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Outpatient procedures and flexible staffing models have become prevalent within the ambulatory surgical and procedural spaces of reproductive endocrinology and infertility practice. High volumes of outpatients are treated daily by rotating nurses, surgeons, and anesthesia staff, often with the added layer of trainees present. "Teaming" can allow stable units and ad hoc groups to partner better for enhanced efficiency, effectiveness, and patient experience in routine procedural activities. These skills then can be parlayed into the rare moments of crisis to improve safety outcomes. Teaming concepts, applied in routine and acute scenarios, can optimize clinical operations, patient experience, and outcomes in our reproductive endocrinology and infertility ambulatory procedural and surgical spaces.

There are many proposed classification systems for müllerian anomalies. The American Fertility Society (AFS) Classification from 1988 has been the most recognized and utilized. The advantages of this iconic classification include its simplicity, recognizability, and correlation with clinical pregnancy outcomes. However, the AFS classification has been criticized for its focus primarily on uterine anomalies, with exclusion of those of the vagina and cervix, its lack of clear diagnostic criteria, and its inability to classify complex aberrations. Despite this classification and others, the wide range of müllerian anomalies is still largely unknown and confusing to many providers. Consequently, müllerian anomalies may go undiagnosed for extended periods, receive inappropriate or inadequate surgical interventions, and result in persistent issues such as pain or loss of reproductive function. The American Society for Reproductive Medicine Task Force on Müllerian Anomalies Classification was formed and charged with designing a new classification. The Task Force set goals for a new classification and chose to base it on the iconic AFS classification from 1988 because of its simplicity and recognizability, while expanding and updating it to include all categories of anomalies. In addition, this was recognized as an opportunity to raise awareness of this area of medicine, educate providers and learners, and promote patient advocacy. Presented here is the new American Society for Reproductive Medicine Müllerian Anomalies Classification 2021.

In this case, pre-operative planning is the key component to all three groups' thought process where the MRI findings are suggestive of an atypical leiomyoma. MIGS and GYN-Onc both recommend an endometrial biopsy to evaluate for leiomyosarcoma. Despite this being a very large transmural fibroid involving the endometrial cavity with suspicious MRI findings, all specialties agree that a laparoscopic approach was appropriate, with MIGS and REI focusing on the inevitability of needing to repair the endometrial defect and avoiding intrauterine adhesions. Further, in view of the patient's advanced age, both MIGS and REI recommend IVF and embryo banking shortly post-operatively now that her ovaries should be accessible and given that her uterus needs time to heal.

To assess physician perceptions regarding weight-related communication, quality of care, and bias in obstetrics-gynecology (OBGYN) and family physician (FP) practices.A cross-sectional survey study based on a convenient sampling of OBGYN and FP was conducted. Physicians completed a 40-question survey assessing perceived obesity management and weight bias in caring for female patients with body mass index ≥25kg/mReponses from 51 physicians (25 OBGYN and 26 FP) were received. There was no difference between specialties in satisfaction with care or level of confidence in treating patients with obesity. However, OBGYNs reported more negative perceptions of patients with obesity (mean score 19.2±3.3 vs. 15.0±4.0, p0.001) and greater weight bias (11.8±2.0 vs. 9.7±2.5, p0.01) compared to FPs. OBGYNs were also more likely to expect less favorable treatment outcomes (13.3±2.5 vs. 15.5±2.8. p0.01). Physicians between 31-50 years old displayed a significantly higher perception of weight bias in their profession when compared to the reference 21-30year olds, and for each unit increase in self-reported BMI there was a 0.18 average increase in the composite score for perceived weight bias.OBGYN physicians reported significantly higher levels of weight bias than FP physicians, indicating a need for improved education in OBGYN training.N/A.

Cryopreservation of embryos has become an essential aspect of assisted reproductive technology, allowing for greater clinical efficiency and increased safety. However, the increasing numbers of cryopreserved embryos in clinics worldwide pose challenges to all stakeholders with respect to the disposition and donation of one's embryos when the gamete providers have completed their family building. The following series of articles provides an update of outcomes, challenges, and controversies related to embryo disposition. The first article describes the current and future medical potential of donated embryos for human stem cell research and other applications. Second, the practice of embryo donation to other intended parent(s) is summarized, and a review of the literature on child outcomes is presented. Third, the logistics and programmatic steps in managing embryos designated for disposal are discussed, including the option for compassionate transfer. Fourth, legal experts summarize precedent setting cases in the United States and the current legal environment of unused embryo management in the setting of the recent Supreme Court decision in Dobbs v. Jackson Women's Health Organization.

Importance As health care providers are increasingly motivated to perform office procedures, there is marginal training and attention related to crisis management (CM). Objective We review the CM in office gynecology and illustrate the value of applying the STOP (stop, think, observe, plan) mental framework to acute management of office hysteroscopy complications. Evidence acquisition We performed a literature review on crisis management in gynecology. Results Concepts of team leadership, simulation training, awareness of human error, and panic control are implemented in CM. Conclusions Health care providers need to be cognizant of the importance of CM for optimizing patient safety and quality improvement and consider its application on office-based procedures. Relevance Crisis management has become increasingly relevant in the outpatient setting, seeking to better equip physicians with the skills to manage adverse outcomes while performing office-based procedures.

Objective To objectively grade all video publications in Fertility and Sterility during the years 2017–2019 and compile a list of the top 10 surgical videos. Design Descriptive presentation of the 10 highest-scoring video publications from Fertility and Sterility in the years 2017–2019. Setting Not applicable. Patient(s)/Animal(s) Not applicable. Intervention(s) All 4 authors acted as independent reviewers of all video publications. A standardized scoring method was used to score all videos. Main Outcome Measure(s) Up to 5 points were awarded for each of the following categories: Scientific merit or clinical relevance of the topic; clarity of video; use of innovative surgical technique; and video editing or use of marking tools on the video to highlight important features or surgical landmarks. This allowed a maximum score of 20 for each video. The number of YouTube views and likes were used as a tiebreaker if ≥2 videos scored similarly. The interclass coefficient from a 2-way random effects model was calculated to assess for agreement between the 4 independent reviewers. Result(s) A total of 40 videos were published in Fertility and Sterility during the years 2017–2019. After averaging scores from all 4 reviewers, a top 10 list was created ( Table ). Only 2 videos (number 6 and 7 spots) had the same average score, and the number of YouTube views and likes were used as a tiebreaker. The overall interclass coefficient for the 4 reviewers was 0.68 (95% confidence interval, 0.52–0.76). Conclusion(s) An overall substantial agreement was noted between the 4 reviewers. Ten videos reigned supreme from a list of very competitive publications that had already undergone the peer review process. The subject matter of these videos ranged from complex surgical procedures, including uterus transplantation and use of a biologic graft for neovaginoplasty, to common procedures like hysteroscopic removal of intrauterine devices during pregnancy and approaches to the stenotic cervix.

In today's ever-changing business climate, reproductive health specialists are realizing that financial fluency is key to growing and maintaining a successful practice. Although financial fundamentals such as accounting may seem complex, both academic and private practice reproductive specialists who understand these topics can benefit in making business decisions for their practices. We describe the key financial fundamentals that reproductive health specialists should know, including basic concepts of finance and accounting, payments and receivables, capital budgeting, and business planning, and interpreting balance sheets, income statements, and cash-flow statements.

Importance Many adolescents and young adults diagnosed with Hodgkin lymphoma (HL) experience disease progression requiring high-dose alkylating salvage therapy, which often results in permanent infertility. Objective The aim of this report is to discuss fertility preservation options in female patients with consideration of chemotherapeutic agents in HL. Evidence acquisition An electronic literature review was performed utilizing a combination of the terms "Hodgkin lymphoma," "fertility preservation," "ovarian tissue cryopreservation," "oocyte cryopreservation," "embryo cryopreservation," and "gonadotropin-releasing hormone agonist." References and data from identified sources were searched and compiled to complete this review. Results Initial treatment of HL is often nonsterilizing; however, salvage therapy and conditioning for stem cell transplantation confer significant gonadotoxicity. Established fertility preservation options for pubertal females include embryo cryopreservation and oocyte cryopreservation. These options are contraindicated within 6 months of receipt of chemotherapy. Ovarian tissue cryopreservation is an option for patients who require salvage therapy within 6 months of first-line therapy. Conclusions Timing and choice of fertility preservation techniques depends on planned first-line chemotherapy and response to treatment. In patients initially treated with low-risk chemotherapy, it is reasonable to defer invasive fertility techniques until treatment failure; however, upfront fertility preservation should be considered in patients planning to undergo primary treatment with high-risk therapy.

Objective To assess if a surgical boot camp improves laparoscopic skill among reproduction endocrinology and infertility (REI) fellows and increases fellow desire to incorporate surgical skills into practice and to examine whether fellowship in vitro fertilization (IVF) volume correlates with surgical efficiency. Design Prospective evaluation. Setting Simulation Center. Patient(s) Forty REI fellows. Intervention(s) Fellows were timed before and after training in laparoscopic suturing and knot tying and while using virtual simulators. Fellows were surveyed before boot camp on prior experience with IVF and reproductive surgery, and immediately and 1 month after boot camp on their desire to incorporate surgical skills into practice. Main Outcome Measure(s) Efficiency of laparoscopic suturing and knot tying before and after boot camp; likelihood and persistence of incorporating surgical skills into practice immediately and 1 month after boot camp; and correlation between fellowship IVF volume and fellow surgical efficiency. Result(s) Fellows experienced significant improvement in laparoscopic suturing (44 sec), intracorporeal knot tying (82 sec), and extracorporeal knot tying (71 sec). Fellows reported being more likely to incorporate operative hysteroscopy (89%), operative laparoscopy (87%), and laparoscopic suturing (84%) into practice immediately following boot camp with no difference 1 month later. Fifty-four percent of fellows reported being more likely to perform robotic surgery after the boot camp, increasing to 70% 1 month later. There were weak correlations between IVF case volume and efficiency in laparoscopic suturing or hysteroscopic polypectomy (Spearman correlation coefficients, -0.14 and -0.03). Conclusion(s) An intensive surgical boot camp enhances surgical skill among REI fellows.

Endometriosis is a major health concern in the adolescent population and significantly impacts daily physical and psychosocial functioning. Endometriosis can have differing presentations in this population, and the diagnosis often involves long delays and multiple visits to specialists.The aim of this review is to discuss adolescent endometriosis, factors specific to this population, accurate diagnosis, and evidence-based surgical and medical management.Computerized searches on the topic of endometriosis and adolescent endometriosis were completed. References from identified sources were then searched manually to allow for a thorough review. Data from relevant sources were synthesized to create the review.The literature supports endometriosis as a frequent cause of secondary dysmenorrhea. The characteristics of adolescents with endometriosis are shown to differ from those of adults. Initial medical therapy includes nonsteroidal anti-inflammatory drugs and combined hormonal contraceptives, but laparoscopy does have a role in the adolescent population, particularly those who have inadequate response to these treatments. Adolescent endometriosis may have a different appearance and be of all stages. Medical therapies are similar to that of the adult population; however, the benefits of medical and surgical management must be tailored to the adolescent patient.Adolescent endometriosis is likely a more prevalent cause of dysmenorrhea than currently appreciated. A high index of suspicion combined with recognition of risk factors and history-based markers of endometriosis may help identify adolescent endometriosis earlier and avoid delays in diagnosis. Expert opinion supports earlier laparoscopic evaluation in patients with symptoms unresponsive to oral medications, those who have failed initial medical therapy, or those who have evidence of deeply invasive disease, such as an endometrioma. Surgeons should be familiar with the unique appearance of lesions in the adolescent and understand the evidence as it relates to surgical therapy. Postoperative medical management is generally advocated by many, although the efficacy remains unclear at present.

Background: While the incidence of cancer continues to rise worldwide, mortality rates have decreased due to advancements in treatment regimens. Many pre-adolescent and reproductive age cancer survivors experience chronic health conditions, including premature ovarian insufficiency (POI) and failure (POF) and greater than 75% of reproductive age cancer survivors report the desire to parent in the future. Fertility preservation counseling and initiation of fertility preservation treatments are an important part of the management of these patients, but its utilization in the Chinese medical system is unclear. Objectives: This study aimed to investigate attitudes and gaps of knowledge regarding fertility preservation among medical and surgical oncology healthcare professionals (HCPs) and breast cancer patients in Chinese academic settings. Materials and Methods: An online questionnaire assessing participants’ demographics, attitudes knowledge, and utilization regarding oncofertility services was designed and distributed to HCPs and breast cancer patients in an academic teaching setting in Shanghai. Results: Surveys were sent to all breast cancer patients of 6 collaborative hospitals and medical and surgical oncology HCPs in the Shanghai district via Wechar-based questionnaire program. To date, 61 HCPs and 52 patients responded to the survey. Sixty-nine percent (42) of HCPs compared to 19.2% (10) of patients were familiar with the term “oncofertility”. Overall, 80.3% (49) of HCPs reported positive attitudes about oncofertility and discussing fertility-sparing options compared to 80.3% (48), 75.4% (41), and 55.7% (34) of their reproductive, adolescent, and pre-adolescent age patients. 40 out of 43 HCPs (93%) stated that they have initiated a discussion about oncofertility options, while only 30.8% of patients (4/13, p Conclusion: Preliminary results suggest that while the majority of academic oncologic Chinese HCPs are aware of oncofertility, their knowledge of eligibility and costs of fertility preservation services is limited. Furthermore, a significant knowledge gap exists between HCPs and breast cancer patients. This may represent ineffective communication or lack of patient comprehension, resulting in severe under-utilization of oncofertility services. Continued education and raised awareness are urgently needed to optimize care. Citation Format: Ewelina Maria Biskup, Xin Zhaochen, Leslie C Appiah, Yun Sun, Yan Lu, Hangwei Zhang, Steven R. Lindheim. Oncofertility awareness and attitudes among health care providers and patients in a Chinese academic setting: Preliminary results [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P1-17-05.

Background: Unlike female breast cancer (fBC), male breast cancer (mBC) holds clinicopathological, radiological, and genetic differences including histologic grade that is often not correlated with clinical outcomes and most being ER/PR positive and Her2 negative. Recently, PGC-1α (hypoxia-related protein, expressed preferentially in cancer cells to enhance oxidative phosphorylation, mitochondrial biogenesis and functional motility/metastasogenesis) has been identified as a prognostic marker for fBC, but its value and impact in mBC have not been studied. Our objective was to assess the utility of PGC-1α as a prognostic marker and an indicator for disease-free survival (DFS) in mBC. Materials & Methods: 7000 female and 23 male patients de novo diagnosed with breast cancer, at the Breast Center, Yangpu Hospital, Tongji University School of Medicine, as well as 30 males with lesions that were non-tumorous (non-mBC, controls) were included prospectively between September 2012 and August 2018. Propensity Score Matching was used to balance confounding factors. Results: Mean PGC-1α plasma levels were significantly higher in fBC compared to mBC cohorts (248.9 ng/dl (95% CI 242.9-254.8) vs 224.9 ng/dl (95% CI 202.9-246.9, P =0.040), though after propensity matching, no differences were noted (225.7 ng/dl (95% CI 202.5-248.7) vs 204.5 ng/dl (95% CI 194.3-214.8, P=0.07). In a total, 681 (658 females and 23 males) out of 723 patients for a median of 43 months (range of 3 to 82 months). By the end of follow-up period, 16.6% (109/658) female patients and 21.7% (5/23, p-NS) male patients had local recurrence and/ or metastasis, 5.6% (38) died, 48.5% (33) due to breast cancer (4.7% (31) females and 8.7% (2) males. In unmatched samples, there were no differences in DFS between fBC and mBC (P = 0.439, log-rank test). After dichotomous division of unmatched patient samples into two groups by median of PGC-1α plasma levels 246.8 ng/dl, all patients with high PGC- 1α plasma levels (>246.813 ng/dl) had a higher risk of recurrence than those with low PGC-1α plasma levels (P= 0.008). When calculated only for unmatched female patients, the results were similar: patients with high PGC- 1α plasma levels (>246.813 ng/dl) had a higher risk of recurrence than those with low PGC-1α plasma levels (P= 0.016). However, in matched samples, 6.4% (5/78) of females and 22.7% (5/22) males had recurrences and the male DFS was significantly poorer than in women (P < 0.033) despite similar baseline clinicopathologic characteristics. After the dichotomous division of matched patient samples into two groups by median of PGC-1α plasma levels of 211.5 ng/dl, 47.4% (37/78) female and 59.1% (13/22) male patients showed high PGC-1α plasma levels (P = 0.334). Despite comparable clinicopathological features, patients with lower PGC- 1α plasma levels ( Conclusion: PGC-1α appears to be an independent marker of poor prognosis and more aggressive cancer characteristics in mBC, with a stronger prognostic value than in fBC. It may represent a non-invasive, innovative option to identify high-risk mBC individuals, predict the outcome, monitor treatment and screen for disease recurrence. Therefore, the marker can assist to determine, tailor and alternate therapy course for the highly fatal disease of mBC, where guidelines are still missing and most therapeutic options are transferred from fBC. Furthermore, inhibition of PGC-1α pathways might be a promising antitumor management option. Citation Format: Ewelina Maria Biskup, Fengfeng Cai, Steven Lindheim. Clinicopathological and prognostic significance of preoperative PGC-1alpha plasma levels in male breast cancer patients [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P4-17-09.

Follitropin-Δ, a new recombinant follicle stimulation hormone, uses a fixed daily dose producing a predictable ovarian response while using less gonadotropins compared to follitropin-α. We report clinical outcomes comparing each in the routine IVF setting and further compare qualified to disqualified subjects based on previous randomized controlled trial (RCT) inclusion criteria.Retrospective analysis of all cycles performed by a single provider between January 2020 to January 2021. All IVF cycles without patient inclusion-exclusion criteria were considered for the analysis. Clinical outcomes in two groups (follitropin-Δ vs follitropin-α ± 75 IU human menopausal gonadotropin (hMG) in expected poor responders) were compared. In addition, comparisons were made between qualified versus disqualified subgroups.No differences in baseline demographics, number of MII oocytes, fertilization/MII oocyte, percent of good quality embryos were noted. Compared to those using follitropin-α, follitropin-Δ resulted in lower daily (170 vs 211 IU/d, p = 0.002) and total Gn used (1739 vs 2194 IU, p = 0.003). Optimal range response (8-14 oocytes) (22/44 [50 %] vs 78/203 [38.6 %]; p = 0.10) and fresh (fCP) and cumulative clinical pregnancy (cCP) rates per transfer (29.5 % vs 24.1 % and 35 % vs 25.1 %, p = 0.08) were similar between groups. Based on previous RCTs, those who would have qualified compared to those who would have disqualified, patients using follitropin-Δ were just as likely to have an optimal oocyte response (qualified: 48 % vs disqualified: 57.1 %) and resulted in similar cCP (41.4 % vs 25 %, p-0.23).While follitropin-Δ requires less daily and total dosing compared to follitropin-α, optimal range of retrieved oocytes and clinical outcomes appear to be comparable. Using RCT inclusion criteria, similar findings were noted in those who would have qualified compared to disqualified patients.

To objectively grade all video publications in Fertility and Sterility during 2020 and compile a list of the top 5 surgical videos.Descriptive presentation of the 5 highest scoring video publications from Fertility and Sterility in 2020 SETTING: Not applicable.Not applicable.J.F., Z.K., J.P.P., and S.R.L. acted as independent reviewers of all video publications. A standardized scoring method was used to score all videos.Up to 5 points were awarded for each of the following categories: scientific merit or clinical relevance of the topic, the clarity of the video, the use of innovative surgical technique, and video editing or the use of marking tools on the video to highlight the important features or surgical landmarks. This allowed a maximum score of 20 for each video. The numbers of YouTube views and likes were used as a tiebreaker if ≥2 videos scored similarly. The interclass coefficient from a 2-way random-effects model was calculated to assess for agreement between the 4 independent reviewers.A total of 20 videos were published in Fertility and Sterility during 2020. After averaging scores from all 4 reviewers, a list of top 5 videos was created (Table 1). The overall interclass coefficient for the 4 reviews was 0.77 (95% confidence interval, 0.56-0.89).An overall substantial agreement was noted among the 4 reviewers. Five videos particularly stood out within the competitive peer reviewed publications. The subject matter of these videos ranged from complex surgical procedures, including transvaginal natural orifice surgery and advanced endometriosis to basic embryology laboratory topics that covered trophectoderm biopsy and novel intracytoplasmic sperm injection techniques.

To assess the impact of an interactive multimedia educational platform and consent process on patient comprehension and anxiety state compared with standard fertility counseling and paper consents in patients undergoing ovulation induction-intrauterine insemination (OI-IUI) or in vitro fertilization (IVF) throughout their first infertility treatment cycle.Prospective randomized controlled trial.A university-affiliated reproductive endocrinology and infertility clinic.Patients aged 18-45 years undergoing their first OI-IUI or IVF cycle.An interactive multimedia educational and consent platform (EngagedMD-[EMD]) before and during the first infertility treatment, in addition to standard fertility counseling by the physician and nurse team.Three survey time points: before the start of treatment (T1), at the start of treatment (T2), and at the completion of the treatment cycle (IUI or oocyte retrieval; T3). The main outcome measure was the comprehension score on a 15-question assessment administered at 2 times points (T2 and T3). The anxiety state at all 3 time points was assessed using a modified Spielberger State-Trait Anxiety Inventory score.Eighty-six patients were included: 21 in the OI-IUI conventional (i.e., standard fertility counseling group) group, 22 in the IVF conventional group, 21 in the OI-IUI EMD group, and 22 in the IVF EMD group. Overall, the average number correct on the 15-question comprehension assessment was significantly higher in the EMD groups than in the conventional groups at T2 (EMD: 13.2 ± 1.8 vs. conventional: 11.7 ± 1.8) but not at T3. For those undergoing IVF, the average number correct was significantly higher at both T2 and T3 in the EMD vs. the conventional group (T2: 14.1 ± 1.3 vs. 12.4 ± 1.8; T3: 14.1 ± 1.7 vs. 12.5 ± 1.5). The average State-Trait Anxiety Inventory scores at each time point were similar between the EMD and conventional groups for both OI-IUI and IVF groups. Age ≤35 years and IVF treatment were significant predictors of increased State-Trait Anxiety Inventory scores.The addition of an interactive multimedia educational platform significantly improved patient comprehension at the initiation of OI-IUI and IVF cycles for patients undergoing fertility treatment for the first time. Those undergoing IVF with access to EMD had sustained, improved comprehension at the end of their treatment. The supplementation of a multimedia platform did not alter anxiety throughout the treatment. Younger patients undergoing IVF may benefit from increased psychological resources.NCT03962257.

Gestational surrogacy can provide an effective family-building method for women whose uterus is absent or dysfunctional and with contraindications to pregnancy, single men, and same-sex male couples. Over the past 30 years, gestational surrogacy cases have represented a growing percentage of third-party reproduction cases, both in the United States and internationally. The following series of articles provides a summary of current topics in optimizing GS arrangements. They focus on medical and psychological screening; psychosocial adjustment of carriers, children, and their families; legal considerations with precedent-setting cases that every clinician should know; and an international overview of cross-border surrogacy.

This retrospective study surveyed decision-making and challenges among 78 gay cisgender male couples utilizing in-vitro fertilization (IVF) and a gestational carrier. While most couples (67.1%) found the decision to actively pursue fertility treatment ‘not difficult’, 32.9% felt that it was ‘somewhat difficult’ or ‘very or extremely difficult’. Almost 30% of couples had not undertaken financial planning for treatment, which introduced delays of >2 years for 25.3% of participants. Conceiving twins was ‘important to very important’ in 52.3% of couples, and 84.2% of couples chose to transfer two embryos to ‘increase the odds’ or reach an ideal family size in a single attempt despite increased complications with multiple pregnancies. Paternal leave was granted for one partner in 47.3% of couples, and for both partners in 43.2% of couples. One-third of couples reported experiencing discrimination, prompting a partner to seek employment, and 38% changed jobs or careers. For 80.3% of couples, the estimated cost exceeded US$100,000. Couples where one partner was aged >50 years were significantly more likely to find the decision to actively pursue fertility treatment ‘very or extremely difficult’ (28.6%), and less likely to agree on becoming parents (64.3%). Gay male couples undergoing assisted reproduction face challenges regarding decision-making, lack of infertility benefits and discrimination, which appear to be influenced by age and country of residence. Policy and educational changes are needed, including broader fertility benefits, more egalitarian parental leave, and greater awareness of risks inherent to multiple gestation. Keywords: gay male couples, gestational surrogacy, IVF, cross-border reproductive care

To estimate the differences in frequency of diagnosis of septate uterus using three different definitions and determine whether these differences are significant in clinical practice, and to examine the association between diagnosis of septate uterus, using each of the three definitions, and infertility and/or previous miscarriage as well as the cost of allocation to surgery.This was a secondary analysis of data from a prospective study of 261 consecutive women of reproductive age attending a private clinic focused on the diagnosis and treatment of congenital uterine malformations. Reanalysis of the datasets was performed according to three different means of defining septate uterus: following the recommendations of the American Society for Reproductive Medicine (ASRM), a 2016 update of those of the American Fertility Society from 1988 (ASRM-2016: internal fundal indentation depth ≥ 1.5 cm, angle of internal indentation 90° and external indentation depth 1 cm); following the recommendations of the European Society of Human Reproduction and Embryology/European Society for Gynaecological Endoscopy (ESHRE/ESGE), published in 2013 and reaffirmed in 2016 (ESHRE/ESGE-2016: internal fundal/uterine indentation depth 50% of uterine-wall thickness and external indentation depth 50% of uterine-wall thickness, with uterine-wall thickness measured above interostial/intercornual line); and using a definition published last year which was based on the decision made most often by a group of experts (Congenital Uterine Malformation by Experts; CUME) (CUME-2018: internal fundal indentation depth ≥ 1 cm and external fundal indentation depth 1 cm). We compared the rate of diagnosis of septate uterus using each of these three definitions and, for each, we estimated the association between the diagnosis and infertility and/or previous miscarriage, and anticipated the costs associated with their implementation using a guesstimation method.Although 32.6% (85/261) of the subjects met the criteria for one of the three definitions of septate uterus, only 2.7% (7/261) of them were defined as having septate uterus according to all three definitions. We diagnosed significantly more cases of septate uterus using ESHRE/ESGE-2016 than using ASRM-2016 (31% vs 5%, relative risk (RR) = 6.7, P 0.0001) or CUME-2018 (31% vs 12%, RR = 2.6, P 0.0001) criteria. We also observed frequent cases that could not be classified definitively by ASRM-2016 (gray zone: neither normal/arcuate nor septate; 6.5%). There were no significant differences (P 0.05) in the prevalence of septate uterus in women with vs those without infertility according to ASRM-2016 (5% vs 4%), ESHRE/ESGE-2016 (35% vs 28%) or CUME-2018 (11% vs 12%). Septate uterus was diagnosed significantly more frequently in women with vs those without previous miscarriage according to ASRM-2016 (11% vs 3%; P = 0.04) and CUME-2018 (22 vs 10%; P = 0.04), but not according to ESHRE/ESGE-2016 (42% vs 28%; P = 0.8) criteria. Our calculations showed that global costs to the healthcare system would be highly dependent on the criteria used in the clinical setting to define septate uterus, with the costs associated with the ESHRE/ESGE-2016 definition potentially being an extra US$ 100-200 billion over 5 years in comparison to ASRM-2016 and CUME-2018 definitions.The prevalence of septate uterus according to ESHRE/ESGE-2016, ASRM-2016 and CUME-2018 definitions differs considerably. An important limitation of the ASRM classification, which needs to be addressed, is the high proportion of unclassifiable cases originally named, by us, the 'gray zone'. The high rate of overdiagnosis of septate uterus according to ESHRE/ESGE-2016 may lead to unnecessary surgery and therefore unnecessary risk in these women and may impose a considerable financial burden on healthcare systems. Efforts to define clinically meaningful and universally applicable criteria for the diagnosis of septate uterus should be encouraged. Copyright © 2019 ISUOG. Published by John WileySons Ltd.Útero septo según las definiciones de ESHRE/ESGE, ASRM y CUME: la relación con la infertilidad y el aborto espontáneo, el costo y advertencias para las mujeres y los sistemas de salud OBJETIVO: Evaluar el rendimiento de la velocidad sistólica máxima de la arteria cerebral media fetal (MCA-PSV, por sus siglas en inglés) ≥1,5 múltiplos de la mediana (MdM) para la predicción de la anemia moderada-severa en fetos sometidos a transfusión y no sometidos. MÉTODOS: Se realizó una búsqueda sistemática para identificar estudios observacionales relevantes reportados en el período 2008-2018 que evaluaron el rendimiento de la MCA-PSV, utilizando un umbral de 1,5MdM para la predicción de la anemia fetal. El diagnóstico de la anemia fetal mediante la toma de muestras de sangre fue el estándar de referencia. Se utilizaron modelos de efectos aleatorios para la elaboración de una curva jerárquica resumen de las características operativas del receptor (hSROC, por sus siglas en inglés). Se realizaron análisis de subgrupos y metarregresión, según el número de transfusiones intrauterinas previas. RESULTADOS: En el metaanálisis se incluyeron doce estudios y 696 fetos. El área bajo la curva (ABC) hSROC para la anemia moderada-severa fue del 83%. La sensibilidad y especificidad agrupadas (IC 95%) fueron del 79% (70-86%) y 73% (62-82%), respectivamente, y los cocientes de verosimilitud positivos y negativos fueron 2,94 (IC 95%: 2,13-4,00) y 0,272 (IC 95%: 0,188-0,371). Cuando solo se consideraron los fetos no sometidos a transfusión, la predicción mejoró, pues se logró un ABC del 87%, una sensibilidad del 86% (IC 95%: 75-93%) y una especificidad del 71% (IC 95%: 49-87%). Se observó una disminución en la sensibilidad de la predicción de la anemia moderada-severa mediante la MCA-PSV ≥1.5MdM (estimación, -5,5% (IC 95%: -10,7 a -0,3%), P=0,039) en función del aumento del número de transfusiones previas. CONCLUSIONES: El uso de la MCA-PSV ≥1.5MdM para la predicción de la anemia moderada-severa en fetos no sometidos a transfusión muestra una precisión moderada (86% de sensibilidad y 71% de especificidad), que disminuye con el aumento del número de transfusiones intrauterinas.基于ESHRE/ESGE、ASRM和CUME定义的纵隔子宫:与不孕和流产的联系, 以及妇女和医疗系统费用和警告 目标: 根据三种不同的定义估算纵隔子宫诊断频率差异, 确定这些差异在临床实践中是否存在显著性, 根据三种定义中的每一种检视纵隔子宫诊断与不孕和/或先前流产、以及手术费用之间的联系。 方法: 这是针对一项前瞻性研究的二次数据分析, 研究对象是261名连续育龄妇女, 她们参加了一家主治先天性子宫畸形的私人诊所组织的研究项目。根据三种不同的纵隔子宫定义方式对数据集进行二次分析:遵循美国生殖医学学会(ASRM)的建议, 1988年美国生育学会2016年最新建议(ASRM-2016:内底凹陷深度≥1.5厘米, 内凹角90°和外部凹陷深度1厘米)；遵循欧洲人类生殖与胚胎学会/欧洲妇科内窥镜检查学会(ESHRE/ESGE)2013年发布, 2016年再次确认的建议(ESHRE/ESGE-2016:内底/子宫凹陷深度大于子宫壁厚的50%, 外部凹陷深度小于子宫壁厚的50%, 测量子宫壁/角膜间线上部的子宫壁厚)；根据去年发布的, 基于专家组作出的最常见决定的定义(先天性子宫畸形专家组；CUME)(内底凹陷深度≥1厘米, 外底凹陷深度1厘米)。我们根据这三种定义中的每一种比较纵隔子宫诊断率, 根据每一种定义估计疾病诊断与不孕和/或先前流产之间的联系, 根据猜测法预测相关的实施成本。 结果: 尽管32.6%(85/261)的受试者符合三种纵隔子宫定义中的某一种标准, 但从全部三种定义来看, 只有2.7%(7/261)的受试者被定义为纵隔子宫患者。我们根据ESHRE/ESGE-2016诊断的纵隔子宫病例, 明显多于根据ASRM-2016(31%对5%, 相对危险度 (RR) 为6.7, P0.0001)或CUME-2018标准(31%对12%, RR为2.6, P0.0001)诊断的病例。我们还观察到一些无法根据ASRM-2016进行明确分类的常见病例(灰色地带:既不正常/呈弓形也不分隔；6.5%)。ASRM-2016(5%对4%)、ESHRE/ESGE-2016(35%对28%)或CUME-2018(11%对12%)表明, 不孕不育妇女与正常妇女的纵隔子宫患病率并无显著差异(P0.05)。ASRM-2016(11%对3%；P=0.04)和CUME-2018(22%对10%；P=0.04)表明, 先前流产的妇女诊断罹患纵隔子宫的机率明显高于正常妇女, 但ESHRE/ESGE-2016标准(42%对28%；P=0.8)表明并无明显区别。我们的计算结果表明, 全球医疗系统成本基本上取决于临床实践中采用的纵隔子宫定义标准；相比ASRM-2016和CUME-2018定义, ESHRE/ESGE-2016定义的相关成本五年内可能额外增加1000-2000亿美元。 结论: 基于ESHRE/ESGE-2016、ASRM-2016和CUME-2018定义的纵隔子宫患病率差异很大。需要克服ASRM分类的一个重要局限性, 即我们最初命名为“灰色地带”的不可分类案例的占比较高。基于ESHRE/ESGE-2016的较高的纵隔子宫过度诊断率可能导致不必要的手术, 从而给这些妇女带来不必要的风险, 可能给医疗系统带来巨大的经济负担。应该鼓励业界努力为纵隔子宫的诊断, 确定一个具有临床意义的普适标准。©2019 ISUOG版权所有。John WileySons Ltd.出版。.

The association between obesity and infertility has gained increasing provider and public awareness. The purpose of this review is to outline the recent research into the pathophysiology regarding obesity and its impact of reproductive function in both women and men.A BMI more than 25 has a detrimental impact on the hypothalamus-pituitary-gonadal (HPG) axis in both men and women, leading to alterations of HPG hormones, gametogenesis, as well as an increase in inflammation and lipotoxicity from excessive adipose tissue. Additionally, BMI likely impacts assisted reproductive technology (ART) outcomes, with a greater influence on women than men. Studies regarding weight loss interventions are heterogenous in methods and outcomes, and it is difficult to extrapolate from current data if weight loss truly leads to improved outcomes.Elevated BMI induces changes in the HPG axis, hormone levels, gametogenesis, and adverse ART outcomes. Inconsistencies regarding weight loss interventions make it difficult to assess the impact on outcomes after weight loss interventions.

The introduction of oocyte vitrification has propelled the field of oncofertility. However, it is becoming increasingly common to offer planned oocyte cryopreservation to healthy, fertile women due to a lack of a partner or other personal issues. The aim of this article is to discuss the pros and cons of planned oocyte cryopreservation along with potential exploitation issues by unregulated clinics and international agencies. This article further encourages obstetricians and gynecologists to discuss these issues of planned oocyte cryopreservation with their patients to empower them to make an educated decision based on research and science rather than be susceptible to entities that stand to gain monetarily by prompting women to fear a childless future.

The business of medicine continues to be an area of growing importance, particularly in reproductive medicine. We provide a synthesis of salient concepts within the spectrum of business in medicine. The topics we review include finances and accounting; business operations as related to human resources, information technology (telemedicine), organizational governance, and practice models; insurance billing and contract negotiations; and the impact of health care policy on reproductive medicine.