Saline contrast sonohysterography and directed extraction, resection and biopsy of intrauterine pathology using a Uterine Explora Curette.

OBJECTIVE: To assess the utility of an endometrial sampling device, the Uterine Explora Curette, with concomitant saline contrast sonohysterography (SCSH) for ultrasound-directed extraction, resection and biopsy of endometrial pathology. METHODS: Use of the Uterine Explora Curette was prospectively evaluated in 20 women with either infertility (n = 14), recurrent miscarriage (n = 2) or peri-/postmenopausal bleeding (n = 4). Findings on SCSH were compared with those on pathological analysis. RESULTS: In all 20 cases the Uterine Explora Curette was used successfully during SCSH to treat endometrial filling defects. The procedure was well tolerated, with an average time from start to finish of 10 (range, 2-23) min. It was without complications, and appeared to remove or biopsy adequately endometrial filling defects in most patients, obviating the need for hysteroscopy. CONCLUSIONS: In properly selected patients, directed extraction, resection and biopsy using the Uterine Explora Curette during SCSH appears to be an effective and easy method for treating intrauterine pathology and provides a cost-effective alternative to operative hysteroscopy.     

Infertility: Altered responses to stress in women undergoing in-vitro fertilization and recipients of oocyte donation

Clinical impressions suggest the presence of considerable anxietyand depression in infertile couples. We utilized a psychologicalstress test to assess adaptations to provoked stress to improvethe psychological profile of infertile women. A psychologicalstress test was administered to four groups: normal menstruatingfemales (controls, n = 13); oocyte donors (n = 13); recipientsof oocyte donation (n = 7); and women undergoing standard in-vitrofertilization (IVF; mean age 38.0 years; n = 8). The psychologicalstress test consisted of three active coping tasks: (i) serialsubtraction, (ii) Stroop colour test, (iii) speech task and(iv) one passive coping task, the cold-pressor test. Haemo-dynamicresponses (HD) were monitored before, during and after the psychologicalstress test, and serum samples were drawn for catecholaminesand cortisol. Baseline blood pressures were similar among groups.The psychological stress test elicited different biophysicalresponses in controls compared with the other groups (P <0.001). Oocyte donors had different speech task responses frombaseline, although these and the other parameters of the psychologicalstress test were not different from either the recipient orIVF groups. Blood pressure responses from baseline were bluntedin both recipients and standard IVF patients following provokedstress. Baseline cortisol and norepi-nephrine were similar amongall groups, yet provoked stress elicited a significant increasein controls (142.0 ± 25.2%, P < 0.001) compared withoocyte donors (17.1 ± 19.7%), recipients and standardIVF patients (mean –15.5 ± 17.3% respectively).Norepinephrine responses were apparently greater in controls(60.1 ± 13.1%) compared with oocyte donors (41.8 ±27%) and recipient and IVF groups combined (21.7 ± 12.4%)but this result was not significant. These data suggest thatinfertile women have blunted biophysical and biochemical reactionsto provoked behavioural stressors. Oocyte donors demonstrateblunted passive coping responses similar to those of infertilewomen, yet still respond to active coping stressors in a mannersimilar to that of normal controls. Our data suggest that infertilitytherapy combined with the anticipation of success or failureresults in blunted patterns of response to passive coping stressors.However, blunted active coping responses are unique to infertilewomen.     

Bilateral serous cystadenofibromas clinically simulating hyperreactio luteinalis following controlled ovarian hyperstimulation and in vitro fertilization

Summary We report a case of bilateral serous cystadenofibromas clinically simulating hyperreactio luteinalis during a normal pregnancy resulting from controlled ovarian stimulation and in vitro fertilization. Incomplete regression at 2-year follow-up prompted surgical intervention. This case demonstrates that the clinical and sonographic features that have been associated with hyperreactio luteinalis are not specific for this condition and emphasizes the need for close clinical follow-up in all presumptive cases for which a histologic diagnosis has not been established.     

Expanded carrier screening: a current survey of physician utilization and attitudes

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?<?0.001). REI subspecialists were more likely to offer ECS (80%) compared to 70% of maternal fetal medicine physicians (MFM). Physicians were comfortable discussing negative results (53.6%) compared to positive results (48.4%). Most physicians (56%) believed that ECS should not be offered until the significance of each disease is understood; 52% believed that testing should be restricted to those conditions important to couples; while 26% felt that testing should be done regardless of the clinical significance.

Conclusions

Discussion and application of ECS has increased in clinical practice. However, lack of comfort with counseling and varying beliefs surrounding ECS continue to hinder its utilization. Further education and training programs, and subsequent evaluation are warranted.

     

Endometriosis and infertility: what do we do for each stage?

Endometriosis and infertility have been linked in the discipline of gynecology for more than a century. There is evidence that endometriosis can and does decrease fertility. However, our ability to determine fertility prognosis based on a staging system is severely limited. Treatment options include medical therapy, surgical intervention, and assisted reproduction. For endometriosis-associated infertility, medical therapy seems to have no value alone. Surgical therapy is beneficial for all stages of diseases, as in assisted reproduction. The relative value of these two latter approaches, however, is untested. Our suggestions for the treatment of early-stage endometriosis are surgery and/or superovulation with intrauterine insemination as first-line treatments. For more advanced disease, with tubal damage, surgery or in vitro fertilization are options. For the most advanced cases, in vitro fertilization preceded by 3 months of medical treatment of the endometriosis is advised.