Fibroids in infertility - consensus statement from ACCEPT (Australasian CREI Consensus Expert Panel on Trial evidence)

The effect of uterine fibroid region and depth on endometrial stress and strain: a finite element approach

Uterine fibroids are common benign gynecological tumors that are observed in up to 80% of premenopausal women. It is understood that as the fibroid size increases, the surrounding tissues will be subject to greater loads. However, the effect of fibroid region on the uterine structure is not as clear. To better understand the mechanical loading of the endometrium due to the presence of a uterine fibroid, we developed a finite element model of the uterus to examine the effect of both fibroid depth and region in relation to the endometrium. The finite element model of the uterus, endometrium, and a uterine fibroid were created from a 3D segmentation of a patient's magnetic resonance images. This model was then loaded into ANSYS Mechanical 2023 R1, and then deformation, stress, and strain of the endometrium was measured for 24 fibroid positions (8 regions × 3 depths). The highest endometrial loads (deformation, stress, strain) were observed when the fibroid region was superior to the uterus and the depth was deep. Superior regions generated 10-20% higher loads on the endometrium in comparison to other regions, while deep locations had 5-10% higher endometrium loads when compared to superficial depths across almost all regions. A simple uterus model was used to show the effect of fibroid position on loads acting on the endometrium. This can provide insight into mechanisms of abnormal uterine bleeding and infertility and better inform clinical decision making.

Exploring Surgical Strategies for Uterine Fibroid Treatment: A Comprehensive Review of Literature on Open and Minimally Invasive Approaches

Background and Objectives: Uterine myomas represent one of the most prevalent pathologies affecting the female population. These benign neoplasms originate from the smooth muscular cells of the uterus, and they can be either single or multiple. Often associated with debilitating symptoms such as pelvic heaviness, pain, constipation, and urinary dysfunctions, the surgical management of myomectomy exhibits considerable variability. This diversity in approaches is influenced by factors such as the number and size of myomas, the patient's age, and overall clinical conditions. This study aims to elucidate and compare the advantages and disadvantages of different surgical approaches, specifically endoscopic procedures versus open surgery, providing valuable insights for clinical decision making. Materials and Methods: A comprehensive bibliographic search spanning from 2013 to 2023 was systematically conducted across databases including Medline, Embase, the Cochrane Database of Systematic Reviews, and ClinicalTrials.gov. The search utilized keywords such as "myomectomy laparoscopic and open", "myomectomy open and minimally invasive", "myomectomy open and laparoscopic", and "myomectomy open vs. laparoscopic." The research methodology, along with predetermined inclusion and exclusion criteria, was established prior to the search, ensuring a systematic and rigorous approach. Subsequently, data analysis was carried out. Results: Following the study selection process, 25 articles met the eligibility criteria for inclusion in this analysis. The average numbers of myomas were 3.7 (ranging from 1 to 13.7) and 5.4 (ranging from 1 to 13.5) for the minimally invasive surgery and open surgery groups, respectively. In terms of myoma size, the total averages across studies were 7 cm (ranging from 4.8 to 14) for the minimally invasive group and 8 cm (ranging from 3.9 to 11.2) for the open surgery group. The average pregnancy and delivery rates were 29.7% (ranging from 1.8 to 100) for the minimally invasive group and 28.5% (ranging from 1.8 to 100) for the open surgery group. Regarding complications, the average rate was 14.2% (ranging from 0 to 50) for the endoscopic group and 22.3% (ranging from 0 to 60.3) for the laparotomic group. Conclusions: In conclusion, a critical factor influencing the choice of surgical approach is primarily the size and quantity of fibroids. The mini-laparotomic approach emerges as a viable alternative to endoscopy, demonstrating favorable surgical outcomes and aesthetic results. Interestingly, the type of surgical procedure appears to have no significant impact on the pregnancy rate.

Comparison of surgical and obstetric outcomes in women with uterine leiomyomas after laparoscopic vs. abdominal myomectomy: A single-center cohort study

Our aim was to study the advantages, complications and obstetrical outcomes of laparoscopic myomectomy (LM) compared with abdominal myomectomy (AM). We conducted a retrospective cohort study at La Paz University Hospital that included LMs and AMs performed between 2012 and 2018, analyzing 254 myomectomies (142 AMs [55.7%] and 112 LMs [43.9%]). The mean number of fibroids was 1.8 ± 1.5 and 3 ± 2.9 for the LM and AM groups, respectively (p < 0.006). The mean size of the largest myoma was 7.6 cm ± 2.7 cm and 10.2 cm ± 5.4 cm for the LM and AM groups, respectively (p < 0.001). LMs were associated with longer surgical times (p < 0.001) and shorter hospitalizations (p = 0.001). There were no significant differences in the intraoperative and postoperative complication rates (p = 0.075 and p = 0.285 for LM and AM, respectively). The subsequent pregnancy rate was higher for the LM group (30.8% vs. 16.8%, p = 0.009), with a vaginal delivery rate of 69% and no cases of uterine rupture.

How to boost an obstetrician's confidence in vaginal delivery after high-intensity focused ultrasound: a comparison study on delivery outcomes

OBJECTIVE

To assess the feasibility of vaginal delivery after HIFU.

METHODS

A total of 37 women who met the trial of labor after HIFU (TOLAH) inclusion criteria and 368 women who met the trial of labor after cesarean delivery (TOLAC) inclusion criteria gave birth at Shanghai First Maternity and Infant Hospital between 14^th June 2018 and 24^th September 2021. The delivery outcomes of the two groups were compared. Multivariable logistic regression analysis was used to estimate the adjusted risk of postpartum hemorrhage (PPH).

RESULTS

In the Qualified Candidates for TOLAH group, vaginal delivery is substantially less common (p = 0.000). The prevalence of PPH in the Qualified Candidates for TOLAH group is lower than in the Candidates for TOLAC group (8.82% vs 10.51%, p = 0.534; 0% vs 2.51%, p = 0.418). Hemoglobin drop in the Qualified Candidates for TOLAH group is also lower (7.03 ± 7.39vs 12.11 ± 12.62, p = 0.001). The rate of using more than two types of uterotonic medications to promote contraction is significantly lower in the Qualified Candidates for TOLAH group (54.05% vs 69.84%, p = 0.04), and the percentage of abnormal uterine contraction is lower in the Qualified Candidates for TOLAH group (35.14% vs 49.18%, p = 0.072). PPH is strongly predicted by abnormal uterine contraction (aOR: 17.177, 95% CI:5.046 ∼ 58.472, p = 0.000), but not by HIFU (aOR:1.105; 95% CI:0.240 ∼ 5.087, p = 0.898). No uterine rupture occurred in the cases after HIFU.

CONCLUSIONS

No uterine rupture occurred in our study group after HIFU. HIFU is not a risk for PPH. It is promising for those after HIFU to choose vaginal delivery.

Successful uterine-sparing surgical management in a patient with a large multi-fibroid uterus

Uterine fibroids are a common gynaecological condition. A key factor when deciding on surgical approach for fibroid management is a patient’s age and desire for fertility with uterine-sparing treatment generally recommended in women who are aiming for future pregnancies. This case report discusses a woman who presented with a very large multi-fibroid uterus. In this case, a hysterectomy was recommended due to safety concerns however, this advice was declined as the patient desired uterine preservation. Fertility testing showed that the patient was not peri-menopausal and abdominal myomectomy was safely performed to good effect. This case report outlines the surgical approach undertaken, in addition to considerations for fertility and pregnancy management.

Standardizing definitions and reporting guidelines for the infertility core outcome set: an international consensus development study† ‡

STUDY QUESTION

Can consensus definitions for the core outcome set for infertility be identified in order to recommend a standardized approach to reporting?

SUMMARY ANSWER

Consensus definitions for individual core outcomes, contextual statements and a standardized reporting table have been developed.

WHAT IS KNOWN ALREADY

Different definitions exist for individual core outcomes for infertility. This variation increases the opportunities for researchers to engage with selective outcome reporting, which undermines secondary research and compromises clinical practice guideline development.

STUDY DESIGN, SIZE, DURATION

Potential definitions were identified by a systematic review of definition development initiatives and clinical practice guidelines and by reviewing Cochrane Gynaecology and Fertility Group guidelines. These definitions were discussed in a face-to-face consensus development meeting, which agreed consensus definitions. A standardized approach to reporting was also developed as part of the process.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Healthcare professionals, researchers and people with fertility problems were brought together in an open and transparent process using formal consensus development methods.

MAIN RESULTS AND THE ROLE OF CHANCE

Forty-four potential definitions were inventoried across four definition development initiatives, including the Harbin Consensus Conference Workshop Group and International Committee for Monitoring Assisted Reproductive Technologies, 12 clinical practice guidelines and Cochrane Gynaecology and Fertility Group guidelines. Twenty-seven participants, from 11 countries, contributed to the consensus development meeting. Consensus definitions were successfully developed for all core outcomes. Specific recommendations were made to improve reporting.

LIMITATIONS, REASONS FOR CAUTION

We used consensus development methods, which have inherent limitations. There was limited representation from low- and middle-income countries.

WIDER IMPLICATIONS OF THE FINDINGS

A minimum data set should assist researchers in populating protocols, case report forms and other data collection tools. The generic reporting table should provide clear guidance to researchers and improve the reporting of their results within journal publications and conference presentations. Research funding bodies, the Standard Protocol Items: Recommendations for Interventional Trials statement, and over 80 specialty journals have committed to implementing this core outcome set.

STUDY FUNDING/COMPETING INTEREST(S)

This research was funded by the Catalyst Fund, Royal Society of New Zealand, Auckland Medical Research Fund and Maurice and Phyllis Paykel Trust. Siladitya Bhattacharya reports being the Editor-in-Chief of Human Reproduction Open and an editor of the Cochrane Gynaecology and Fertility Group. J.L.H.E. reports being the Editor Emeritus of Human Reproduction. R.S.L. reports consultancy fees from Abbvie, Bayer, Ferring, Fractyl, Insud Pharma and Kindex and research sponsorship from Guerbet and Hass Avocado Board. B.W.M. reports consultancy fees from Guerbet, iGenomix, Merck, Merck KGaA and ObsEva. C.N. reports being the Editor-in-Chief of Fertility and Sterility and Section Editor of the Journal of Urology, research sponsorship from Ferring, and a financial interest in NexHand. E.H.Y.N. reports research sponsorship from Merck. A.S. reports consultancy fees from Guerbet. J.W. reports being a statistical editor for the Cochrane Gynaecology and Fertility Group. A.V. reports that he is a Statistical Editor of the Cochrane Gynaecology & Fertility Review Group and of the journal Reproduction. His employing institution has received payment from Human Fertilisation and Embryology Authority for his advice on review of research evidence to inform their 'traffic light' system for infertility treatment 'add-ons'. N.L.V. reports consultancy and conference fees from Ferring, Merck and Merck Sharp and Dohme. The remaining authors declare no competing interests in relation to the work presented. All authors have completed the disclosure form.

TRIAL REGISTRATION NUMBER

Core Outcome Measures in Effectiveness Trials Initiative: 1023.

Top 10 priorities for future infertility research: an international consensus development study

STUDY QUESTION

Can the priorities for future research in infertility be identified?

SUMMARY ANSWER

The top 10 research priorities for the four areas of male infertility, female and unexplained infertility, medically assisted reproduction, and ethics, access, and organization of care for people with fertility problems were identified.

WHAT IS KNOWN ALREADY

Many fundamental questions regarding the prevention, management, and consequences of infertility remain unanswered. This is a barrier to improving the care received by those people with fertility problems.

STUDY DESIGN, SIZE, DURATION

Potential research questions were collated from an initial international survey, a systematic review of clinical practice guidelines, and Cochrane systematic reviews. A rationalized list of confirmed research uncertainties was prioritized in an interim international survey. Prioritized research uncertainties were discussed during a consensus development meeting. Using a formal consensus development method, the modified nominal group technique, diverse stakeholders identified the top 10 research priorities for each of the categories male infertility, female and unexplained infertility, medically assisted reproduction, and ethics, access, and organization of care.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Healthcare professionals, people with fertility problems, and others (healthcare funders, healthcare providers, healthcare regulators, research funding bodies and researchers) were brought together in an open and transparent process using formal consensus methods advocated by the James Lind Alliance.

MAIN RESULTS AND THE ROLE OF CHANCE

The initial survey was completed by 388 participants from 40 countries, and 423 potential research questions were submitted. Fourteen clinical practice guidelines and 162 Cochrane systematic reviews identified a further 236 potential research questions. A rationalized list of 231 confirmed research uncertainties were entered into an interim prioritization survey completed by 317 respondents from 43 countries. The top 10 research priorities for each of the four categories male infertility, female and unexplained infertility (including age-related infertility, ovarian cysts, uterine cavity abnormalities, and tubal factor infertility), medically assisted reproduction (including ovarian stimulation, IUI, and IVF), and ethics, access, and organization of care, were identified during a consensus development meeting involving 41 participants from 11 countries. These research priorities were diverse and seek answers to questions regarding prevention, treatment, and the longer-term impact of infertility. They highlight the importance of pursuing research which has often been overlooked, including addressing the emotional and psychological impact of infertility, improving access to fertility treatment, particularly in lower resource settings, and securing appropriate regulation. Addressing these priorities will require diverse research methodologies, including laboratory-based science, qualitative and quantitative research, and population science.

LIMITATIONS, REASONS FOR CAUTION

We used consensus development methods, which have inherent limitations, including the representativeness of the participant sample, methodological decisions informed by professional judgement, and arbitrary consensus definitions.

WIDER IMPLICATIONS OF THE FINDINGS

We anticipate that identified research priorities, developed to specifically highlight the most pressing clinical needs as perceived by healthcare professionals, people with fertility problems, and others, will help research funding organizations and researchers to develop their future research agenda.

STUDY FUNDING/ COMPETING INTEREST(S)

The study was funded by the Auckland Medical Research Foundation, Catalyst Fund, Royal Society of New Zealand, and Maurice and Phyllis Paykel Trust. Geoffrey Adamson reports research sponsorship from Abbott, personal fees from Abbott and LabCorp, a financial interest in Advanced Reproductive Care, committee membership of the FIGO Committee on Reproductive Medicine, International Committee for Monitoring Assisted Reproductive Technologies, International Federation of Fertility Societies, and World Endometriosis Research Foundation, and research sponsorship of the International Committee for Monitoring Assisted Reproductive Technologies from Abbott and Ferring. Siladitya Bhattacharya reports being the Editor-in-Chief of Human Reproduction Open and editor for the Cochrane Gynaecology and Fertility Group. Hans Evers reports being the Editor Emeritus of Human Reproduction. Andrew Horne reports research sponsorship from the Chief Scientist's Office, Ferring, Medical Research Council, National Institute for Health Research, and Wellbeing of Women and consultancy fees from Abbvie, Ferring, Nordic Pharma, and Roche Diagnostics. M. Louise Hull reports grants from Merck, grants from Myovant, grants from Bayer, outside the submitted work and ownership in Embrace Fertility, a private fertility company. Neil Johnson reports research sponsorship from Abb-Vie and Myovant Sciences and consultancy fees from Guerbet, Myovant Sciences, Roche Diagnostics, and Vifor Pharma. José Knijnenburg reports research sponsorship from Ferring and Theramex. Richard Legro reports consultancy fees from Abbvie, Bayer, Ferring, Fractyl, Insud Pharma and Kindex and research sponsorship from Guerbet and Hass Avocado Board. Ben Mol reports consultancy fees from Guerbet, iGenomix, Merck, Merck KGaA and ObsEva. Ernest Ng reports research sponsorship from Merck. Craig Niederberger reports being the Co Editor-in-Chief of Fertility and Sterility and Section Editor of the Journal of Urology, research sponsorship from Ferring, and retains a financial interest in NexHand. Jane Stewart reports being employed by a National Health Service fertility clinic, consultancy fees from Merck for educational events, sponsorship to attend a fertility conference from Ferring, and being a clinical subeditor of Human Fertility. Annika Strandell reports consultancy fees from Guerbet. Jack Wilkinson reports being a statistical editor for the Cochrane Gynaecology and Fertility Group. Andy Vail reports that he is a Statistical Editor of the Cochrane Gynaecology & Fertility Review Group and of the journal Reproduction. His employing institution has received payment from HFEA for his advice on review of research evidence to inform their 'traffic light' system for infertility treatment 'add-ons'. Lan Vuong reports consultancy and conference fees from Ferring, Merck and Merck Sharp and Dohme. The remaining authors declare no competing interests in relation to the present work. All authors have completed the disclosure form.

TRIAL REGISTRATION NUMBER

Not applicable.

Top 10 priorities for future infertility research: an international consensus development study† ‡

STUDY QUESTION

Can the priorities for future research in infertility be identified?

SUMMARY ANSWER

The top 10 research priorities for the four areas of male infertility, female and unexplained infertility, medically assisted reproduction and ethics, access and organization of care for people with fertility problems were identified.

WHAT IS KNOWN ALREADY

Many fundamental questions regarding the prevention, management and consequences of infertility remain unanswered. This is a barrier to improving the care received by those people with fertility problems.

STUDY DESIGN, SIZE, DURATION

Potential research questions were collated from an initial international survey, a systematic review of clinical practice guidelines and Cochrane systematic reviews. A rationalized list of confirmed research uncertainties was prioritized in an interim international survey. Prioritized research uncertainties were discussed during a consensus development meeting. Using a formal consensus development method, the modified nominal group technique, diverse stakeholders identified the top 10 research priorities for each of the categories male infertility, female and unexplained infertility, medically assisted reproduction and ethics, access and organization of care.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Healthcare professionals, people with fertility problems and others (healthcare funders, healthcare providers, healthcare regulators, research funding bodies and researchers) were brought together in an open and transparent process using formal consensus methods advocated by the James Lind Alliance.

MAIN RESULTS AND THE ROLE OF CHANCE

The initial survey was completed by 388 participants from 40 countries, and 423 potential research questions were submitted. Fourteen clinical practice guidelines and 162 Cochrane systematic reviews identified a further 236 potential research questions. A rationalized list of 231 confirmed research uncertainties was entered into an interim prioritization survey completed by 317 respondents from 43 countries. The top 10 research priorities for each of the four categories male infertility, female and unexplained infertility (including age-related infertility, ovarian cysts, uterine cavity abnormalities and tubal factor infertility), medically assisted reproduction (including ovarian stimulation, IUI and IVF) and ethics, access and organization of care were identified during a consensus development meeting involving 41 participants from 11 countries. These research priorities were diverse and seek answers to questions regarding prevention, treatment and the longer-term impact of infertility. They highlight the importance of pursuing research which has often been overlooked, including addressing the emotional and psychological impact of infertility, improving access to fertility treatment, particularly in lower resource settings and securing appropriate regulation. Addressing these priorities will require diverse research methodologies, including laboratory-based science, qualitative and quantitative research and population science.

LIMITATIONS, REASONS FOR CAUTION

We used consensus development methods, which have inherent limitations, including the representativeness of the participant sample, methodological decisions informed by professional judgment and arbitrary consensus definitions.

WIDER IMPLICATIONS OF THE FINDINGS

We anticipate that identified research priorities, developed to specifically highlight the most pressing clinical needs as perceived by healthcare professionals, people with fertility problems and others, will help research funding organizations and researchers to develop their future research agenda.

STUDY FUNDING/COMPETING INTEREST(S)

The study was funded by the Auckland Medical Research Foundation, Catalyst Fund, Royal Society of New Zealand and Maurice and Phyllis Paykel Trust. G.D.A. reports research sponsorship from Abbott, personal fees from Abbott and LabCorp, a financial interest in Advanced Reproductive Care, committee membership of the FIGO Committee on Reproductive Medicine, International Committee for Monitoring Assisted Reproductive Technologies, International Federation of Fertility Societies and World Endometriosis Research Foundation, and research sponsorship of the International Committee for Monitoring Assisted Reproductive Technologies from Abbott and Ferring. Siladitya Bhattacharya reports being the Editor-in-Chief of Human Reproduction Open and editor for the Cochrane Gynaecology and Fertility Group. J.L.H.E. reports being the Editor Emeritus of Human Reproduction. A.W.H. reports research sponsorship from the Chief Scientist's Office, Ferring, Medical Research Council, National Institute for Health Research and Wellbeing of Women and consultancy fees from AbbVie, Ferring, Nordic Pharma and Roche Diagnostics. M.L.H. reports grants from Merck, grants from Myovant, grants from Bayer, outside the submitted work and ownership in Embrace Fertility, a private fertility company. N.P.J. reports research sponsorship from AbbVie and Myovant Sciences and consultancy fees from Guerbet, Myovant Sciences, Roche Diagnostics and Vifor Pharma. J.M.L.K. reports research sponsorship from Ferring and Theramex. R.S.L. reports consultancy fees from AbbVie, Bayer, Ferring, Fractyl, Insud Pharma and Kindex and research sponsorship from Guerbet and Hass Avocado Board. B.W.M. reports consultancy fees from Guerbet, iGenomix, Merck, Merck KGaA and ObsEva. E.H.Y.N. reports research sponsorship from Merck. C.N. reports being the Co Editor-in-Chief of Fertility and Sterility and Section Editor of the Journal of Urology, research sponsorship from Ferring and retains a financial interest in NexHand. J.S. reports being employed by a National Health Service fertility clinic, consultancy fees from Merck for educational events, sponsorship to attend a fertility conference from Ferring and being a clinical subeditor of Human Fertility. A.S. reports consultancy fees from Guerbet. J.W. reports being a statistical editor for the Cochrane Gynaecology and Fertility Group. A.V. reports that he is a Statistical Editor of the Cochrane Gynaecology & Fertility Review Group and the journal Reproduction. His employing institution has received payment from Human Fertilisation and Embryology Authority for his advice on review of research evidence to inform their 'traffic light' system for infertility treatment 'add-ons'. N.L.V. reports consultancy and conference fees from Ferring, Merck and Merck Sharp and Dohme. The remaining authors declare no competing interests in relation to the present work. All authors have completed the disclosure form.

TRIAL REGISTRATION NUMBER

N/A.

Standardizing definitions and reporting guidelines for the infertility core outcome set: an international consensus development study

STUDY QUESTION

Can consensus definitions for the core outcome set for infertility be identified in order to recommend a standardized approach to reporting?

SUMMARY ANSWER

Consensus definitions for individual core outcomes, contextual statements, and a standardized reporting table have been developed.

WHAT IS KNOWN ALREADY

Different definitions exist for individual core outcomes for infertility. This variation increases the opportunities for researchers to engage with selective outcome reporting, which undermines secondary research and compromises clinical practice guideline development.

STUDY DESIGN, SIZE, DURATION

Potential definitions were identified by a systematic review of definition development initiatives and clinical practice guidelines and by reviewing Cochrane Gynaecology and Fertility Group guidelines. These definitions were discussed in a face-to-face consensus development meeting, which agreed consensus definitions. A standardized approach to reporting was also developed as part of the process.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Healthcare professionals, researchers, and people with fertility problems were brought together in an open and transparent process using formal consensus development methods.

MAIN RESULTS AND THE ROLE OF CHANCE

Forty-four potential definitions were inventoried across four definition development initiatives, including the Harbin Consensus Conference Workshop Group and International Committee for Monitoring Assisted Reproductive Technologies, 12 clinical practice guidelines, and Cochrane Gynaecology and Fertility Group guidelines. Twenty-seven participants, from 11 countries, contributed to the consensus development meeting. Consensus definitions were successfully developed for all core outcomes. Specific recommendations were made to improve reporting.

LIMITATIONS, REASONS FOR CAUTION

We used consensus development methods, which have inherent limitations. There was limited representation from low- and middle-income countries.

WIDER IMPLICATIONS OF THE FINDINGS

A minimum data set should assist researchers in populating protocols, case report forms, and other data collection tools. The generic reporting table should provide clear guidance to researchers and improve the reporting of their results within journal publications and conference presentations. Research funding bodies, the Standard Protocol Items: Recommendations for Interventional Trials statement, and over 80 specialty journals have committed to implementing this core outcome set.

STUDY FUNDING/COMPETING INTEREST(S)

This research was funded by the Catalyst Fund, Royal Society of New Zealand, Auckland Medical Research Fund, and Maurice and Phyllis Paykel Trust. Siladitya Bhattacharya reports being the Editor-in-Chief of Human Reproduction Open and an editor of the Cochrane Gynaecology and Fertility group. Hans Evers reports being the Editor Emeritus of Human Reproduction. Richard Legro reports consultancy fees from Abbvie, Bayer, Ferring, Fractyl, Insud Pharma and Kindex and research sponsorship from Guerbet and Hass Avocado Board. Ben Mol reports consultancy fees from Guerbet, iGenomix, Merck, Merck KGaA and ObsEva. Craig Niederberger reports being the Editor-in-Chief of Fertility and Sterility and Section Editor of the Journal of Urology, research sponsorship from Ferring, and a financial interest in NexHand. Ernest Ng reports research sponsorship from Merck. Annika Strandell reports consultancy fees from Guerbet. Jack Wilkinson reports being a statistical editor for the Cochrane Gynaecology and Fertility group. Andy Vail reports that he is a Statistical Editor of the Cochrane Gynaecology & Fertility Review Group and of the journal Reproduction. His employing institution has received payment from HFEA for his advice on review of research evidence to inform their 'traffic light' system for infertility treatment 'add-ons'. Lan Vuong reports consultancy and conference fees from Ferring, Merck and Merck Sharp and Dohme. The remaining authors declare no competing interests in relation to the work presented. All authors have completed the disclosure form.

TRIAL REGISTRATION NUMBER

Core Outcome Measures in Effectiveness Trials Initiative: 1023.

Surgical treatment of fibroids for subfertility

BACKGROUND

Fibroids are the most common benign tumours of the female genital tract and are associated with numerous clinical problems including a possible negative impact on fertility. In women requesting preservation of fertility, fibroids can be surgically removed (myomectomy) by laparotomy, laparoscopically or hysteroscopically depending on the size, site and type of fibroid. Myomectomy is however a procedure that is not without risk and can result in serious complications. It is therefore essential to determine whether such a procedure can result in an improvement in fertility and, if so, to then determine the ideal surgical approach.

OBJECTIVES

To examine the effect of myomectomy on fertility outcomes and to compare different surgical approaches.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group (CGFG) Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, Epistemonikos database, World Health Organization (WHO) International Clinical Trials Registry Platform search portal, Database of Abstracts of Reviews of Effects (DARE), LILACS, conference abstracts on the ISI Web of Knowledge, OpenSigle for grey literature from Europe, and reference list of relevant papers. The final search was in February 2019.

SELECTION CRITERIA

Randomised controlled trials (RCTs) examining the effect of myomectomy compared to no intervention or where different surgical approaches are compared regarding the effect on fertility outcomes in a group of infertile women suffering from uterine fibroids.

DATA COLLECTION AND ANALYSIS

Data collection and analysis were conducted in accordance with the procedure suggested in the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

This review included four RCTs with 442 participants. The evidence was very low-quality with the main limitations being due to serious imprecision, inconsistency and indirectness. Myomectomy versus no intervention One study examined the effect of myomectomy compared to no intervention on reproductive outcomes. We are uncertain whether myomectomy improves clinical pregnancy rate for intramural (odds ratio (OR) 1.88, 95% confidence interval (CI) 0.57 to 6.14; 45 participants; one study; very low-quality evidence), submucous (OR 2.04, 95% CI 0.62 to 6.66; 52 participants; one study; very low-quality evidence), intramural/subserous (OR 2.00, 95% CI 0.40 to 10.09; 31 participants; one study; very low-quality evidence) or intramural/submucous fibroids (OR 3.24, 95% CI 0.72 to 14.57; 42 participants; one study; very low-quality evidence). Similarly, we are uncertain whether myomectomy reduces miscarriage rate for intramural fibroids (OR 1.33, 95% CI 0.26 to 6.78; 45 participants; one study; very low-quality evidence), submucous fibroids (OR 1.27, 95% CI 0.27 to 5.97; 52 participants; one study; very low-quality evidence), intramural/subserous fibroids (OR 0.80, 95% CI 0.10 to 6.54; 31 participants; one study; very low-quality evidence) or intramural/submucous fibroids (OR 2.00, 95% CI 0.32 to 12.33; 42 participants; one study; very low-quality evidence). This study did not report on live birth, preterm delivery, ongoing pregnancy or caesarean section rate. Laparoscopic myomectomy versus myomectomy by laparotomy or mini-laparotomy Two studies compared laparoscopic myomectomy to myomectomy at laparotomy or mini-laparotomy. We are uncertain whether laparoscopic myomectomy compared to laparotomy or mini-laparotomy improves live birth rate (OR 0.80, 95% CI 0.42 to 1.50; 177 participants; two studies; I² = 0%; very low-quality evidence), preterm delivery rate (OR 0.70, 95% CI 0.11 to 4.29; participants = 177; two studies; I² = 0%, very low-quality evidence), clinical pregnancy rate (OR 0.96, 95% CI 0.52 to 1.78; 177 participants; two studies; I² = 0%, very low-quality evidence), ongoing pregnancy rate (OR 1.61, 95% CI 0.26 to 10.04; 115 participants; one study; very low-quality evidence), miscarriage rate (OR 1.25, 95% CI 0.40 to 3.89; participants = 177; two studies; I² = 0%, very low-quality evidence), or caesarean section rate (OR 0.69, 95% CI 0.34 to 1.39; participants = 177; two studies; I² = 21%, very low-quality evidence). Monopolar resectoscope versus bipolar resectoscope One study evaluated the use of two electrosurgical systems during hysteroscopic myomectomy. We are uncertain whether bipolar resectoscope use compared to monopolar resectoscope use improves live birth/ongoing pregnancy rate (OR 0.86, 95% CI 0.30 to 2.50; 68 participants; one study, very low-quality evidence), clinical pregnancy rate (OR 0.88, 95% CI 0.33 to 2.36; 68 participants; one study; very low-quality evidence), or miscarriage rate (OR 1.00, 95% CI 0.19 to 5.34; participants = 68; one study; very low-quality evidence). This study did not report on preterm delivery or caesarean section rate.

AUTHORS' CONCLUSIONS

There is limited evidence to determine the role of myomectomy for infertility in women with fibroids as only one trial compared myomectomy with no myomectomy. If the decision is made to have a myomectomy, the current evidence does not indicate a superior method (laparoscopy, laparotomy or different electrosurgical systems) to improve rates of live birth, preterm delivery, clinical pregnancy, ongoing pregnancy, miscarriage, or caesarean section. Furthermore, the existing evidence needs to be viewed with caution due to the small number of events, minimal number of studies and very low-quality evidence.

Temporary Ligation of the Uterine Artery at Its Origin Using a Removable "Shoelace" Knot

STUDY OBJECTIVE

To demonstrate a technique of temporary ligation of the uterine artery at its origin.

DESIGN

A step-by-step demonstration of the surgery in an instructional video.

SETTING

A private hospital in Mumbai, India.

INTERVENTION

The peritoneum over the pelvic side wall was dissected bilaterally to expose the uterine arteries at their origins. Using a polyglactin absorbable suture, a double thread loop was used to create a removable "shoelace" knot (Video 1). Both uterine arteries were ligated in this manner. The myomectomy was completed uneventfully, and the myoma bed was sutured in 2 layers using polyglactin sutures. Once suturing was completed, the shoelace knot was untied by simply pulling one end of the thread to restore blood supply to the uterus. Intraoperative blood loss was 30 mL, and the total operation time was 120 minutes.

CONCLUSION

Laparoscopic ligation of the uterine arteries at their origin is known to reduce intraoperative blood loss [1,2]. However, in patients desiring future fertility, the effect of permanent ligation of these vessels bilaterally remains under study [3-5]. The removable "shoelace" knot is a low-cost, readily available alternative to metallic titanium clips that requires no special surgical expertise to implement.

Perinatal outcome and long-term pediatric morbidity of pregnancies with a fibroid uterus

BACKGROUND

Uterine fibroids are a common morbidity in women and its prevalence is increasing with age. As maternal age rises, fibroids become more prevalent during pregnancy.

AIM

To assess perinatal outcome and long-term health of children to mothers with uterine fibroids during pregnancy.

STUDY DESIGN

A population-based cohort analysis assessing long-term hospitalizations of offspring, up to the age of 18 years, due to gastrointestinal, neurological, cardiovascular, endocrine, and respiratory morbidity, following pregnancies diagnosed with and without a fibroid uterus. Multivariable generalized estimating equation (GEE) analysis adjusted for maternal clusters and other possible confounders was performed. Kaplan-Meier survival curves and Cox survival regression models were used to compare cumulative morbidity incidence and control for confounders.

SUBJECTS

All singleton deliveries occurring between 1991 and 2014.

OUTCOME MEASURES

Perinatal outcome and long-term pediatric morbidity.

RESULTS

A total of 242,445 singleton deliveries were included; 0.5% of which were diagnosed with uterine fibroids (n = 1237). In the GEE multivariable analyses, advanced maternal age, hypertensive disorder and diabetes mellitus, fetal growth restriction, low birthweight (<2500 g), and small for gestational age newborns, were all independently associated with uterine fibroids during pregnancy. Hospitalizations up to the age of 18 years in the different health categories were comparable between the groups, using Cox regression models, controlled for clinically significant confounders in the long-term outcomes.

CONCLUSION

Maternal uterine fibroids appear to negatively impact perinatal outcome, mainly fetal growth. However, no independent major impact on future health of the offspring can be detected.

Ovarian reserve after uterine artery embolization in women with morbidly adherent placenta: A cohort study

Objective

To evaluate ovarian reserve in women after preservative cesarean delivery using uterine artery embolization due to morbidly adherent placenta.

Study design

A historical cohort study including all women admitted to a single tertiary care center, with morbidly adherent placenta that had preservative cesarean delivery with bilateral uterine artery embolization. Inclusion criteria included gestational age >24 weeks, singleton pregnancy and placenta increta / percreta. Exclusion criteria included maternal age > 43 years old and cesarean hysterectomy. Control group included women attending the infertility clinic due to male factor or single women conceiving via sperm donation, matched by age. Blood samples were collected on day 2–5 of menstruations for hormonal profile and Anti Mullarian Hormone (AMH) levels. Primary outcome was ovarian reserve evaluated by the levels of AMH.

Results

59 women underwent preservative cesarean delivery using uterine artery embolization during the study period. 21 women met inclusion criteria (33.9%) and were matched controls (n = 40). Circulating levels of E2 and FSH did not differ significantly between the two groups (p = 0.665, p = 0.396, respectively). AMH was lower in the study group (median 0.8 IQR 0.44–1.80) compared to the controls (median 2.08 IQR 1.68–3.71) (p = 0.001). This finding was consistent in linear multivariate regression analysis where the group of cesarean delivery using bilateral artery embolization due to placenta accrete was significantly predictive for the levels of AMH (B = -1.308, p = 0.012).

Conclusion

Women post preservative cesarean delivery using uterine artery embolization due to placenta accrete have lower ovarian reserve compare to controls matched by age.

Unusual Case of a Torted Mesenteric Fibroid

Extrauterine leiomyomas are very rare and present a clinical and diagnostic challenge due to their unusual growth patterns and behaviours. A 47-year-old woman was transferred to our tertiary specialist obstetrics and gynaecology hospital with acute abdominal pain and a palpable abdominal mass. She was taken immediately to theatre with the presumptive diagnosis of an ovarian torsion. Intraoperatively, a large necrotic mass originating from the mesentery and attachments to the bowel at the ileocaecal junction was noted. When converted to laparotomy due to limited access and poor visualisation, the uterus, ovaries, and tubes were found to be normal. A right partial hemicolectomy was performed with the assistance of the colorectal surgeon due to suspicion of bowel malignancy. Histology revealed a benign infarcted leiomyoma with adhesions to the adjacent ileum. The diagnosis of a primary torted mesenteric fibroid was made.

The Effect of Intramural Myomas Without an Intracavity Component on In Vitro Fertilization Outcomes in Single Fresh Blastocyst Transfer Cycles

STUDY OBJECTIVE

To assess clinical pregnancy rate (CPR) and live birth rate (LBR) in the presence of non-cavity-deforming intramural myomas in single fresh blastocyst transfer cycles.

DESIGN

Retrospective cohort study (Canadian Task Force classification II-2).

SETTING

Academic fertility center.

PATIENTS

A total of 929 fresh single blastocyst transfer cycles were included, 94 with only non-cavity-distorting intramural myomas and 764 without myomas. Cleavage embryo transfers were excluded to reduce bias based on embryo quality.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

CPR and LBR were assessed. There were no differences noted in gravidity, parity, or body mass index between patients with myomas and those without myomas. Women with myomas required higher doses of gonadotropins (mean, 2653 ± 404 IU vs 2350 ± 1368 IU; p = .04) than women without myomas. However, the total number of mature oocytes collected and the total number of blastocysts created were similar. CPR (47% vs 32%; p = .005) and LBR (37.8% vs 25.5%; p = .02) were lower in patients who had intramural myomas compared with those without myomas. CPR and LBR were significantly reduced in the presence of even 1 myoma (odds ratio [OR], 0.53; 95% confidence interval [CI], 0.33-0.83 and OR, 0.56; 95% CI, 0.35-0.92, respectively). In patients with myomas >1.5 cm, LBR was also significantly reduced, even after adjusting for age, smoking, quality of embryo transferred, antral follicle count, and dose of gonadotropins (OR, 0.53; 95% CI, 0.29-0.97). This LBR finding was not significant if all myomas were included (including those <1.5 cm in diameter), but CPR was still significantly reduced.

CONCLUSION

Relatively small (>1.5 cm) non-cavity-distorting intramural myomas negatively affect CPR and LBR in in vitro fertilization cycles, even in the presence of only 1 myoma.

Fibroids that do not distort the uterine cavity and IVF success rates: an observational study using extensive matching criteria

OBJECTIVE

To assess the impact of non-cavity-distorting fibroids on in vitro fertilisation (IVF) pregnancy outcomes.

DESIGN

A retrospective, matched, single-centre, cohort study was performed.

SETTING

The IVF unit of a tertiary, university hospital.

POPULATION

We analysed all women with non-cavity-distorting uterine fibroids undergoing IVF/intracytoplasmic sperm injection (ICSI) cycles from 1 January 2011 to 1 May 2015.

METHODS

Each woman was matched with two separate controls of the same age (±6 months), stimulation protocol (gonadotropin-releasing hormone agonist or antagonist), starting dose of follicle-stimulating hormone (FSH), number of embryos transferred (one or two), day of transfer (day 3 or day 5), and no uterine fibroids identified by transvaginal ultrasound.

MAIN OUTCOME MEASURES

Clinical pregnancy and live birth rates.

RESULTS

Our study demonstrates that the presence of non-cavity-distorting fibroids appears to negatively affect clinical pregnancy (odds ratio, OR 0.62; 95% confidence interval, 95% CI 0.41-0.94) and live birth rates (OR 0.58; 95% CI 0.48-0.78) in patients undergoing their first IVF/ICSI cycle, when matched with controls of the same age, starting dose of FSH, stimulation protocol, number of embryos, and day of embryo transfer. The deleterious effect of fibroids on live birth rates was significant in women with two or more fibroids (OR 0.47; 95% CI 0.26-0.83) and in women with fibroids of ≥30 mm in diameter (OR 0.41; 95% CI 0.19-0.89). The negative impact of non-cavity-distorting fibroids was also present in women with an embryo transfer on day 5 (OR 0.58; 95% CI 0.35-0.94). Conversely, in women with single fibroids of <30 mm in diameter, no difference in pregnancy outcomes was identified.

CONCLUSIONS

A well-designed, adequately powered, randomised controlled trial is required to address the role of medical or surgical interventions in patients with intramural and subserosal fibroids before undergoing fertility treatment.

TWEETABLE ABSTRACT

Non-cavity-distorting fibroids negatively affect pregnancy rates after IVF.

Pregnancy complications in spontaneous and assisted conceptions of women with infertility and subfertility factors. A comprehensive review

In the literature, there is growing evidence that assisted reproductive techniques increase the risk of pregnancy complications in subfertile couples. Moreover, many concomitant preconception risk factors for subfertility are frequently present in the same subject and increase the risk of pregnancy complications. This review aimed to summarize in a systematic fashion the best current evidence regarding the effects of preconception maternal factors on maternal and neonatal outcomes. A literature search up to March 2016 was performed in IBSS, SocINDEX, Institute for Scientific Information, PubMed, Web of Science and Google Scholar. An evidence-based hierarchy was used to determine which articles to include and analyse. Available data show that the risk of pregnancy complications in spontaneous and assisted conceptions is likely multifactorial, and the magnitude of this risk is probably very different according specific subgroups of patients. Notwithstanding the only moderate level and quality of the available evidence, available data suggest that the presence and the treatment of specific preconception cofactors of subfertility should be always taken into account both in clinical practice and for scientific purposes.

Physiological Aspects of Female Fertility: Role of the Environment, Modern Lifestyle, and Genetics

Across the Western World there is an increasing trend to postpone childbearing. Consequently, the negative influence of age on oocyte quality may lead to a difficulty in conceiving for many couples. Furthermore, lifestyle factors may exacerbate a couple's difficulty in conceiving due mainly to the metabolic influence of obesity; however, the negative impacts of low peripheral body fat, excessive exercise, the increasing prevalence of sexually transmitted diseases, and smoking all have significant negative effects on fertility. Other factors that impede conception are the perceived increasing prevalence of the polycystic ovary syndrome, which is further exacerbated by obesity, and the presence of uterine fibroids and endometriosis (a progressive pelvic inflammatory disorder) which are more prevalent in older women. A tendency for an earlier sexual debut and to have more sexual partners has led to an increase in sexually transmitted diseases. In addition, there are several genetic influences that may limit the number of oocytes within the ovary; consequently, by postponing attempts at childbearing, a limitation of oocyte number may become evident, whereas in previous generations with earlier conception this potentially reduced reproductive life span did not manifest in infertility. Environmental influences on reproduction are under increasing scrutiny. Although firm evidence is lacking however, dioxin exposure may be linked to endometriosis, phthalate exposure may influence ovarian reserve, and bisphenol A may interfere with oocyte development and maturation. However, chemotherapy or radiotherapy is recognized to lead to ovarian damage and predispose the woman to ovarian failure.

Is Myomectomy Prior to Assisted Reproductive Technology Cost Effective in Women with Intramural Fibroids?

AIM

To evaluate the cost effectiveness of surgery to remove intramural (IM) fibroids prior to assisted reproductive technology (ART).

METHODS

The decision tree mathematical model along with sensitivity analysis was performed to analyze cost effectiveness of: (1) myomectomy followed by ART or (2) ART with IM myoma(s) in situ.

RESULTS

At the median ongoing pregnancy (OP) rate (OPR) reported in the literature for a fresh, autologous ART cycle with IM fibroids in situ vs. post-IM myomectomy, average cost per OP was $72,355 vs. 66,075, indicating a cost savings with myomectomy. Sensitivity analysis over the range of reported OPRs demonstrated that pre-ART IM myomectomy was always cost effective when OPR among women with in situ myomas was <15.4%. However, for OPRs ≥15.4%, pre-ART IM myomectomy was only cost effective if it increased OPR by at least 9.6%. At the high end of OPRs reported for patients with IM myomas in situ (31.4%), a 19.5% improvement in OPR was needed to justify IM myomectomy from a cost perspective.

CONCLUSION

Myomectomy should be used sparingly in cases where the goal of surgery is to achieve improvement in the outcomes of ART.

Medical Therapies for Uterine Fibroids - A Systematic Review and Network Meta-Analysis of Randomised Controlled Trials

Background

Uterine fibroids are common, often symptomatic and a third of women need repeated time off work. Consequently 25% to 50% of women with fibroids receive surgical treatment, namely myomectomy or hysterectomy. Hysterectomy is the definitive treatment as fibroids are hormone dependent and frequently recurrent. Medical treatment aims to control symptoms in order to replace or delay surgery. This may improve the outcome of surgery and prevent recurrence.

Purpose

To determine whether any medical treatment can be recommended in the treatment of women with fibroids about to undergo surgery and in those for whom surgery is not planned based on currently available evidence.

Study Selection

Two authors independently identified randomised controlled trials (RCT) of all pharmacological treatments aimed at the treatment of fibroids from a list of references obtained by formal search of MEDLINE, EMBASE, Cochrane library, Science Citation Index, and ClinicalTrials.gov until December 2013.

Data Extraction

Two authors independently extracted data from identified studies.

Data Synthesis

A Bayesian network meta-analysis was performed following the National Institute for Health and Care Excellence—Decision Support Unit guidelines. Odds ratios, rate ratios, or mean differences with 95% credible intervals (CrI) were calculated.

Results and Limitations

A total of 75 RCT met the inclusion criteria, 47 of which were included in the network meta-analysis. The overall quality of evidence was very low. The network meta-analysis showed differing results for different outcomes.

Conclusions

There is currently insufficient evidence to recommend any medical treatment in the management of fibroids. Certain treatments have future promise however further, well designed RCTs are needed.

Uterine fibroids associated with infertility

In recent years, there has been an increasing focus on the contributory role of uterine fibroids to infertility. The prevalence of these tumors increases with age, which becomes significant as more women are delaying childbearing. Therefore, fibroids and infertility frequently occur together. Treatment varies with fibroid location and size. The various methods of treatment include open myomectomy, laparoscopic or robot-assisted myomectomy, medical treatment, uterine artery embolization and magnetic resonance guided focused ultrasound surgery. While there is a general consensus on the treatment of submucosal fibroids, the management of intramural fibroids in the infertility patient remains controversial. This paper aims to review and summarize the current literature in regards to the approach to uterine fibroids in the infertile patient.

Consensus statement on prevention and detection of ovarian hyperstimulation syndrome

BACKGROUND

Ovarian hyperstimulation syndrome is an important condition with considerable morbidity and a small risk of mortality, which most commonly results as an iatrogenic condition following follicular stimulation of the ovaries.

AIM

To produce evidence-based and consensus statements on the prevention and detection of ovarian hyperstimulation syndrome (OHSS).

METHOD

The CREI Consensus Group met in 2008 and identified issues for inclusion and review. Review of the available evidence was conducted and consensus statements prepared. Areas of dissent of expert opinion and for further research were noted.

RESULTS

The group considered that there is a need for standardisation of the definition and classification of the clinical syndrome of OHSS to allow further conclusive research. Interventions with evidence of effect in reducing OHSS include the use of metformin in women with PCOS, use of GnRH antagonist rather than GnRH agonist and use of GnRH agonist triggers in GnRH antagonist stimulation cycles. The consensus view was that reducing the dose of FSH, freezing all embryos and transferring a single embryo were appropriate interventions to reduce OHSS. Agreement could not be reached on coasting, the lowest number of oocytes to consider freezing all embryos and management after cancellation of oocyte collection.

CONCLUSION

OHSS is a serious condition for which there are a number of proven preventative strategies. OHSS is an area requiring ongoing research and development of a universally agreed definition will allow development of optimal prevention strategies and facilitate improved early detection of women at risk.

Successful pregnancy after treatment with ulipristal acetate for uterine fibroids

This case report presents a clinical pregnancy after ulipristal acetate (UA) to decrease uterine fibroid size. A 37-year-old patient, gravida 1, abortus 1, with uterine fibroids was treated with 5 mg of UA daily for 13 weeks starting eight months after a multiple laparotomic myomectomy. Fibroid shrinkage and restoration of the morphology of endometrial cavity were evaluated in order to allow a subsequent pregnancy. A decrease of the uterine fibroids and a normal morphology of the endometrial cavity were noted by transvaginal ultrasound after treatment. An endometrial biopsy excluded histologic endometrial changes. Three months after the end of UA the patient reported amenorrhea for 5 weeks and a clinical pregnancy was confirmed with transvaginal ultrasound. She underwent a subsequent uneventful pregnancy. Thus, the spontaneous pregnancy after UA to reduce fibroid size may support the potential clinical utility of this selective progesterone receptor modulator in the management of women with pregnancy desire and uterine fibroids after a prior myomectomy. Patients who refuse a new surgical procedure and/or those who are going to undergo assisted reproductive techniques would benefit from UA. It effectively shrinks fibroids, avoids risks of a new surgical procedure, and allows an immediate attempt at conception after the end of treatment.

Reproductive tract tumours: the scourge of woman reproduction ails Indian rhinoceroses

In Indian rhinoceros, extensive leiomyoma, a benign smooth muscle tumour, was sporadically diagnosed post mortem and commonly thought of as contributing factor for reduced fecundity of this species in captivity. However, to date, the prevalence of reproductive tract tumours and their relevance for fecundity are unknown. Our analysis of the international studbook now reveals that females cease reproducing at the age of 18.1±1.2 years; equivalent to a reproductive lifespan of just 9.5±1.3 years. This short reproductive life is in sharp contrast to their longevity in captivity of over 40 years. Here we show, after examining 42% of the captive female population, that age-related genital tract tumours are highly prevalent in this endangered species. Growth and development of these tumours was found to be age-related, starting from the age of 10 years. All females older than 12 years had developed genital tumours, just 7–9 years past maturity. Tumour sizes ranged from 1.5–10 cm. With age, tumours became more numerous, sometimes merging into one large diffuse tumour mass. These tumours, primarily vaginal and cervical, presumably cause widespread young-age infertility by the age of 18 years. In few cases, tumour necrosis suggested possible malignancy of tumours. Possible consequences of such genital tract tumour infestation are hindered intromission, pain during mating, hampered sperm passage, risk of ascending infection during pregnancy, dystocia, or chronic vaginal bleeding. In humans, leiomyoma affect up to 80% of pre-menopause women. While a leading cause for infertility, pregnancy is known to reduce the risk of tumour development. However, different from human, surgical intervention is not a viable treatment option in rhinoceroses. Thus, in analogy to humans, we suggest early onset and seamless consecutive pregnancies to help reduce prevalence of this disease, better maintain a self-sustained captive population and improve animal welfare.

Overt hypothyroidism is associated with the presence of uterine leiomyoma: a retrospective analysis

OBJECTIVE

A possible correlation between uterine leiomyoma and thyroid disease was reported decades ago. We aimed to evaluate the possible associations between the presence of uterine leiomyomas and (i) the presence of overt hypothyroidism, (ii) the level of anti-thyroid peroxidase antibodies (TPO-Ab) and thyroglobulin antibodies (TG-Ab), and (iii) thyroid stimulating hormone (TSH) levels.

STUDY DESIGN

In a retrospective study, all 215 sterile women who underwent reproductive surgery (hysteroscopy and laparoscopy/laparotomy) at our department from January 2007 to January 2011 were included. All leiomyomas suspected on gynecologic ultrasound were verified during surgery. As risk factors for uterine leiomyomas, thyroid parameters, age, African heritage, age at menarche, parity, and body mass index were included.

RESULTS

One or more uterine leiomyomas were found in 51 cases (23.7%). After multivariate analysis, three parameters remained significant, with African heritage the most important (odds ratio, OR, 27.80), followed by overt hypothyroidism (OR 3.10) and increasing age (OR 1.23). Larger leiomyomas were found in women with overt hypothyroidism than in those without overt hypothyroidism (median, 70 mm; range, 5-88 vs. median, 30 mm; range, 2-93, respectively; p=0.007).

CONCLUSIONS

Overt hypothyroidism, but not autoantibodies against the thyroid gland, was associated with the presence of uterine leiomyoma in our study.

Uterine Fibroid Embolisation - Potential Impact on Fertility and Pregnancy Outcome

The current standard therapy to treat myomas in women wishing to have children consists of minimally invasive surgical myomectomy. Uterine artery embolisation (UAE) has also been discussed as another minimally invasive treatment option to treat myomas. This review evaluates the literature of the past 10 years on fibroid embolisation and its impact on fertility and pregnancy. Potential problems associated with UAE such as radiation exposure of the ovaries, impairment of ovarian function and the impact on pregnancy and child birth are discussed in detail. Previously published reports of at least 337 pregnancies after UAE were evaluated. The review concludes that UAE to treat myomas can only be recommended in women with fertility problems due to myomas who refuse surgery or women with an unacceptably high surgical risk, because the evaluated case reports and studies show that UAE significantly increases the risk of spontaneous abortion; there is also evidence of pathologically increased levels for other obstetric outcome parameters. There are still very few prospective studies which provide sufficient evidence for a definitive statement on the impact of UAE therapy on fertility rates and pregnancy outcomes.

Comparison of characteristics of fibroids in African American and white women undergoing premenopausal hysterectomy

OBJECTIVE

To compare pathologic characteristics and epidemiologic risk factors for uterine fibroids in African American and white women undergoing hysterectomy.

DESIGN

Cross-sectional analysis of women undergoing premenopausal hysterectomy.

SETTING

Two university-associated hospitals in North Carolina.

PATIENT(S)

African American (n = 225) and white women (n = 135) with fibroid diagnosis.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Data were obtained from an in-person interview and abstracted from operative and pathologic reports. Analysis of variance and multiple linear regression models were used to identify characteristics associated with higher uterine weight, greater number of fibroids, and size of the largest fibroid.

RESULT(S)

African American women had substantially more fibroids (9.9 vs. 4.5) with a concomitant higher mean uterine weight (477 vs. 267 g). Although African American women had a higher prevalence of established risk factors for fibroids, such as high body mass index (BMI) and hypertension, these factors were not associated with larger uteri or more numerous fibroids. In multiple linear regression models, the only factors statistically significantly associated with higher uterine weight, larger fibroids, and more numerous fibroids were race and nulligravidity.

CONCLUSION(S)

The presentation of fibroids as measured by uterine size or number of fibroids is more severe in African American women compared with white women. The differences in presentation cannot be explained by racial differences in the prevalence of known risk factors. Additional research is needed on environmental and genetic factors that may increase the risk for fibroids.

Surgical treatment of fibroids for subfertility

BACKGROUND

Fibroids are the most common benign tumours of the female genital tract and are associated with numerous clinical problems including a possible negative impact on fertility. In women requesting preservation of fertility, fibroids can be surgically removed (myomectomy) by laparotomy, laparoscopically or hysteroscopically depending on the size, site and type of fibroid. Myomectomy is however a procedure that is not without risk and can result in serious complications. It is therefore essential to determine whether such a procedure can result in an improvement in fertility and, if so, to then determine the ideal surgical approach.

OBJECTIVES

To examine the effect of myomectomy on fertility outcomes and to compare different surgical approaches.

SEARCH METHODS

We searched the Cochrane Menstrual Disorders and Subfertility Group (MDSG) Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, Database of Abstracts of Reviews of Effects (DARE), LILACS, conference abstracts on the ISI Web of Knowledge, OpenSigle for grey literature from Europe, and ongoing clinical trials registered online. The final search was in June 2012.

SELECTION CRITERIA

Randomised controlled trials examining the effect of myomectomy compared to no intervention or where different surgical approaches are compared regarding the effect on fertility outcomes in a group of infertile women suffering from uterine fibroids.

DATA COLLECTION AND ANALYSIS

Data collection and analysis were conducted in accordance with the procedure suggested in the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

One study examined the effect of myomectomy on reproductive outcomes and showed no evidence for a significant effect on the clinical pregnancy rate for intramural (OR 1.88, 95% CI 0.57 to 6.14), submucous (OR 2.04, 95% CI 0.62 to 6.66), combined intramural and subserous (OR 2.00, 95% CI 0.40 to 10.09) and combined intramural submucous fibroids (OR 3.24, 95% CI 0.72 to 14.57). Similarly, there was no evidence for a significant effect of myomectomy for any of the described types of fibroids on the miscarriage rate (intramural fibroids OR 0.89 (95% CI 0.14 to 5.48), submucous fibroids OR 0.63 (95% CI 0.09 to 4.40), combined intramural and subserous fibroids OR 0.25 (95% CI 0.01 to 4.73) and combined intramural submucous fibroids OR 0.50 (95% CI 0.03 to 7.99).Two studies compared open versus laparoscopic myomectomy and found no evidence for a significant effect on the live birth rate (OR 0.80, 95% CI 0.42 to 1.50), clinical pregnancy rate (OR 0.96, 95% CI 0.52 to 1.78), ongoing pregnancy rate (OR 1.61, 95% CI 0.26 to 10.04), miscarriage rate (OR 1.31, 95% CI 0.40 to 4.27), preterm labour rate (OR 0.68, 95% CI 0.11 to 4.43) and caesarean section rate (OR 0.59, 95% CI 0.13 to 2.72).

AUTHORS' CONCLUSIONS

There is currently insufficient evidence from randomised controlled trials to evaluate the role of myomectomy to improve fertility. Regarding the surgical approach to myomectomy, current evidence from two randomised controlled trials suggests there is no significant difference between the laparoscopic and open approach regarding fertility performance. This evidence needs to be viewed with caution due to the small number of studies. Finally, there is currently no evidence from randomised controlled trials regarding the effect of hysteroscopic myomectomy on fertility outcomes.

Medication and transference in psychoanalytically oriented psychotherapy of the borderline patient

The regressive potential of the borderline patient has been recognized ever since the term was first introduced by Adolph Stern in 1938. He believed these patients were "too ill for classical psychoanalysis," and indeed almost all who have written on this subject have supported Stern's view, recognizing the severe regressive potential of a borderline patient in unmodified psychoanalysis. Taking medication is not generally considered to be a particularly regressive experience. It should be remembered, however, that for many patients and especially for patients with borderline personality disorder, medication can be both an overvalued hope and a terrifying assault. Thus, although the pharmacologic action of the medication may help to integrate the patient's ego functioning, the very taking of the medication may at the same time initiate subtle and unanticipated regressive drives. Two forces are then set in motion with potentially different effects. In a treatment where the same physician is prescribing medication and doing psychotherapy, the common pathway of these forces is transference. Thus, pharmacologic action may modify transference. And more importantly, because it is less easily recognized, transference issues may affect the patient's subjective experience of the action of the medication. For this reason, it is particularly important that not only diagnostic issues but also transference issues be understood before medication is prescribed.(ABSTRACT TRUNCATED AT 250 WORDS)