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Objectives: Assessing dienogest's efficacy in endometriosis patients undergoing in vitro fertilization (IVF)., Data Sources: Systematic search in databases (PubMed, MEDLINE, Embase, Web of Science, Cochrane CENTRAL, Google Scholar) until 1 October 2022., Study Selections: Randomized trials and observational studies comparing extended dienogest pre-treatment, no pre-treatment, or gonadotropin-releasing hormone (GnRH) agonist pre-treatment in endometriosis-linked IVF., Outcome Measures: live birth, clinical pregnancy rates, oocytes collected, miscarriage rate, gonadotropin consumption., Data Extractions and Syntheses: Two authors independently assessed eligibility. Dichotomous variables were analyzed via a random-effect model and Mantel-Haenszel method to calculate weighted estimates and 95% confidence intervals (CI). I2 statistic gauged study heterogeneity; GRADE criteria evaluated evidence quality., Conclusions: Out of 191 publications, five studies with 723 participants were included. Uncertainty persists on whether prolonged dienogest affects live birth (RR 1.42, 95% CI 0.29 to 6.84; 3 studies, n = 289; I2 86%) and clinical pregnancy rates (RR 1.33, 95% CI 0.31 to 5.65; 3 studies, n = 289; I2 86%) compared to conventional IVF. Moreover, uncertainty remains regarding intervention impact on live birth (RR 1.46, 95% CI 0.63 to 3.37; 1 study, n = 34) and clinical pregnancy rates (RR 1.32, 95% CI 0.78 to 2.23; 3 studies, n = 288; I2 0%) versus long-term GnRH agonist therapy before IVF. Given limited data and very low evidence quality, doubts arise about the benefits of long-term dienogest pre-treatment before conventional IVF in endometriosis patients., (Copyright © 2023 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Research Question: Does endometriosis have an effect on the placental histopathology pattern and perinatal outcome in singleton live births resulting from IVF treatment?, Design: Retrospective cohort study evaluating the data on all live births following IVF treatment between 2009 and 2017 at one university-affiliated tertiary hospital. All patients had placentas sent for full gross and histopathology assessment, irrespective of complication status or delivery mode. The primary outcomes of the study included anatomical, inflammation, vascular malperfusion and villous maturation placental disorders. The secondary outcomes included fetal, maternal, perinatal and delivery complications. A multivariate logistic model was used to adjust the results for confounding factors potentially associated with significant placental characteristics., Results: A total of 1057 live births were included in the final analysis and were allocated to the group of women with endometriosis (n = 75) and those without (n = 982). After adjustment for confounding factors, endometriosis was found to be significantly associated with acute chorioamnionitis with moderate to severe maternal (odds ratio [OR] 2.2, 95% confidence interval [95% CI] 1.1-4.6) and fetal (OR 4.9, 95% CI 1.8-13.1) inflammatory response, placenta previa (OR 3.1, 95% CI 1.2-7.8), subchorionic fibrin deposition (OR 3.4, 95% CI 1.2-9.1), intervillous thrombosis (OR 3.4, 95% CI 1.5-8.1), and fetal vascular malperfusion (OR 5.1, 95% CI 1.4-18.1), as well as with preterm birth (OR 2.5, 95% CI 1.4-4.7)., Conclusions: Endometriosis has a significant impact on the placental histopathology and is associated with a higher incidence of preterm birth., (Copyright © 2022. Published by Elsevier Ltd.)

Background: The insertion of intrauterine devices (IUDs) is associated with a small increased risk of pelvic inflammatory disease and ascending infection, particularly in patients with risk factors. However, the risk of sepsis and toxic shock syndrome after insertion of an IUD is a rare event, described only through case reports in the literature., Case: This report describes the case of a 40-year-old woman who presented with high fever, myalgias, and abdominal pain 2 days following the insertion of a levonorgestrel-releasing IUD. She was found to have group A Streptococcus infection in the vagina that led to a diagnosis of streptococcal toxic shock syndrome and required admission to the intensive care unit., Conclusion: Toxic shock syndrome is a rare but potentially catastrophic complication after the insertion of an IUD. Health care providers should be conscious of this complication, particularly among patients presenting with fever and sepsis soon after IUD insertion., (Copyright © 2019 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Objective: The incidence of placenta accreta spectrum (PAS) has risen over the past decades, primarily in response to increasing Caesarean section rates. The surgical management of PAS is associated with significant morbidity, including hemorrhage and intensive care unit (ICU) admission. This study sought to evaluate the surgical outcomes of a PAS operative approach., Methods: A single-centre retrospective chart review of all Caesarean hysterectomies for PAS by an assigned surgeon over a 16-year period was performed. Surgical outcomes were described (Canadian Task Force Classification II-2)., Results: The described surgical approach involves a midline skin incision, high midline hysterotomy, a rapid single-layer uterine closure with no placental removal attempt, constant cephalad uterine traction, and liberal choice of subtotal hysterectomy. A total of 47 patients were included: 19 (40.4%) with placenta accreta, 14 (29.8%) with placenta increta, and 14 (29.8%) with placenta percreta. Mean estimated blood loss was 1416 ± 699 mL, and mean operative time was 112 ± 49 minutes. Overall, 16 patients (34.0%) required blood transfusion, and 4 patients (8.5%) required ICU admission. The average hospitalization was 5.2 days, with no re-admission within 30 days. The use of internal iliac balloons did not result in a difference in blood loss or operative time (P > 0.05). Patients with placenta percreta had significantly more blood loss (P = 0.02) and longer operative time (P = 0.007) compared with those with placenta accreta and increta., Conclusion: The current surgical model for planned Caesarean hysterectomy for PAS exhibits a low complication rate. Further research is needed for developing a standardized approach to the management of PAS., (Copyright © 2019 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Research Question: Does the addition of a gonadotrophin-releasing hormone (GnRH) antagonist to cabergoline treatment during the luteal phase in fresh IVF cycles triggered with a GnRH agonist, and planned for freeze-all, reduce the rate of mild and moderate ovarian hyperstimulation syndrome (OHSS)?, Design: Retrospective cohort study of 480 IVF patients at risk for OHSS with GnRH agonist trigger from 2011 to 2018, stratified into three groups based on treatment received: GnRH agonist trigger alone (Group 1, n = 208), GnRH agonist trigger + cabergoline (Group 2, n = 167) or GnRH agonist trigger + cabergoline + GnRH antagonist (Group 3, n = 105). Data on patient demographics, incidence, severity and symptomatology of OHSS and laboratory findings were collected., Results: Group 1 had more free peritoneal fluid than Group 2 (28% versus 19%, P = 0.04) or Group 3 (28% versus 5%, P = 0.001). Group 1 reported abdominal discomfort and bloating more than Group 2 (33% versus 21%, P = 0.01) or Group 3 (33% versus 18%, P = 0.006). Group 1 had more electrolyte abnormalities than Group 2, who had more than Group 3. No patients developed severe OHSS. Mild and moderate OHSS rate was higher in Group 1 (38%) than Group 2 (29%, P = 0.048) or Group 3 (18%, P = 0.006) and in Group 2 than Group 3 (P = 0.046)., Conclusion: Addition of cabergoline to GnRH agonist triggering in high-risk OHSS patients, and subsequent addition of GnRH antagonist for 5 days in the luteal phase, sequentially reduces the risk of mild and moderate OHSS and improves patient comfort compared with GnRH agonist trigger alone., (Copyright © 2019 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.)

Objective: Cannabis is the most commonly used recreational drug during pregnancy in the United States. This study aimed to describe the rate of cannabis dependence or abuse use during pregnancy and its effect on obstetrical and neonatal outcomes., Methods: A retrospective population-based cohort of births in the United States between 1999 and 2013 was created using data from the National Inpatient Sample. Births to mothers who reported cannabis dependence or abuse were identified using ICD-9 codes, and the effect on various obstetrical and neonatal outcomes was assessed using logistic regression, adjusting for relevant confounders (Canadian Task Force Classification II-2)., Results: A total of 12 578 557 births were included in our analysis. The incidence of cannabis abuse or dependence rose from 3.22 in 1000 births in 1999 to 8.55 in 1000 births in 2013 (P < 0.0001). Women reporting cannabis dependence or abuse were more likely to have a preterm premature rupture of membranes (odds ratio [OR] 1.46; 95% confidence interval [CI] 1.35-1.58), a hospital stay of >7 days (OR 1.17; 95% CI 1.11-1.23), and an intrauterine fetal demise (OR 1.50; 95% CI 1.39-1.62). Neonates born to exposed mothers had a higher risk of prematurity (OR 1.40; 95% CI 1.36-1.43) and growth restriction (OR 1.35; 95% CI 1.30-1.41)., Conclusion: Cannabis use during pregnancy steadily increased over the study period. Users of cannabis during gestation were more likely to have adverse outcomes during delivery and require longer periods of hospitalization. Neonates born to exposed mothers were more likely to be born preterm and underweight., (Copyright © 2018 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Objective: This study sought to evaluate perceptions and insights regarding uterine transplantation among members of a women's health care national specialty organization in Canada., Methods: The investigators obtained permission and used an electronic survey developed by Bortoletto et al. to conduct a cross-sectional study of members of the SOGC between April and May 2018. Participants were requested to answer a total of 29 questions grouped into four different categories: personal opinions and attitudes, medical opinions, ethical opinions, and demographics. The investigators compared answers with a published survey of members of the American Society for Reproductive Medicine (ASRM) and the American Association of Gynecologic Laparoscopists (AAGL)., Results: Of a total 247 responses, 230 were complete, for a completion rate of 93%. Respondents were primarily female, White, obstetrician-gynaecologists within 15 years of starting practice. Statements viewed favourably by most of respondents (strongly agree or agree) included "Women should be allowed to donate or receive a transplanted uterus" (53.5%), "Uterine transplantation should be considered a potential treatment option for infertile women with severe uterine factor infertility" (42.4%), and "Uterine transplantation is ethical" (39.9%). Statements that were viewed unfavourably by the majority of respondents (strongly disagree or disagree) included "Uterine transplantation carries an acceptable risk for recipients" (43.7%) and "Uterine transplantation for severe uterine factor infertility should be covered by health insurance" (59.1%). When compared with members of the ASRM and AAGL, the degree of agreement was similar, except with regards to "Uterine transplantation carries an acceptable risk for donors" (50.0% vs. 65.3% ASRM/67.8% AAGL; P < 0.001), and "In countries or states where gestational surrogacy is illegal, uterine transplantation is a more permissible ethical option" (42.0% vs. 65.0% ASRM/51.4% AAGL; P < 0.001)., Conclusion: Most respondents either felt that uterine transplantation was ethical or were neutral to the subject. However, only a small minority would currently recommend the procedure to their patients. As advances in uterine transplants are made, future studies should re-evaluate providers' perceptions towards this procedure before it is introduced into clinical practice., (Copyright © 2018 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

The uterine transplant is an innovative surgical procedure whereby a healthy uterus is transplanted into a woman with uterine factor infertility (UFI) for the purpose of procreation. Twelve uterine transplants have been attempted in the world in the last two decades, and five have led to viable births. While uterine transplantation is still in its experimental stages, it remains unclear whether Canadian centres plan to attempt the procedure in the near future. Herein, I raise several observations that are specific to the Canadian setting and apply the Montreal Criteria for the Ethical Feasibility of Uterine Transplantation to determine whether there is fertile ground for a uterine transplantation program to be adopted in Canada., (Copyright © 2016 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Objective: To compare early versus delayed postoperative feeding in women undergoing major gynaecological surgery with regard to clinical outcomes, duration of postoperative stay, and patient satisfaction., Methods: We conducted a parallel-randomized controlled trial at a tertiary care centre in Montreal, Quebec, between June 2000 and July 2001. Patients undergoing major gynaecological surgery were randomized following a 1:1 allocation ratio to receive either early postoperative feeding in which oral clear fluids were begun up to six hours after surgery followed by solid foods as tolerated, or delayed postoperative feeding, in which clear fluids were begun on the first postoperative day and solid foods on the second or third day as tolerated. The primary outcomes analyzed were duration of postoperative stay and patient satisfaction. Secondary outcomes included mean time to appetite, passage of flatus, and bowel movement, as well as the presence of symptoms of paralytic ileus., Results: A total of 119 patients were randomized; 61 patients were assigned to the early feeding group and 58 to the delayed feeding group. Demographic characteristics, including age, weight, smoking status, and prior surgical history were comparable between both groups. There was no difference in length of postoperative stay between the two groups (86.4 ± 21.0 hours in the early feeding group vs. 85.6 ± 26.2 hours in the delayed feeding group; P > 0.05). No significant difference was noted in patient satisfaction (P > 0.05). No difference was found in the frequency of postoperative ileus, mean time to appetite, passage of flatus, or first bowel movement., Conclusion: The introduction of early postoperative feeding appears to be safe and well tolerated by patients undergoing major gynaecological surgery. The duration of postoperative stay, patient satisfaction, and gastrointestinal symptoms are comparable between patients undergoing early or delayed postoperative feeding.

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Embryonic aneuploidy is highly prevalent in IVF cycles and contributes to decreased implantation rates, IVF cycle failure and early pregnancy loss. Preimplantation genetic screening (PGS) selects the most competent (euploid) embryos for transfer, and has been proposed to improve IVF outcomes. Use of PGS with fluorescence-in-situ hybridization technology after day 3 embryo biopsy (PGS-v1) significantly lowers live birth rates and is not recommended for use. Comprehensive chromosome screening technology, which assesses the whole chromosome complement, can be achieved using different genetic platforms. Whether PGS using comprehensive chromosome screening after blastocyst biopsy (PGS-v2) improves IVF outcomes remains to be determined. A systematic review of randomized controlled trials was conducted on PGS-v2. Three trials met full inclusion criteria, comparing PGS-v2 and routine IVF care. PGS-v2 is associated with higher clinical implantation rates, and higher ongoing pregnancy rates when the same number of embryos is transferred in both PGS and control groups. Additionally, PGS-v2 improves embryo selection in eSET practice, maintaining the same ongoing pregnancy rates between PGS and control groups, while sharply decreasing multiple pregnancy rates. These results stem from good-prognosis patients undergoing IVF. Whether these findings can be extrapolated to poor-prognosis patients with decreased ovarian reserve remains to be determined., (Copyright © 2014 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.)

Objective: To develop an operative knowledge assessment tool to evaluate the cognitive competence of trainees in obstetric and gynaecologic surgery and to determine the rate of change in competence during a five-year residency program., Methods: Twenty-eight participants in five training groups (PGY-1 to PGY-5) in McGill University's residency program in obstetrics and gynaecology underwent an evaluation based on surgical cognitive competence (SCC) assessment tools developed for three different obstetric and gynaecologic operations: open total abdominal hysterectomy (TAH), Caesarean section, and laparoscopic bilateral tubal sterilization (BTL). The tools were developed as checklists listing every step in each operation based on techniques described in current surgical texts. Using analysis of variance and linear regressions, statistical significance was established for procedure-specific scores and overall SCC scores. In addition, the rate of change of cognitive competence throughout the training years was calculated. Finally, using a t test, the overall SCC score was compared to a "critical steps score"., Results: Critical steps scores and overall SCC scores increased with training experience at an average yearly rate of 13.36% (P < 0.001). Procedure-specific scores increased yearly, by 15.73% for TAH (P < 0.001), 8.06% for Caesarean section (P < 0.001), and 16.31% for BTL (P < 0.001). The difference between overall scores and critical steps scores was not statistically significant for the study cohort (P = 0.94)., Conclusion: Surgical cognitive competence among obstetrics and gynaecology residents can be reliably assessed with our evaluation tool, and it increases proportionally with residency education, reaching maximum scores during the final year of training. This type of information may be helpful in ascertaining how long a residency program should be.