytes; however, data on oocyte source were missing for 13% of cycles in CARTR Plus, resulting in a moderate degree of agreement, kappa = 0.45 (95% CI, 0.37, 0.52). Embryo transfer and number of embryos transferred had nearly perfect agreement, with kappa coefficients greater than 0.90, whereas that for elective single or double embryo transfer was much lower (kappa = 0.55; 95% CI: 0.49, 0.61). Agreement was nearly perfect for pregnancy type, and number of fetal sacs and fetal hearts on ultrasound, all with kappa coefficients greater than 0.90.LARGE-SCALE DATAN/ALIMITATIONS, REASONS FOR CAUTIONCARTR Plus contains over 200 variables, of which only 25 were assessed in this study. This foundational validation work should be extended to other CARTR Plus database variables in future studies.WIDER IMPLICATIONS OF THE FINDINGSThis study provides the first assessment of the quality of the data translation process of the CARTR Plus database, and we found very high quality for the majority of the variables that were analyzed. We identified key data points that are either too often lacking or inconsistent with chart data, indicating that changes in the data entry process may be required.STUDY FUNDING/COMPETING INTEREST(S)This study was funded by Canadian Institutes of Health Research (CIHR) (Grant Number FDN-148438) and by the Canadian Fertility and Andrology Society Research Seed Grant (Grant Number: N/A). The authors report no conflict of interest.TRIAL REGISTRATION NUMBERNot applicable.

Objective A recent retrospective study demonstrated that anovulatory infertile women who did not have a progestogen-induced withdrawal bleed before treatment with clomiphene citrate (CC) had higher pregnancy rates than women who had a withdrawal bleed and those who had spontaneous menstrual bleeding. We sought to assess endometrial thickness at the time of ovulation in oligo-ovulatory and anovulatory women who took CC with or without a preceding progestogen-induced withdrawal bleed. Methods We conducted a pilot randomized trial in which women with infertility and oligomenorrhea or amenorrhea were randomly assigned to take either CC after a withdrawal bleed induced by medroxyprogesterone acetate (MPA) 10 mg daily for 10 days or to take CC without such a bleed. Study participants underwent cycle monitoring with ultrasound assessment of endometrial thickness at the time of LH surge or a human chorionic gonadotropin trigger, followed by timed intercourse or intrauterine insemination. Women who had not ovulated by cycle day 21 took an increased dose of CC, with or without an MPA-induced withdrawal bleed, to a maximum of three cycles. Participants and nurses were asked to complete a questionnaire about the study. Results There was no significant difference in endometrial thickness on the day of LH surge or human chorionic gonadotropin trigger between women who had a progestogen-induced withdrawal bleed and those who did not ( P = 0.65). On average, the time to ovulation was 15 days longer in women who took MPA than in women who did not, but this difference was not statistically significant ( P = 0.65). Satisfaction with the study was reported as high by both patients and nurses. Conclusion In anovulatory or oligo-ovulatory women treated with CC, we found no significant difference in endometrial thickness whether or not the use of CC was preceded by a withdrawal bleed induced by MPA.

Study question Are routinely collected data from fertility populations adequately validated? Summary answer Of the 19 studies included, only one validated a national fertility registry and none reported their results in accordance with recommended reporting guidelines for validation studies. What is known already Routinely collected data, including administrative databases and registries, are excellent sources of data, particularly for reporting, quality assurance, and research. However, these data are subject to misclassification bias due to misdiagnosis or errors in data entry and therefore need to be validated prior to using for clinical or research purposes. Study design size duration We conducted a systematic review by searching Medline, Embase, and CINAHL from inception to 6 October 2016 to identify validation studies of databases that contain routinely collected data in an ART setting. Webpages of international ART centers were also searched. Participants/materials setting methods We included studies that compared at least two data sources to validate ART population data. Key words and MeSH terms were adapted from previous systematic reviews investigating routinely collected data (e.g. administrative databases and registries), measures of validity (including sensitivity, specificity, and predictive value), and ART (including infertility, IVF, advanced reproductive age, and diminished ovarian reserve). Only full-text studies in English were considered. Results were synthesized qualitatively. The electronic search yielded 1074 citations, of which 19 met the inclusion criteria. Main results and the role of chance Two studies validated a fertility database using medical records; seven studies used an IVF registry to validate vital records or maternal questionnaires, and two studies failed to adequately describe their reference standard. Four studies investigated the validity of mode of conception from birth registries; two studies validated diagnoses or treatments in a fertility database; four studies validated a linkage algorithm between a fertility registry and another administrative database; one study created an algorithm in a single database to identify a patient population. Sensitivity was the most commonly reported measure of validity (12 studies), followed by specificity (9 studies). Only three studies reported four or more measures of validation, and five studies presented CIs for their estimates. The prevalence of the variable in the target population (pre-test prevalence) was reported in seven studies; however, only four of the studies had prevalence estimates from the study population (post-test prevalence) within a 2% range of the pre-test estimate. The post-test estimate was largely discrepant from the pre-test value in two studies. Limitations reasons for caution The search strategy was limited to the studies and reports published in English, which may not capture validation studies from countries that do not speak English. Furthermore, only three specific fertility-based diagnostic variables (advanced reproductive age, diminished ovarian reserve, and chorionicity) were searched in Medline, Embase, and CINAHL. Consequently, published studies with other diagnoses or conditions relevant to infertility may not have been captured in our review. Wider implications of the findings There is a paucity of literature on validation of routinely collected data from a fertility population. Furthermore, the prevalence of the markers that have been validated are not being presented, which can lead to biased estimates. Stakeholders rely on these data for monitoring outcomes of treatments and adverse events; therefore, it is essential to ascertain the accuracy of these databases and make the reports publicly available. Study funding/competing interests This study was supported by Canadian Institutes of Health Research (CIHR) (FDN-148438). There are no competing interests for any of the authors. Registration number International Prospective Register of Systematic Reviews ID: CRD42016048466.

Objective The authors sought to study whether there is differential access to fertility services for immigrant women in a single-payer system. Methods A cross-sectional quantitative survey was administered to 265 patients over 3 months. All participants were female patients in heterosexual relationships at a university-affiliated hospital-based fertility clinic in a large metropolitan city. Data on sociodemographic characteristics, reproductive history, and experience accessing fertility services were collected. Statistical analysis, including chi-square and ANOVA regression, was completed using JMP software. Results The response rate of the survey was 86.6%. A total of 265 women participated, 124 (47%) immigrants and 141(53%) non-immigrants. Immigrants more commonly left questions unanswered. Long-term immigrants had a significantly longer average duration of infertility than non-immigrant women (47 months vs. 34 months; P = 0.04). There was a trend towards a delay in seeing a health care provider among long-term immigrants. The most commonly reported reasons for delaying fertility care were “not knowing there was a problem” and “treatments being too expensive.” Although participants across all groups relied on their primary care provider to supply information on fertility services, a greater percentage (17%) of recent immigrants than non-immigrant participants (7%) used the Internet to obtain information. Conclusion Immigrant women addressed their fertility needs even when they had fewer resources and less social stability than did non-immigrant women. However, they experienced a delay in receiving specialized care for infertility. Immigrant women also appeared less comfortable disclosing personal information in a health care setting.

This study sought to examine the effect of changing TSH threshold recommendations from 2.5 to 4 mIU/L before fertility therapy on the prevalence of early gestational subclinical hypothyroidism (SCH) (TSH22.5 mIU/L) and to evaluate implications on progression to clinical pregnancy (defined as detection of cardiac activity on ultrasound).A retrospective chart review was performed in an academic fertility clinic on all patients with a measured pre-treatment TSH (TSH1) and positive beta-human chorionic gonadotropin following fertility treatment. The study assessed the effect of TSH2 on ongoing pregnancy, both in patients newly diagnosed with SCH and in patients previously receiving LT4, stratified by initial TSH.Of 482 women included in the study, baseline TSH (TSH1) was2.5 mIU/L in 333 women (69%) and 2.5-4 mIU/L in 64 women (13.2%). Eighty-five women were taking LT4 at baseline (17.6%). Among women with a TSH1 between 2.5 and 4 mIU/L, the corresponding TSH in early pregnancy (TSH2) was2.5 mIU/L in 35 women (55%). Overall, there was no difference in progression to clinical pregnancy between women with a TSH2 of 2.5-4 mIU/L compared with women with a TSH22.5 mIU/L (OR 0.70; 95% CI 0.44-1.09). Similarly, when excluding women taking LT4 at baseline, there was no difference in progression to clinical pregnancy (OR 0.90; 95% CI 0.28-2.86).Rate of progression to clinical pregnancy was equivalent between women with an early pregnancy TSH (TSH2) 2.5 and women with a TSH2 of 2.5-4.0 mIU/L. Our findings support initiating LT4 in early pregnancy, as opposed to pre-pregnancy if the TSH remains above cut-off because there does not appear to be a difference in in early pregnancy outcomes if treatment is delayed.

Decreased mortality, decreased risk of vertical HIV transmission, and many people living with HIV (PLWHIV) being of reproductive age have led many PLWHIV to consider pregnancy. However, scarce data exist regarding the conception planning resources required and available for PLWHIV to have safe and healthy pregnancies. This study aimed to identify gaps between the need for, knowledge of, and access to conception planning information and services among PLWHIV in Ontario, Canada. PLWHIV from three large and two small urban sites in Ontario were recruited (n = 63). Participants completed a cross-sectional survey assessing demographics, expectations and plans for conception, and knowledge about and access to existing conception information and services for PLWHIV. Univariate correlations and ranked analyses were used to assess the associations between the need for, knowledge of, and access to conception planning resources with various demographic variables. Participants’ median age was 40 years (interquartile ...

Objective To describe the use of Essure microinsert placement in patients with hydrosalpinges before IVF. Design Retrospective case-series. Setting An advanced endoscopic practice within a university-affiliated teaching hospital. Patient(s) Five women with unilateral or bilateral hydrosalpinges on transvaginal ultrasound, laparoscopy, or hysterosalpingogram who were planning further fertility therapy. In all patients, laparoscopy was felt to be relatively contraindicated because of previous extensive abdominopelvic surgery. Intervention(s) Hysteroscopic placement of the Essure microinsert in four patients under general anesthesia. One patient underwent fluoroscopically guided placement. Main Outcome Measure(s) Placement rates and postoperative recovery, technical challenges in Essure placement, and results of subsequent treatment with IVF when available. Result(s) Successful bilateral Essure placement was confirmed in two of five patients. Unilateral placement was achieved in two of five. There were no postoperative complications. No pregnancies have occurred thus far. Conclusion(s) Hysteroscopic placement of the Essure microinsert is a minimally invasive option for proximal tubal occlusion. In patients requiring occlusion of hydrosalpinges before IVF and with contraindications to abdominal surgery, this technique may offer a safer alternative. Preoperative documentation of proximal tubal patency helps predict placement success. Further research into this unique clinical scenario is required.

This study describes what health care providers (HCPs) of fertility services perceive their patients to value most, as well as HCPs’ self-evaluation in provision of patient centered infertility care (PCIC). The Patient Centeredness Questionnaire Infertility (PCQ-I) was administered to all clinic staff and completed by approximately 60%. Mean scores and standard deviations were calculated for each dimension as well as for the global score. HCPs ranked staff communication as the highest of the dimensions and accessibility of care as the lowest, respectively indicating areas of strength and weakness. Degree of variance within scoring was used as a marker of consistency of assessment. Ranking of staff competence was the most uniform and ranking of accessibility the most varied, suggesting HCPs are confident in assessing patients’ perceptions of competence, but not with respect to accessibility. Staff communication was thought to be the most important dimension of PCIC for patients, based on the correlation with global score, while care organization was thought to be the least important, showing the lowest correlation with the global satisfaction score. This is the first study to describe North American HCPs’ perceptions of PCIC. This information will inform further professional development in provision of quality PCIC.

This study evaluated the psychological side-effects of clomiphene citrate (CC) and hMG in women undergoing fertility treatment.This study was a cross-sectional, self-report survey of 454 women at various stages of treatment for infertility. At the time of study, 139 women had not taken fertility drugs and 315 women had taken one or more cycles of CC or hMG. All subjects were asked to complete the State-Trait Anxiety Inventory (STAI). Women taking CC or hMG were also asked to complete a self-administered questionnaire on the side-effects of their medications.In the CC group (n = 162) and hMG group (n = 153), 77.8% (126 of 162) and 94.8% (145 of 153) reported at least one side-effect, respectively. Irritability, mood swings, feeling down, and bloating had high frequencies in both CC and hMG groups, with a higher mean number of side effects reported in the hMG group (4.4 +/- 3.7 for the CC group and 6.8 +/- 3.7 for the hMG group, p0.001). There was no significant difference among the CC, hMG and no medication groups for mean state and trait anxiety scores. However, there were significant differences among the three side-effect groups (those who reported 1 to 4, 5 to 7, and more than 7 side-effects) for the mean scores of state (df = 2, F = 8.7, p0.001) and trait (df = 2, F = 11.9, p0.001) anxiety in women taking fertility drugs.Women taking CC or hMG reported high frequencies of psychological side-effects, and should be advised of these before treatment.

BACKGROUND: Although estradiol levels remain an integral part of monitoring in most IVF programmes, the effect of falling estradiol on IVF outcome has not been adequately quantified. The objective of this study was to evaluate the effect of falling estradiol levels prior to hCG on IVF outcome. METHODS: This was a retrospective cohort study carried out in a university-based fertility clinic. A total of 112 IVF patients in whom estradiol levels fell prior to the administration of hCG were matched for age and year of treatment with 112 control IVF patients. IVF outcomes including oocytes retrieved, fertilization rate, embryos for transfer, and pregnancy rates were compared between the groups. RESULTS: Seventy per cent of women in the falling estradiol group experienced spontaneously falling estradiol levels. Spontaneously falling estradiol was associated with fewer oocytes retrieved (median 5 versus 8, P 5 0.001), increased rates of failed fertilization (18 versus 6%, P 5 0.018) and lower clinical pregnancy rates (12 versus 26%, P 5 0.012) compared to controls. Despite marked decreases in estradiol levels, IVF outcomes for patients whose estradiol levels fell as a result of deliberate protocol modification had similar fertilization and clinical pregnancy rates as controls. CONCLUSIONS: Subtle (< 10%) spontaneous decreases in estradiol levels are associated with very poor IVF outcomes.

The Royal College Competence by Design curriculum in obstetrics and gynaecology will launch in 2019, and it will depend heavily on multiple tools for accurate resident assessment. Several Canadian obstetrics and gynaecology residency programs use rotation-specific examinations at the end of various rotations for formative feedback. The obstetrics and gynaecology residency program at the University of Toronto adopted end-of-rotation examinations (EOREs) in 2014. We conducted a national survey to assess the current use of EOREs across Canada and to examine the attitudes and beliefs of residents and program directors regarding their use. We discuss faculty and resident experiences with EOREs and their perceptions of them. We also consider the role and benefit of these examinations in the context of the educational literature, and how they may integrate with future competency-based medical education frameworks.

Objective To compare the relative long-term effects on ovarian reserve of treating fibroids in reproductive-aged women with uterine artery embolization (UAE) versus laparoscopic myomectomy (LM), using sensitive measures including antral follicle count (AFC) and serum anti-Mullerian hormone (AMH). Methods We undertook a retrospective cohort pilot study to evaluate the utility and feasibility of carrying out a larger prospective trial. Thirteen women were evaluated in this study, including eight in the UAE group and five in the LM group. They were identified from a larger group of 125 women who had undergone LM and 200 women who had undergone UAE at a participating institution at least 12 months previously; of these, 32 who had UAE and 27 who had LM were of reproductive age and eligible to participate. Participants had an assessment of ovarian reserve including measurements of serum AMH, estradiol, and FSH, and ultrasound assessment of AFC and ovarian volume. Results Median serum AMH levels were significantly lower in women who had undergone UAE at least 12 months previously than in women who had undergone LM (0.78 ng/mL [range 0.67 to 1.28] vs. 2.17 ng/mL [range 1.17 to 2.38], P = 0.01). Median AFC per ovary was also significantly lower in women who had UAE than in those who had LM (3.5 [range 2 to 7] vs. 7 [range 6 to 11], P = 0.03). Median levels of FSH and E 2 and of ovarian volume were not significantly different between the two groups. Conclusion Reproductive-aged women who have undergone treatment of fibroids with UAE may have lower ovarian reserve over the long term (> 12 months) than women with fibroids treated with LM. This could have an adverse impact on future response to fertility treatment and/or fecundity. This finding may inform the choice of minimally invasive treatment for fibroids in reproductive-aged women who have not completed childbearing. It suggests that further study in this area is warranted before the application of UAE is expanded to young reproductive-aged women.

In vitro fertilization (IVF) is a medically-assisted reproduction technique, enabling infertile couples to achieve successful pregnancy. Given the unpredictability of the task, we propose to use a case-based reasoning system that exploits past experiences to suggest possible modifications to an IVF treatment plan in order to improve overall success rates. Once the system's knowledge base is populated with a sufficient number of past cases, it can be used to explore and discover interesting relationships among data, thereby achieving a form of knowledge mining. The article describes the TA 3 IVF system—a case-based reasoning system which relies on context-based relevance assessment to assist in knowledge visualization, interactive data exploration and discovery in this domain. The system can be used as an advisor to the physician during clinical work and during research to help determine what knowledge sources are relevant for a treatment plan.

Objective To determine reproductive services offered to lesbian patients by Canadian fertility clinics, policies of practice, ease of access to these services, and sensitivity of clinics to this population of patients. Design Survey sent to assisted reproductive technology (ART) clinic directors. Setting Academic medical center, university-based ethics institute. Patient(s) None. Intervention(s) None. Main Outcome Measure(s) The percentage of Canadian fertility clinics that will provide reproductive services to lesbian patients; services offered; the presence of clinic policies on lesbian care; and the presence on web sites of heteronormative material. Result(s) Completed surveys were received from 71% (24/34) of clinics. All clinics surveyed provided reproductive services to lesbian patients, with the exception of one clinic. Five of 24 (21%) clinics have a written policy on care for lesbian patients; 29% (7/24) will provide services to lesbian patients without prior investigations. All clinics will offer IUI and cycle monitoring to lesbian patients. Twenty-three of 24 clinics (96%) will offer IVF services when required. Fourteen of 32 clinic web sites (44%) make mention of lesbian patients and 27% (8/30) have heteronormative information only. Conclusion(s) Lesbians encounter several barriers to accessing reproductive services in Canada. Addressing these issues could improve experiences of lesbian women and couples seeking care at fertility clinics.

Introduction: The purpose of this cross-sectional study was toexplore factors associated with oncology patients’ decision to banksperm prior to cancer treatment.Materials andMethods: Patients who were referred to the oncologysperm banking program between January 2009 and March 2010 were invited to complete an 18-item questionnaire during one oftheir sperm banking visits.Results: Of the 157 cancer patients referred to the Mount Sinai Oncology Sperm and Tissue Bank for sperm banking during the15-month period, 79 questionnaires were returned (50% response rate). Of the respondents, 89% were informed about sperm bankingby their physician. Future family planning was cited as the mainreason to bank. Cost was not a barrier for the vast majority ofrespondents. Forty percent of respondents banked sperm within 4days prior to initiating cancer treatment. Most respondents reliedon their physician for verbal information on sperm banking. Eighty-one percent were unaware of any patient organizations that have educational materials on oncology fertility preservation.Conclusion: Sperm banking prior to cancer treatment is the only proven method of preserving fertility for cancer patients. The two main determinants associated with deciding whether to bank sperm were: the physician’s recommendation and the patient’s desirefor future fatherhood. Physicians play a key role in influencing patients’ decisions. The recommendation to bank sperm is a persuasive message if patients are clearly informed about their potential risk of infertility post-cancer treatment, and that sperm banking is an effective way of preserving fertility. Providing patients with education materials might enhance compliance in sperm banking.

Objective To determine whether there is a difference in the pregnancy rate in women with Turner's syndrome (45,X) in an ovum donation program compared with women with other causes of premature ovarian failure. Design Retrospective chart review of women with Turner's syndrome (n = 11) and premature ovarian failure (n = 38) in a donor ovum program using variable dose and duration of E2 replacement therapy for endometrial preparation and using only transvaginal ultrasonographic assessment of endometrial response before ET. Results The pregnancy rates in Turner's syndrome patients and control subjects were 27% and 25%, respectively. Pregnancy rates were higher in the first cycle than in subsequent cycles for both groups (40% versus 8%). Conclusions Turner's syndrome patients given a variable dose of estrogen, for endometrial preparation, with response assessed exclusively by transvaginal ultrasonography demonstrated pregnancy rates equal to patients with other causes of premature ovarian failure.

The purpose of this cross-sectional study is to assess the desire, need, perceptions, and knowledge of assisted reproductive technologies (ARTs) for women living with HIV (WLWHIV) and determine correlates of ART knowledge desire. WLWHIV of reproductive age were surveyed using the survey instrument “The HIV Pregnancy Planning Questionnaire” at HIV/AIDS service organizations across Ontario, Canada. Of our cohort of 500 WLWHIV, median age was 38, 88% were previously pregnant, 78% desired more information regarding ART, 59% were open to the idea of receiving ART, 39% felt they could access a sperm bank, and 17% had difficulties conceiving (self-reported). Age, African ethnicity, and residence in an urban center were correlated with desire for more ART information. Of participants, 50% wanted to speak to an obstetrician/gynecologist regarding pregnancy planning, and 74% regarded physicians as a main source of fertility service information. While the majority of participants in our cohort desire access to ART information, most do not perceive these services as readily accessible. Healthcare practitioners were viewed as main sources of information regarding fertility services and need to provide accurate information regarding access. Fertility service professionals need to be aware of the increasing demand for ART among WLWHIV.

Objective To determine whether vaginal sonographic measurements can be used to monitor the endometrial preparation of recipients in a donor egg program. Design Prospective clinical trial. Setting University hospital-based IVF and donor egg program. Patients Twelve women without ovarian function. Interventions [1] In a control cycle, patients received 4 or 8mg of oral E 2 and vaginal ultrasound (US) daily until endometrial thickness ≥6mm with a triple-line pattern (favorable endometrium) was seen. Progesterone (P) in oil, 100mg/d, was then added. [2] An endometrial biopsy was performed on day 7 of P therapy. [3] In a treatment cycle, US monitoring of endometrial development during estrogen (E) administration was used; and ET was performed on the 3rd day of P therapy. Results In the control cycle, 8mg/d or 4mg/d of micronized E 2 resulted in favorable endometrium development in all patients in a mean time of 5 and 7days, respectively. After P treatment, only 1 of 12 endometrial biopsies was in phase. In the treatment cycles, the overall clinical pregnancy rate (PR) was 42%. In those patients with a favorable endometrium in the E replacement phase, before addition of P, the PR was 62.5%. All of the pregnant patients but only 42.8% of the nonpregnant patients had a favorable endometrium on US before the addition of P. Conclusion An endometrium that is favorable for implantation can result from the use of a simple fixed dose of E 2 , with higher doses achieving favorable endometrial development in shorter time. Vaginal sonography of endometrial development before P administration is more accurate than endometrial biopsy in predicting a successful donor egg cycle. Endometrial preparation in donor oocyte programs can be simplified by the use of vaginal US monitoring.

To evaluate the efficacy of a levonorgestrel-releasing intrauterine system (LNG-IUS) compared with a combined oral contraceptive containing 1 mg norethindrone acetate and 20 mg ethinyl estradiol (OC1/20) in reducing menstrual blood loss (MBL) in women with idiopathic menorrhagia.A prospective, randomized, open-label study was conducted in nine centres in Canada. Healthy women over 30 years of age suffering from idiopathic menorrhagia were treated either with LNG-IUS (n = 20) or with OC1/20 (n = 19) over 12 months. The primary endpoint was the change in MBL from baseline to 12 months. Secondary endpoints included treatment success (defined as a MBL score100 after 12 months), hemoglobin levels, and the menorrhagia severity score.In both treatment groups, MBL decreased significantly from baseline to 12 months (P0.001). For the primary endpoint, the MBL score decreased significantly more in the LNG-IUS group (median from 228 to 13, mean percent change-83%) compared to the OC1/20 group (median from 290 to 72; mean percent change-68%) (P = 0.002) after 12 months. In the LNG-IUS group, 80% of subjects had treatment success compared with 36.8 % in the OC1/20 group (P0.009). Both treatments increased hemoglobin concentrations significantly between baseline and 12 months. The menorrhagia severity score was consistently lower in the LNG-IUS group at all study time points and was significantly lower (P = 0.045) at six months. Both treatments were well tolerated.Both the LNG-IUS and the combined oral contraceptive effectively decreased menstrual blood loss in women with idiopathic menorrhagia. The overall clinical benefit was more pronounced with LNG-IUS than with OC1/20.

(1) To determine if women faculty members in departments of Obstetrics and Gynaecology were less likely than men to achieve promotion; and (2) to assess gender differences in attitudes towards promotion.Department chairs at the 16 medical schools in Canada were approached to participate in this study. A questionnaire was mailed to the obstetricians/gynaecologists in faculties of medicine at the 15 Canadian medical schools that agreed to participate. Likelihood of promotion for women and men was compared using survival analysis, controlling for other factors. Survival (event) time was the time in years between completion of residency and achieving promotion.The response rate was 72% (376/522). Overall, 37% of respondents were women, and 63% were men. The women respondents were younger than the men, with a mean age of 43.4 +/- 7.9 years compared to 52.8 +/- 8.9 years. Of those in an academic stream, 39% of women (29/75) and 62% of men (90/145) had attained senior academic ranks. Completing residency more recently was associated with a higher likelihood of promotion to Assistant Professor (hazard ratio [HR], 1.05; P0.001). The likelihood of promotion to Professor was lower for women than for men (HR, 0.40; P = 0.05). Having a mentor was associated with a higher likelihood of promotion to Professor (HR, 2.33; P = 0.002). Women were more likely to perceive barriers to promotion, such as family care responsibilities (P0.001).Independent of the respondent's gender, recent completion of residency and having a mentor were the most significant factors increasing the likelihood of promotion in Canadian medical school departments of Obstetrics and Gynaecology. As women were found to be less likely than men to achieve promotion to Professor, mentoring and strategies that focus on facilitating promotion for women should be encouraged to ensure there are academic leaders in obstetrics and gynaecology in the future.

Objective: To determine the feasibility of asking women undergoing fertility treatment the maximum increased risk of ovarian cancer they would be willing to tolerate in order to take ovulation-induction drugs. Design: A prospective pilot study of women attending fertility clinics over a 2-month period. Setting: Two tertiary care fertility clinics in Toronto. Patient(s): Sixty-one English-speaking women were approached and 85% (n = 52) were enrolled. Intervention(s): A self-administered questionnaire with fertility-specific questions. Thirty-eight women also were asked to complete standardized scales of anxiety and optimism. Main Outcome Measure(s): Women's report of the maximum level of lifetime risk of ovarian cancer they were willing to tolerate in order to undergo fertility treatment. Result(s): Seventy-nine percent were willing to accept an increased risk of ovarian cancer. Only 24% understood that treatment for ovarian cancer usually was not curative. Conclusion(s): A majority of patients were willing to tolerate a modest increase in their lifetime risk of ovarian cancer because of fertility treatment, most basing their estimate of acceptable risk on limited awareness of the issue.

Background: We performed a retrospective chart review in 2006 to review oncology patients’ use of banked semen samples in fertility treatments at a tertiary care centre. Methods: From 2002 to 2005, 367 oncology patients banked semen. During the same period, 31 patients used banked samples in 48 treatment cycles. Samples were used for intrauterine insemination (IUI) in 28 cycles and for in vitro fertilization (IVF) with or without intracytoplasmic sperm injection (ICSI) in 20 cycles. Results: Pregnancy rates per cycle were 21% for IUI and 50% for IVF with or without ICSI. Overall, 16 of the 31 couples achieved a pregnancy with assisted reproductive technologies (52%). Conclusion: This data indicates high pregnancy success rates with the use of banked semen samples from men with cancer. Contexte : Une revue retrospective de dossiers a ete effectuee afin d’examiner le recours a des echantillons de sperme provenant de patients cancereux pour le traitement de l’infertilite dans un centre de soins tertiaires. Methodes : Entre 2002 et 2005, des echantillons de sperme provenant d’un total de 367 patients atteints de cancer ont ete mis en banque. Durant la meme periode, 31 patientes ont utilise ces echantillons au cours de 48 cycles de traitement. Les echantillons ont ete utilises pour insemination intra-uterine (IIU) lors de 28 cycles et pour fertilisation in vitro (FIV) avec ou sans injection intracytoplasmique de sperme (ICSI) lors de 20 cycles. Resultats : Le taux de grossesse par cycle etait de 21 % avec l’IIU et de 50 % pour la FIV avec ou sans ICSI. Au total, 16 des 31 patientes sont devenues enceintes (52 %). Conclusion : Ces donnees montrent des taux eleves de grossesse obtenus par l’utilisation d’echantillons de sperme provenant d’hommes atteints de cancer.

1Women and HIV Research Program, Women’s College Research Institute, Women’s College Hospital, Toronto, ON, Canada M5G 1N6 2Faculty of Medicine, University of Toronto, Toronto, ON, Canada M5S 3K1 3Department of Obstetrics and Gynecology, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada M5B 1W8 4Clinical Decision Making and Health Care, University Health Network, Toronto, ON, Canada M5G 2C4 5Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada M5S 1A1 6Department of Psychology, Ryerson University, Toronto, ON, Canada M5B 2K3 7Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada M5G 1X5 8Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada M4N 3M5 9Department of Obstetrics and Gynecology, Credit Valley Hospital, Mississauga, ON, Canada L5M 2N1

Charts of 443 postdate pregnancies were reviewed to determine the effect of late maternal age on pregnancy outcome. There were significantly more low 1-minute Apgar scores, intrapartum decelerations, and cesarean sections in the group of women greater than 35 years old. Use of oxytocin percentages and the results were similar with regard to both groups. Five-minute Apgar scores also were similar. Women greater than 35 years of age are less able to be delivered of postdate infants with optimal outcomes, but it is still safe to allow them to exceed 42 weeks' gestation.