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Endometrial polyps have a reported prevalence from 7.8% up to 30% and are one of the most cost-consuming gynecological conditions for our specialty. There are strong practitioner beliefs that surgical removal of endometrial polyps is highly beneficial, particularly for those with abnormal uterine bleeding and infertility. Additionally, polypectomy is indicated to reduce the risk of malignancy. Transvaginal ultrasound is the first-line diagnostic option for detection of endometrial polyps, while sonohysterography has similar accuracy as hysteroscopy in the diagnostic confirmation. Blind dilatation and curettage is not recommended for polyp removal; rather, hysteroscopy in the operating room and office setting using small-diameter hysteroscopic equipment is the standard approach. This can be performed without anesthesia in most women. While hysteroscopy is an effective method for polypectomy with a low complication rate, it is unknown whether this is truly beneficial for reproductive-age women with infertility and prior assisted reproduction therapy. The risk of malignancy in women with postmenopausal bleeding justifies the necessity of polypectomy with histologic tissue examination. In asymptomatic women, the risk of malignancy is low, and there are no known benefits of polyp removal in the prevention of malignant transformation. Cost-effective studies remain to be done to provide us with the optimal approach to endometrial polyps including the management of asymptomatic and/or infertile women, ideal location including office-based or the operating room setting, complication prevention including intrauterine adhesions, and recurrence issues.

ObjectiveConcern regarding the adverse impact of pretreatment of oral contraceptives (OC) prior to ovarian stimulation for in vitro fertilization (IVF) on pregnancy outcome has been debated. We investigated factors that may be associated with live birth rate (LBR) in fresh embryo transfer cycles after OC pretreatment.MethodsA retrospective study was conducted at the Reproductive Center of Ren Ji Hospital, Shanghai, China. 814 women aged 20–35 years undergoing their first autologous IVF cycle and fresh embryo transfer after OC pretreatment were included. Long gonadotropin releasing hormone (GnRH) agonist (a) or GnRH antagonist (ant) protocol was used for ovarian stimulation. Predictive factors for LBR were identified using multivariate logistic regression analysis.ResultsMultivariate logistic regression analysis demonstrated that using GnRH-ant protocol for ovarian stimulation was associated with significantly lower LBR (OR 0.70, 95% CI 0.52–0.93), while endometrial thickness on day of hCG trigger was associated with increased LBR (OR 1.16, 95% CI 1.06–1.27). Despite comparable patients’ age, duration of infertility, BMI and basal FSH between GnRH-a and GnRH-ant groups, those using GnRH-ant resulted in significantly lower LBR compared to the GnRH-a group (37.4 vs. 48.5%, p = 0.002). Using ROC analysis and a cut-off endometrial thickness of < and ≥ 9.5 mm, those < 9.5 mm using GnRH-ant resulted in significantly lower LBR (28.5 vs. 43.4%, p = 0.004), while no differences were noted with an endometrial thickness ≥9.5 mm (49.6 vs. 51.1%, p = 0.78).ConclusionsLive birth was significantly impacted in OC pre-treated GnRH-ant cycles with an endometrial thickness of

To estimate the diagnostic efficacy of saline-air hysterosalpingo-contrast sonography (SA-HyCoSy) compared with the modified hysterosalpingogram (mHSG) for confirmation of both coil location and tubal occlusion following hysteroscopic sterilization.This study included 19 women who underwent both SA-HyCoSy and mHSG where 1 test was followed by the other. Sensitivity, specificity, and positive and negative predictive values for tubal occlusion against the mHSG were calculated for each fallopian tube by 2 independent interpreters. Interrater reliability was assessed using Cohen κ statistic. Procedure time and pain level by 11-point numeric rating scale of SA-HyCoSy and mHSG were also compared.Thirty-eight fallopian tubes were evaluated. Tubal occlusion was noted in 97.3% of tubes for both interpreters with the mHSG compared with 92.1% and 94.7% with SA-HyCoSy. The positive and negative predictive values for tubal occlusion were 100%/100% and 50%/33%, respectively, with an overall agreement of 97.4% and 95.7%, κ = 0.48, P0.01. Saline-air HyCoSy changed interpretation of coil insert location in 50% and 44.7% for each interpreter, being downgraded from optimal to satisfactory in 42.9% (9/21) and 36% (9/25) and upgraded to optimal in 58.8% (10/17) and 61.5% (8/13), respectively. There were no statistically significant differences in procedural time (7.5 vs 9.4 minutes, P0.05) or maximum pain scores (2.3 vs 3.1, P0.05) for the mHSG compared with SA-HyCoSy.Our findings revealed a high degree of diagnostic accuracy with SA-HyCoSy for tubal occlusion, although coil location changed in nearly half of cases. Avoidance of radiation and patient convenience/compliance with SA-HyCoSy may outweigh the drawbacks.

Author(s): Smith, Meghan B; Ho, Jacqueline; Ma, Lihong; Lee, Miryoung; Czerwinski, Stefan A; Glenn, Tanya L; Cool, David R; Gagneux, Pascal; Stanczyk, Frank Z; McGinnis, Lynda K; Lindheim, Steven R | Abstract: ObjectiveTo examine the changes in AMH levels longitudinally over time and their relationship with both body composition, particularly abdominal adiposity, and milestones of pubertal development in female children.DesignSecondary analysis of a prospective, longitudinal study.SettingUniversity affiliated research center and laboratories.PatientsEighty-nine females were examined between 1990 and 2015 to study child growth and development.InterventionsDemographic, anthropometric, growth, and pubertal milestone data with serum samples stored and subsequently analyzed for AMH.Main outcome measuresLongitudinal change in AMH and predicted AMH levels based on body composition, age, and pubertal milestones including, pubarche, thelarche, and menarche.ResultsNatural log-transformed AMH (AMHlog) levels appeared to have a nonlinear relationship with age, decreasing between 10 and 14 years of age, increasing until 16 years. A mixed effect linear model demonstrated that increased abdominal adiposity (waist/height ratio, WHtR) was significantly associated with the predicted increased AMHlog levels (β=1.37). As females progressed through the Tanner stages, the model predicted decreasing AMHlog values when adjusting for age and WHtR.ConclusionsDeclining AMH levels during puberty may not be reflective of diminished ovarian reserve as observed in adults, but may suggest a permissive role of AMH in the activation of the hypothalamic-pituitary-ovarian axis.

Objective To evaluate the impact of oral contraceptives (OC) on live birth rate (LBR) following a fresh embryo transfer and cumulative live birth rate (cLBR) in normal ovulatory women undergoing in vitro fertilization (IVF). Design Retrospective cohort study. Setting Reproductive center. Patients A total of 3,110 normo-ovulatory women aged 20–40 years undergoing IVF either using or not using OC pretreatment in their first autologous cycle. Intervention(s) Patients initiated gonadotropins for their IVF cycle either after a spontaneous menses or following OC pretreatment, which was at the discretion of the provider or according to patients preference. Main Outcome Measure(s) The primary outcomes were LBR after fresh transfer (fLBR) and cLBR. Results fLBR was significantly lower in women using OC compared to those not (42.6% vs. 52.8%). Although LBR after frozen embryo transfer cycles were similar (42.7% vs. 41.1%), cLBR was significantly lower in women using OC (62.8% vs. 67.6%). Multivariate logistic and COX regression analysis adjusting for baseline characteristics demonstrated that IVF cycle synchronization with OC was significantly associated with a lower fLBR (adjusted odds ratio 0.73, 95% confidence interval 0.62−0.86) and cLBR (adjusted hazard ratio 0.89, 95% confidence interval 0.80−0.98). Conclusions Pretreatment OC use is associated with a reduction in fLBR and cLBR.

Objectives To identify uterine measurements that are reliable and accurate to distinguish between T-shaped and normal/arcuate uterus, and define T-shaped uterus, using Congenital Uterine Malformation by Experts (CUME) methodology, which uses as reference standard the decision made most often by several independent experts. Methods This was a prospectively planned multirater reliability/agreement and diagnostic accuracy study, performed between November 2017 and December 2018, using a sample of 100 three-dimensional (3D) datasets of different uteri with lateral uterine cavity indentations, acquired from consecutive women between 2014 and 2016. Fifteen representative experts (five clinicians, five surgeons and five sonologists), blinded to each others' opinions, examined anonymized images of the coronal plane of each uterus and provided their independent opinion as to whether it was T-shaped or normal/arcuate; this formed the basis of the CUME reference standard, with the decision made most often (i.e. that chosen by eight or more of the 15 experts) for each uterus being considered the correct diagnosis for that uterus. Two other experienced observers, also blinded to the opinions of the other experts, then performed independently 15 sonographic measurements, using the original 3D datasets of each uterus. Agreement between the diagnoses made by the 15 experts was assessed using kappa and percent agreement. The interobserver reliability of measurements was assessed using the concordance correlation coefficient (CCC). The diagnostic test accuracy was assessed using the area under the receiver-operating-characteristics curve (AUC) and the best cut-off value was assessed by calculating Youden's index, according to the CUME reference standard. Sensitivity, specificity, negative and positive likelihood ratios (LR- and LR+) and post-test probability were calculated. Results According to the CUME reference standard, there were 20 T-shaped and 80 normal/arcuate uteri. Individual experts recognized between 5 and 35 (median, 19) T-shaped uteri on subjective judgment. The agreement among experts was 82% (kappa = 0.43). Three of the 15 sonographic measurements were identified as having good diagnostic test accuracy, according to the CUME reference standard: lateral indentation angle (AUC = 0.95), lateral internal indentation depth (AUC = 0.92) and T-angle (AUC = 0.87). Of these, T-angle had the best interobserver reproducibility (CCC = 0.87 vs 0.82 vs 0.62 for T-angle vs lateral indentation depth vs lateral indentation angle). The best cut-off values for these measurements were: lateral indentation angle = 7 mm (sensitivity, 95%; specificity, 77.5%; LR+, 4.2; LR-, 0.06) and T-angle = 7 mm, lateral indentation angle

Human fertility is a vast, complex, and entirely imperfect system. Overall 20% of clinically recognized pregnancies result in first trimester miscarriage with up to 50% attributed to chromosomal abnormalities. The American Society of Reproductive Medicine (ASRM) defines recurrent pregnancy loss (RPL) as at least two failed clinical pregnancies. By these estimates, 5% of the population have RPL, 1% will experience three or more losses, and up to 50% of these individuals with an unknown etiology.

The health impacts of obesity are numerous and include reduced fertility and impaired outcomes of ART. While conflicting literature exists, it appears that obesity reduces ovulation, increases Gn dose requirements, reduces clinical pregnancy rates after ART, and increases the risk of miscarriage after ART. To avoid potential risks, it is recommended that women with obesity seeking to have children through natural or assisted conception make positive lifestyle changes in regard to diet and exercise. It is not recommended that ART be withheld from women with elevated BMI, but appropriate counseling about increased risks should be given along with referrals for comprehensive weight management. Further research is needed, using consistent BMI cutoffs and prospective research design, to clarify the risks and improve outcomes for women with obesity seeking ART.

As transplantation medicine progresses, patients of child-bearing age and younger are receiving allograft transplants to treat advanced disease. A younger population of organ transplant recipients (OTRs) demands consideration of the reproductive future of these individuals. This chapter discusses the application of assisted reproductive technology (ART) in OTRs, addressing the unique medical considerations of the post-transplant patient. The toll of pregnancy on the OTR will be discussed, with special attention paid to maternal and fetal complications. Additionally, the impact of post-transplant immunosuppression on future fertility will be addressed. If post-transplant infertility persists or secondary infertility develops, ART is a reliable option that will be discussed in depth. This chapter also explores uterine transplantation as an innovative treatment for infertility caused by structural uterine factors. With skillful administration of ART, infertility in the OTR may be overcome, allowing patients the full experience of family planning and childbirth post-transplant.

The immune system plays an important role in the initiation and maintenance of pregnancy. The human leukocyte antigen (HLA) is the region in the genome that codes for major histocompatibility complex (MHC) proteins that are charged with the recognition of self from non-self proteins. MHC proteins protect the body against infection and foreign antigens. The immune system undergoes specific and precise immunomodulation to accommodate pregnancy. HLA-G is an immunosuppressive molecule that is abundantly expressed in the trophoblast cells. It promotes immunotolerance and suppresses uteroplacental immune function to prevent rejection of the fetus. Some HLA-G genotypes have been linked to infertility, implantation failure, recurrent pregnancy loss, poor placentation, and pregnancy complications. This article will provide basic review of the immune system with a focus on the MHC and their impact on in vitro fertilization (IVF) and implantation failure.

Once unimaginable, fertility management is now a nationally established part of cancer care in institutions, from academic centers to community hospitals to private practices. Over the last two decades, advances in medicine and reproductive science have made it possible for men, women and children to be connected with an oncofertility specialist or offered fertility preservation soon after a cancer diagnosis. The Oncofertility Consortium's National Physicians Cooperative is a large-scale effort to engage physicians across disciplines – oncology, urology, obstetrics and gynecology, reproductive endocrinology, and behavioral health – in clinical and research activities to enable significant progress in providing fertility preservation options to children and adults. Here, we review the structure and function of the National Physicians Cooperative and identify next steps.

OBJECTIVE: To assess the impact of hysteroscopic tissue removal systems (TRS) on histopathology tissue diagnosis. MEASUREMENTS AND METHODS: This is a paired-comparison ex vivo study in which 23 endometrial sections from hysterectomized uteri (13 benign and 10 hyperplasia/cancer) were analyzed in a simulation laboratory center at a university teaching hospital. After routine tissue processing, a section of endometrium was provided for ex vivo TRS with suture mounting to a uterine model (Polly, Remedy). Morcellated specimens using the Hologic(®) MyoSure hysteroscopic device were processed for histopathologic analysis by two blinded pathologists (Pa and Pb) and compared to the original specimens’ tissue diagnoses. RESULTS: Sufficient tissue for evaluation was found in 100% (23/23) of TRS specimens by Pa and 91.3% by Pb. TRS specimen diagnoses were concordant with routine histologic diagnosis 86.9% (20/23, k = 0.76) for Pa and 80.9% (17/21, k = 0.68) for Pb. Sensitivity and specificity were 70%/100% for Pa and 80%/91% for Pb, respectively. The false-positive (overdiagnosed) and false-negative rates (underdiagnosed) were 0%/30% and 9%/20% for Pa and Pb. Both Pa and Pb underdiagnosed most specimens confirmed by routine tissue diagnosis. TRS specimen diagnoses between Pa and Pb were concordant in 76.2% (16/21, k = 0.60). CONCLUSION: TRS may adversely impact the ability to provide a histologic tissue analysis. Up to 30% of samples were overdiagnosed and 20% underdiagnosed. If confirmed, pathologists may need to reassess workflows to better offset potential underdiagnosis of malignant specimens as findings may be obscured through TRS. Additionally, surgeons may need to reconsider specimen handling, so highest yield specimens are provided to pathology.

Cesarean scar ectopic pregnancy (CSEP) has a high rate of morbidity with nonspecific signs and symptoms making identification difficult. The criterion-standard treatment of CSEP has been subject to debate.This review defines CSEP, discusses pathogenesis and diagnosis, and compares treatment options and outcomes.A literature review was performed utilizing the termFive basic pathways have been identified in treatment of CSEP: expectant management, medical therapy, surgical intervention, uterine artery embolization, or a combination approach. Expectant management has the highest probability of morbid outcomes, including hemorrhage, uterine rupture, and preterm delivery. Medical management often requires further treatment with additional medication or surgery. Different surgical methods have been explored including uterine artery embolization; dilation and curettage; surgical removal via vaginal, laparoscopic, or laparotomic approach; and hysterectomy. Each method has various levels of success and depends on surgeon skill and patient presentation.Recent research supports any method that removes the pregnancy and scar to reduce morbidity and promote future fertility. Laparoscopic and transvaginal approaches are options for CSEP treatment, although continued research is required to identify the optimal approach.As cesarean delivery numbers rise, a subsequent increase in CSEPs can be anticipated. The ability to accurately diagnose and treat this morbid condition is vital to the practice of any specialist in general obstetrics and gynecology.

Objectives To assess the level of agreement between experts in distinguishing between septate and normal/arcuate uterus using their subjective judgment when reviewing the coronal view of the uterus from three-dimensional ultrasound. Another aim was to determine the interobserver reliability and diagnostic test accuracy of three measurements suggested by recent guidelines, using as reference standard the decision made most often by experts (Congenital Uterine Malformation by Experts (CUME)). Methods Images of the coronal plane of the uterus from 100 women with suspected fundal internal indentation were anonymized and provided to 15 experts (five clinicians, five surgeons and five sonologists). They were instructed to indicate whether they believed the uterus to be normal/arcuate (defined as normal uterine morphology or not clinically relevant degree of distortion caused by internal indentation) or septate (clinically relevant degree of distortion caused by internal indentation). Two other observers independently measured indentation depth, indentation angle and indentation-to-wall-thickness (I:WT) ratio. The agreement between experts was assessed using kappa, the interobserver reliability was assessed using the concordance correlation coefficient (CCC), the diagnostic test accuracy was assessed using the area under the receiver–operating characteristics curve (AUC) and the best cut-off value was assessed using Youden's index, considering as the reference standard the choice made most often by the experts (CUME). Results There was good agreement between all experts (kappa, 0.62). There were 18 septate and 82 normal/arcuate uteri according to CUME; European Society of Human Reproduction and Embryology (ESHRE)-European Society for Gynaecological Endoscopy (ESGE) criteria (I:WT ratio > 50%) defined 80 septate and 20 normal/arcuate uteri, while American Society for Reproductive Medicine (ASRM) criteria defined five septate (depth > 15 mm and angle 90°) and 13 uteri that could not be classified (referred to as the gray-zone). The agreement between ESHRE-ESGE and CUME was 38% (kappa, 0.1); the agreement between ASRM criteria and CUME for septate was 87% (kappa, 0.39), and considering both septate and gray-zone as septate, the agreement was 98% (kappa, 0.93). Among the three measurements, the interobserver reproducibility of indentation depth (CCC, 0.99; 95% CI, 0.98–0.99) was better than both indentation angle (CCC, 0.96; 95% CI, 0.94–0.97) and I:WT ratio (CCC, 0.92; 95% CI, 0.90–0.94). The diagnostic test accuracy of these three measurements using CUME as reference standard was very good, with AUC between 0.96 and 1.00. The best cut-off values for these measurements to define septate uterus were: indentation depth ≥ 10 mm, indentation angle 110% . Conclusions The suggested ESHRE-ESGE cut-off value overestimates the prevalence of septate uterus while that of ASRM underestimates this prevalence, leaving in the gray-zone most of the uteri that experts considered as septate. We recommend considering indentation depth ≥ 10 mm as septate, since the measurement is simple and reliable and this criterion is in agreement with expert opinion. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Simple Summary The following review addresses the effects of cancer and cancer treatments on fertility and reproductive health, and reviews standard and novel fertility preservation options. This article presents a needs assessment focusing on disparities in access to care for the pediatric, adolescent, and young adult (AYA) population to include cost, provider bias, inequitable referral patterns to reproductive specialists, and a lack of knowledge within the medical community regarding assisted reproductive technologies and reproductive health care in survivorship. The information presented in this article is targeted to oncologists, gynecologists, pediatric subspecialists, and primary care providers who care for this population and introduces areas for further research to address gaps in care and improve access for this population. Abstract Advancements in cancer screening and implementation of targeted treatments have significantly improved survival rates to 85% for pediatric and AYA survivors. Greater than 75% of survivors will live to experience the long-term adverse outcomes of cancer therapies, termed late effects (LE), that disrupt quality of life (QoL). Infertility and poor reproductive outcomes are significant disruptors of QoL in survivorship, affecting 12–88% of survivors who receive at-risk therapies. To mitigate risk, fertility preservation (FP) counseling is recommended as standard of care prior to gonadotoxic therapy. However, disparities in FP counseling, implementation of FP interventions, and screening for gynecologic late effects in survivorship persist. Barriers to care include a lack of provider and patient knowledge of the safety and breadth of current FP options, misconceptions about the duration of time required to implement FP therapies, cost, and health care team bias. Developing strategies to address barriers and implement established guidelines are necessary to ensure equity and improve quality of care across populations.

The prevalence of uterine malformations has been reported in up to 7% of the general population and 18% of those with recurrent pregnancy loss. The diagnosis, classification, management, and outcome of the management have been subject to debate for decades.The aim of this article is to summarize the current knowledge regarding the genetics of müllerian anomalies, the varied classification schemes, the appropriate diagnostic modalities, the surgical methods, and the obstetric outcomes related to these surgical methods.An extensive literature review using the key wordsCurrent evidence favors continued use of the American Society of Reproductive Medicine classification. Three-dimensional sonography, especially when combined with saline infusion, can be very helpful in accurately classifying müllerian anomalies.Müllerian anomalies are relatively common. Accurate knowledge of the advantages and limitations of various diagnostic modalities, the limitations of the classification systems, the surgical options available where appropriate, and the obstetric outcomes after these surgeries will help in the optimal management of these patients.

Objective To demonstrate various types of longitudinal vaginal septa (LVS), their classification, and the surgical management of typical and unique morphologic conditions of LVS. Design Video presentation of clinical appearance and surgical techniques for treatment of LVS. Setting University hospital and two private. Patient(s) Representative cases from 121 consecutive women treated from 2013 to 2018 with LVS as a part of complex uterovaginal malformations or in isolated forms with [1] typical morphologic configuration of LVS, [2] rarer variants, or [3] specific anatomic restrictions. Intervention(s) Resection of LVS performed as a main surgical procedure in cases with didelphys and bicornuate uterus in symptomatic women and as a part of corrective surgery of complete septate uterus. The three main nonsuturing techniques used were speculoscopy and septum excision using three different electrosurgical modalities; speculoscopy with laparoscopic devices; and vaginoscopy with hysteroscopic instruments. Main Outcome Measure(s) Clinical appearance and suggested classification, feasibility of surgery, and perioperative and anatomic results in a short follow-up period (3 months). Result(s) We identified distinct types of longitudinal vaginal septa. Considering clinical appearance, we suggest classification of LVS based on four main features: [2] completeness of vaginal division: partial and complete type; [2] the symmetricity: symmetric and asymmetric position (with dominant left and right side); [3] association with the cervix: merged and isolated forms; and [4] concomitant vaginal openings: normal, and narrow openings: vaginal stenosis and hymen persistent ( Fig. 1 ). Vaginoscopic techniques by hysteroscope were successful in atraumatic treatment of women with substantial anatomic restrictions, and all of the presented techniques can be effectively used for typical LVS. However, vessel-sealing systems allow for bloodless surgery in contrast with other methods. This study was based on previously acquired data during large prospective study approved by the local ethics committee, and written informed consent to participate in the prospective study and permit publishing anonymous data regarding the medical images, videos of procedures, and results was obtained from all patients. Conclusion(s) A new classification of longitudinal vaginal septum allows better characterization compared with the currently available classification systems. Different surgical modalities are discussed with their respective advantages and disadvantages. Vaginoscopic incision using resectoscope is a reasonable alternative for women with an intact hymen and vaginal stenosis. The impact of vaginal septum resection on obstetric, reproductive, and sexual outcomes should be assessed in randomized controlled trials and large well-designed studies.

In the last 10 years, expanded preconception carrier screening has become widely available and helps patients/couples make more informed decisions with regard to their reproductive options and facilitates more effective preconception planning, prenatal diagnosis, condition-specific counseling, and condition-specific care. This review provides an overview of expanded preconception carrier screening's high-throughput genotyping and sequencing approaches, current guidelines, implementation challenges and evolving ethical quandaries.

PURPOSE: Expanded genetic carrier screening (ECS) is an important part of gynecological practice and preconception planning. We evaluated the awareness and attitudes among women regarding ECS and factors that may influence decision-making in a family planning context. METHODS: A 32-question survey in an academic university practice was given to 521 women who were either currently pregnant (n = 108), undergoing gynecologic care who were considering future fertility (n = 308), and considering or receiving fertility treatment (n = 105). Data are reported descriptively. RESULTS: Forty-seven percent (n = 246) of patients were aware of ECS. Though most reported feeling positive or neutral towards ECS, 51% (n = 263) reported no desire for testing. Fifty-eight percent (n = 303) felt it beneficial to know their carrier status, and 55% (n = 257) said it was their responsibility to undergo testing. Those considering future fertility were found to have a more positive attitude towards ECS (51.4%) than those considering or receiving fertility treatment (34%). For positive carriers of a genetic disorder, 228 (49%) of patients would proceed with having their partner screened, 58 (13%) would undergo prenatal screening only and 12 (2.6%) would continue with vitro fertilization (IVF). Related to cost for ECS, 53.5% (n = 191) would be willing to pay at least $50–100 for testing, while 29% (n = 146) would not pay anything out of pocket. CONCLUSIONS: Despite patients’ beliefs that it would be beneficial and their responsibility to undergo carrier status testing, the majority reported no desire for ECS and many were unwilling to pay out of pocket. Further education is necessary to reconcile the gap between technology and patient decision-making.

Cervical stenosis is a challenging clinical entity that requires prompt identification and management in order to avoid iatrogenic injury at the time of endocervical canal cannulation.The aim of this study was to identify cervical stenosis and discuss associated etiologies, risk factors, and review medical and surgical approaches for overcoming cervical stenosis.Computerized searches of MEDLINE and PubMed were conducted using the key words "cervix", "cervical stenosis," "embryo transfer," "hysteroscopy complications," "misoprostol," and "ultrasound." References from identified sources were manually searched to allow for a thorough review. Data from relevant sources were compiled to create this review.Transcervical access to the uterine cavity is frequently required for procedures such as hysteroscopy, dilation and curettage, endometrial biopsy, sonohysterogram, hysterosalpingogram, intrauterine insemination, embryo transfer in those undergoing in vitro fertilization, and insertion of intrauterine devices. These procedures can become complicated when difficult cannulation of the endocervical canal is encountered. Management strategies include preprocedural use of cervical-ripening agents or osmotic dilators, ultrasound guidance, no-touch vaginoscopy, manual dilatation, and hysteroscopic resection of the obstructed endocervical canal.Cervical stenosis is associated with iatrogenic complications that can result in significant patient morbidity. In patients undergoing in vitro fertilization, difficult embryo transfer is associated with lower pregnancy rates. The clinician should carefully consider the patient's menopausal status, risk factors, and symptoms in order to anticipate difficult navigation of the endocervical canal. Various medical and surgical management strategies, including hysteroscopic resection, can be used to overcome the stenotic cervix.

Objective With a high incidence of insulin resistance, central obesity and dyslipidemia, women with polycystic ovary syndrome are susceptible to metabolic syndrome (MetS). Our objective was to explore whether metabolic syndrome had an effect on overall female fertility and in vitro fertilization outcomes in infertile women with polycystic ovary syndrome. Study Design This was a secondary analysis of a multicenter randomized trial in 1508 women with polycystic ovary syndrome, which was originally designed to compare the live birth rate after fresh-embryo transfer vs frozen embryo transfer (Frefro-PCOS). At baseline, metabolic parameters, including body mass index, waist and hip circumference, blood pressure, lipid profile, fasting, and 2 hour glucose and insulin levels after a 75 g oral glucose tolerance test were measured. All subjects were divided into a metabolic syndrome group (metabolic syndrome) and absence of metabolic syndrome group (nonmetabolic syndrome) according to diagnostic criteria. Descriptive statistics and logistic regression models tested the association between metabolic syndrome and overall fertility and in vitro fertilization cycle stimulation characteristics and clinical outcomes. Results Metabolic syndrome was identified in 410 of 1508 infertile women with polycystic ovary syndrome (27.2%). Patients with metabolic syndrome had longer infertility duration (4.0 ± 2.2 vs 3.7 ± 2.2, P = .004) compared with those without metabolic syndrome. During ovarian stimulation, those with metabolic syndrome required significantly higher and longer doses of gonadotropin and had lower peak estradiol level, fewer retrieved oocytes, available embryos, a lower oocyte utilization rate, and ovarian hyperstimulation syndrome than those with nonmetabolic syndrome. The cumulative live birth rate did not show a significant between-group difference (57.8% vs 62.2%, P = .119). Multivariate logistic regression analysis adjusted for age, duration of infertility, body mass index, thyroid-stimulating hormone, metabolic syndrome group, homeostatic model assessment of insulin resistance, metformin utilization, number of available embryos, and embryos transferred showed that the number of embryos transferred and the number of available embryos were positively but metabolic syndrome negatively associated with the cumulative live birth rate (odds ratio, 2.18, 1.10, and 0.70, respectively, P Conclusion Women with polycystic ovary syndrome with metabolic syndrome have a negative impact from female fecundity, and this suggests an adverse effect on in vitro fertilization cycle stimulation characteristics and clinical outcomes.

PURPOSE: Expanded carrier screening (ECS) is an available component of preconception and prenatal care. There is complexity around offering, administering, and following-up test results. The goal of this study is to evaluate current physicians’ utilization and attitudes towards ECS in current practice. METHODS: This was a prospective qualitative survey study. A 32-question electronic survey was distributed during a 1-year period to obstetricians-gynecologists who were identified using a Qualtrics listserv database. RESULTS: While more than 90% of physicians offered ethnic-based carrier screening (CS), ECS was offered significantly less (2010, 20.6%, and 2016, 27.1%). Physicians who were not fellowship-trained in reproductive endocrinology and infertility (REI) preferred ethnic-based carrier screening (95.9 vs 16.8%; P

The practice of ovulation induction often falls to the reproductive endocrinology and infertility specialist. However, attitudes toward the evaluation and treatment of infertility has shifted among general obstetrician-gynecologists (OB-GYN). This review discusses the underlying scientific basis of anovulation and clinical guidelines regarding the use of different medications for the purpose of promoting follicular recruitment and ovulation for the general OB-GYN.

Objective To study patient and provider feedback on how a multimedia platform (EngagedMD) helps patients to understand the risks and consequences of in vitro fertilization (IVF), ovulation induction (OI), and intrauterine insemination (IUI) treatments and the impact of the informed consent process. Design Prospective survey study. Setting IVF units in the United States. Patient(s) Six-thousand three-hundred and thirty-three patients who viewed the multimedia platform before IVF or OI-IUI treatment at 13 U.S. IVF centers and 128 providers. Intervention(s) Quantitative survey with 17 questions. Main Outcome Measure(s) Assessment of the impact of a multimedia platform on patient anxiety, comprehension, and satisfaction and provider/nurse feedback related to the informed consent process. Result(s) The survey was completed by 3,097 respondents (66% IVF treatment; 34% OI-IUI treatment) and 44 providers. Overall, 93% felt the media platform was intuitive, and 90% and 95% felt it had appropriate duration and detail, respectively. Most agreed/strongly agreed it better prepared them to consent (88%), increased their comfort in pursuing treatment (77%) and increased their satisfaction with their care (83%). Compared with the OI-IUI group, statistically significantly more participants who viewed the IVF media platform strongly agreed that the comprehension questions reinforced key concepts (47% vs. 40%), educated them about treatment risks (55% vs. 44%), helped them ask providers informed questions (45% vs. 36%), and better prepared them to sign consent forms (46% vs. 37%). Overall, 63% of providers felt that the media platform improved patient learning, made patients more accountable, and standardized information dissemination. Conclusion(s) The EngagedMD media platform improves patient knowledge, satisfaction, and control over medical decision making and better prepares patients to give informed consent. Furthermore, it is well-liked by providers and is easily implemented.

Objectives To demonstrate a minimally invasive approach and management in three different types of Robert's uterus. Design Video presentation of surgical and ultrasound techniques. Setting University hospital and two private centers. Patients Patients with three types of Robert's uterus; a rare form of septate uterus consisting of non-communicating hemicavity, a contralateral unicornuate uterine cavity in a single uterine body with normal fundus: with large hematometra in the blind hemi-cavity and acute pelvic pain; with an inactive blind hemi-cavity without hematometra and recurrent miscarriages; and with small hematometra in the blind hemi-cavity. Interventions Three-dimensional ultrasound with saline infusion sonohysterography and automatic volume calculation software (SonoHySteroAVC) were used for differential diagnosis and surgical planning. Transrectally guided hysteroscopic metroplasty, a incision of myometrium between two parts of cavities by resectoscope and Collin's electrode, were performed and recorded. Sequentional balloon anti-adhesion therapy and three-dimensional ultrasound with saline infusion sonohysterography with SonoHysteroAVC were used in post-operative management. Main outcome measures Pre-, intra- and postoperative findings regarding uterine morphology, feasibility of surgery and anatomical and clinical outcomes. Results A successful unification of non-communicating and communicating uterine cavity parts during surgery, better shape and several times higher volume of uterine cavity, and total elimination of pain associated with obstruction after healing period were recorded. Conclusions Three-dimensional ultrasound techniques seem to be the best tool for complex pre- and postoperative management of Robert's uterus. Minimally invasive ultrasound-guided hysteroscopic metroplasty should be considered as the first choice of treatment because of the potential for normalization of uterine morphology and function.

Objectives To demonstrate the hymen-sparing management of a blind hemivagina in obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome with the use of transrectal ultrasound (TRUS)–guided vaginoscopic septoplasty supported by pre- and postoperative diagnostics with the use of a novel ultrasound technique: 3-dimensional saline-solution infusion contrast sonovaginocervicography (3D-SVC) with virtual speculoscopy. Design Video presentation of surgical and ultrasound techniques. Setting University hospital and two private centers. Patient(s) We are demonstrating four cases with blind hemivagina as a component of OHVIRA syndrome and varying level and features of obstruction including: 1) hemihydrocolpos; 2) hemihematocolpos; 3) "old blood" deposits in small hemivagina; and 4) narrow hymenal opening. Interventions(s) The patients were diagnosed preoperatively by means of 3D-SVC with the use of TRUS. Surgery was planned according to available data from ultrasound and 3D-SVC, and the place of incision of the vaginal septum and blinded hemivagina with cervix were performed with the use of TRUS guidance. Wide septal incision was performed with the use of a monopolar or bipolar resectoscope with needle Collin electrode, and after incision the occult second of double cervix or part of septate cervix was visualized, and the septum was excised with the use of a loop electrode. In narrow hymenal opening, a small diagnostic sheath was used for wide septal incision. Anatomic results in the vagina were assessed with the use of 3D-SVC 2 months after surgery. Main Outcome Measure(s) Agreement between imaging from preoperative diagnostics with the use of 3D-SVC and intraoperative findings, and anatomic (hymenal integrity, obstruction, status of vagina and cervix) and clinical outcomes (pain). Result(s) In these four cases, 3D-SVC accurately recognized the morphology of blind hemivagina, oblique vaginal septa, and double or septate cervix. Successful minimally invasive wide septoplasty with preservation of hymen were performed with the use of hysteroscope and TRUS guidance. Concomitant laparoscopy was performed if endometriosis and hematosalpinx were present. No peri- or late postoperative complications occurred. Patients were discharged within 3 hours or within 12 hours in case of laparoscopy. Anatomic results were optimal (lack of septum) or suboptimal (wide opening) after septum resection and incision, respectively, without recurrence of obstruction according to 3D-SVC. Pain was not noticed 2 months after the primary surgery. Conclusion(s) 3D-SVC is a useful and accurate technique in diagnosis, surgery planning, and postoperative assessment in women with blind hemivagina and intact hymen. TRUS-guided vaginoscopic septoplasty is a reasonable alternative to traditional vaginal surgery and allows hymen preservation.