Enhancing interprofessional collaboration and interprofessional education in women's health

This article is from the 'To The Point' series from the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee. The purpose of this review is to provide an understanding of the differing yet complementary nature of interprofessional collaboration and interprofessional education as well as their importance to the specialty of Obstetrics and Gynecology. We provide a historical perspective of how interprofessional collaboration and interprofessional education have become key aspects of clinical and educational programs, enhancing both patient care and learner development. Opportunities to incorporate interprofessional education within women's health educational programs across organizations are suggested. This is a resource for medical educators, learners, and practicing clinicians from any field of medicine or any health-care profession.

Integration of health systems science and women's healthcare

Health systems science addresses the complex interactions in healthcare delivery. At its core, health systems science describes the intricate details required to provide high-quality care to individual patients by assisting them in navigating the multifaceted and often complicated US healthcare delivery system. With advances in technology, informatics, and communication, the modern physician is required to have a strong working knowledge of health systems science to provide effective, low-cost, high-quality care to patients. Medical educators are poised to introduce health systems science concepts alongside the basic science and clinical science courses already being taught in medical school. Because of the common overlap of women's healthcare subject matter with health systems science topics, such as interprofessional collaboration, ethics, advocacy, and quality improvement, women's health medical educators are at the forefront of incorporating health systems science into the current medical school educational model. Here, the authors have described the concept of health systems science and discussed both why and how it should be integrated into the undergraduate medical education curriculum. Medical educators must develop physicians of the future who can not only provide excellent patient care but also actively participate in the advancement and improvement of the healthcare delivery system.

Stakeholder Perspectives on Standardizing the Residency Application and Interview Processes

OBJECTIVE

The purpose of this study was to examine stakeholder perspectives on recommended standards for the obstetrics and gynecology (OBGYN) residency application and interview processes proposed for the 2019 to 2020 application cycle. The authors aimed to assess the acceptance and perception of key stakeholders on the feasibility of implementing the standards as well as the effect of these changes on applicant anxiety.

DESIGN AND SETTING

The authors electronically distributed an anonymous survey in February 2020 to OBGYN residency applicants, clerkship directors, student affairs deans, program directors, and program managers. Participants received a 15-item survey, with questions assessing the importance and adoption of the guidelines, as well as their effect on perceived applicants' anxiety. Responses were measured on a 5-item Likert scale. Multiple regression analysis was used to explore which residency factors were associated with compliance with the standards. IRB exemption was granted by the University of Michigan.

PARTICIPANTS

A total of 1358 participants completed the survey for an overall response rate of 39.26%. Response rates were 36.04% for applicants (904/2508), 46.67% for CDs (105/225), 34.84% for members of GSAs (34/155), 59.43% for program directors (167/281), and 51.03% for program managers (148/290).

RESULTS

The overall response rate was 39.26% (1358/3459) with 36.04% of applicants (904/2508), 46.67% of clerkship directors (105/225), 34.84% of student affairs deans (34/155), 59.43% of program directors (167/281), and 51.03% of program managers (148/290). The recommendations were perceived as important by all stakeholders. More than 90% of program directors reported compliance with some or all of the recommendations and more than 90% of all applicants, clerkship directors and student affairs deans reported that the standards reduced applicant anxiety. All stakeholders rated each guideline to be important to extremely important.

CONCLUSIONS

This study demonstrates the feasibility and acceptance of universal standards for the residency application process in the field of OBGYN. The vast majority of stakeholders surveyed supported the initiative and participated in the guidelines. Applicant respondents perceived the guidelines to be important and to decrease anxiety surrounding the application and interview timelines. These findings are important for other specialties when considering similar interventions.

To the Point: advising students applying to Obstetrics and Gynecology residency in 2020 and beyond

This article, from the "To the Point" series by the Undergraduate Medical Education Committee of the Association of Professors of Gynecology and Obstetrics, is a guide for advising medical students applying to Obstetrics and Gynecology residency programs. The residency application process is changing rapidly in response to an increasingly complex and competitive atmosphere, with a wider recognition of the stress, expense, and difficulty of matching into graduate training programs. The coronavirus disease 2019 pandemic and societal upheaval make this application cycle more challenging than ever before. Medical students need reliable, accurate, and honest advising from the faculty in their field of choice to apply successfully to residency. The authors outline a model for faculty career advisors, distinct from mentors or general academic advisors. The faculty career advisor has detailed knowledge about the field, an in-depth understanding of the application process, and what constitutes a strong application. The faculty career advisor provides accurate information regarding residency programs within the specialty, helping students to strategically apply to programs where the student is likely to match, decreasing anxiety, expense, and overapplication. Faculty career advisor teams advise students throughout the application process with periodic review of student portfolios and are available for support and advice throughout the process. The authors provide a guide for the faculty career advisor in Obstetrics and Gynecology, including faculty development and quality improvement.

Fostering Inclusive Approaches to Lesbian, Gay, Bisexual, and Transgender (LGBT) Healthcare on the Obstetrics and Gynecology Clerkship

This article from the "To the Point" series prepared by the Association of Professors in Gynecology and Obstetrics (APGO) Undergraduate Medical Education Committee (UMEC) provides educators with strategies for inclusion of Lesbian, Gay, Bisexual, Transgender (LGBT)-related content into the medical school curriculum. With a focus on the Obstetrics and Gynecology (OB/GYN) clerkship, we also address ways to enhance visibility of these curricula within existing clinical and teaching experiences.

To the Point: a prescription for well-being in medical education

This article is from the "To The Point" series prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee. The purpose of this review was to provide an overview of the importance of well-being in medical education. A literature search was performed by a Reference Librarian who used Ovid/MEDLINE to identify scholarly articles published in English on learner well-being, using the search terms "burnout," "resilience," "wellness," and "physicians" between 1946 and January 11, 2019. The accreditation expectations and standards, available assessment tools for learner well-being, existing programs to teach well-being, and some key elements for curriculum development are presented. This is a resource for medical educators, learners, and practicing clinicians from any field of medicine.

To the point: undergraduate medical education learner mistreatment issues on the learning environment in the United States

This article, from the To the Point series prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee, is an overview of issues to consider regarding learner mistreatment and its effects on the undergraduate medical education learning environment in the United States. National data from the American Association of Medical Colleges Graduate Questionnaire and local data regarding learner mistreatment provide evidence that the learning environment at most medical schools needs to be improved. The American Association of Medical Colleges' definition of learner mistreatment focuses on active mistreatment, but data on passive mistreatment also contribute to a negative learning environment. The lack of tolerance for active mistreatment issues such as public humiliation and sexual and racial harassment need to be made transparent through institutional and departmental policies. Additionally, reporting mechanisms at both levels need to be created and acted upon. Passive mistreatment issues such as unclear expectations and neglect can also be addressed at institutional and departmental levels through training modules and appropriate communication loops to address these concerns. To fully confront and solve this challenging issue regarding learner mistreatment at the undergraduate medical education level, solutions to need to be implemented for faculty, residents, and students in the institutional, departmental, and clerkship settings.

12-month outcomes of the US patient cohort in the SONATA pivotal IDE trial of transcervical ablation of uterine fibroids

Objective

The prospective SONATA pivotal Investigational Device Exemption (IDE) trial was performed in the United States (US) and Mexico to examine the safety and effectiveness of transcervical fibroid ablation (TFA) in the treatment of symptomatic uterine fibroids. This is an analysis of 12-month clinical outcomes in the US cohort.

Methods

TFA with the Sonata^® System was performed on women with symptomatic uterine fibroids. The 12-month co-primary endpoints were reduction in menstrual blood loss and freedom from surgical reintervention. Symptom severity, quality of life, patient satisfaction, safety, and reductions in uterine and fibroid volumes were also evaluated.

Results

One hundred twenty-five patients were enrolled and treated in the US. Both co-primary endpoints were achieved in this US-based cohort, as 65.3% of patients reported ≥50% reduction in menstrual bleeding and 99.2% of patients were free from surgical reintervention. Symptom improvement was noted by 97.4% of patients and 98.3% were satisfied. Ninety-five percent of patients reported reduced menstrual bleeding at 12 months, and 86.8% noted >20% reduction. Significant mean improvements at 12 months were realized in both symptom severity and health-related quality of life (33.8 points and 45.8 points, respectively; all P<0.0001). Mean maximal fibroid volume reduction per patient was 63.8%. There was a 0% incidence of device related adverse events. Mean length of stay was 2.5 hrs and 50% of patients returned to normal activity within 1 day.

Conclusion

This analysis of US patients in the SONATA pivotal IDE trial demonstrates results consistent with those in the full cohort. TFA with Sonata significantly reduced fibroid symptoms with a low surgical reintervention rate through 12 months. These results support the efficacy and safety of the Sonata system as a first-line treatment for women affected by symptomatic uterine fibroids.

Medical or surgical treatment before embryo transfer improves outcomes in women with abnormal endometrial BCL6 expression

PURPOSE

To evaluate the effect of medical or surgical treatment prior to embryo transfer in women with elevated endometrial BCL6 expression and suspected endometriosis in a prospective, cohort study design at a university-associated infertility clinic.

METHODS

All subjects had at least 1 year of unexplained infertility (UI) and each prospectively underwent endometrial biopsy and immunostaining for the oncogene BCL6, prior to embryo transfer during an assisted reproductive technology (ART) cycle. To be included, subjects had to have an abnormal BCL6 result, defined by elevated HSCORE ≥ 1.4. Women that were pre-treated with laparoscopy or medical suppression with GnRH agonist (depot leuprolide acetate; Lupron®, Abbvie, Inc., Chicago, IL) for 2 months were compared to a group that went untreated (controls). Endpoints included implantation rate (IR), clinical pregnancy rate (CPR), and live birth rate (LBR), and as well as cycle characteristics. Miscarriage rate were also compared between treatment and control group.

RESULTS

Women in each group had similar characteristics. Those treated by medical suppression and those undergoing laparoscopy for endometriosis had a significantly higher LBR, (5/10; 50%; 95%CI 23.7 to 76.3%) and (11/21; 52.4%; 95%CI 32.4 to 71.7), respectively, compared to controls (4/54; 7.4%; 95%CI 2.9 to 17.6). An absolute benefit of 44.2% (16/31; 95%CI 24.6 to 61.2) and a number need to treat of 3 for those that received treatment (medical suppression and laparoscopy), compared to no treatment. Miscarriages were significantly more common in the control group.

CONCLUSIONS

Women with suspected endometriosis and aberrant endometrial BCL6 expression have worse reproductive outcomes following embryo transfer, including a high miscarriage rate, poor IR, and low LBR and CPR compared to cycles pre-treated with medical and surgical management.

To the Point: The expanding role of simulation in obstetrics and gynecology medical student education

This article, from the "To the Point" series prepared by the Association of Professors of Gynecology and Obstetrics (APGO) Undergraduate Medical Education Committee (UMEC), provides educators with an overview of the use of simulation in undergraduate medical education in the field of obstetrics and gynecology. Simulation plays an important role in the education of medical students. Students are increasingly serving as clinical observers and providing less direct patient care. Simulation can help standardize education and ensure quality and comparability across an enlarging educational environment. This article summarizes the expanding role of simulation in undergraduate medical education in obstetrics and gynecology and its effect on important learner outcomes such as confidence, knowledge, skills, workplace behaviors, and translation to patient care.

To the point: gender differences in the obstetrics and gynecology clerkship

Gender differences in performance on the obstetrics and gynecology clerkship have been reported, with female students outperforming male students. Male students report that their gender negatively affects their experience during the clerkship. Additionally, there are fewer male students applying for obstetric/gynecology residency. This "To The Point" article by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee will describe the gender differences that have been found, examine factors that could be contributing to these issues, and propose measures to correct these disparities.

Barriers and Strategies to Engaging Our Community-Based Preceptors

ISSUE

This article, from the "To the Point" series that is prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee, is a review of commonly cited barriers to recruiting and retaining community-based preceptors in undergraduate medical education and potential strategies to overcome them.

EVIDENCE

Community-based preceptors have traditionally served as volunteer, nonsalaried faculty, with academic institutions relying on intrinsic teaching rewards to sustain this model. However, increasing numbers of learners, the burdens of incorporating the electronic medical record in practice, and increasing demands for clinical productivity are making recruitment and retention of community-based preceptors more challenging.

IMPLICATIONS

General challenges to engaging preceptors, as well as those unique to women's health, are discussed. Potential solutions are reviewed, including alternative recruitment strategies, faculty development to emphasize efficient teaching practices in the ambulatory setting, offers of online educational resources, and opportunities to incorporate students in value-added roles. Through examples cited in this review, clerkship directors and medical school administrators should have a solid foundation to actively engage their community-based preceptors.

To the point: medical education, technology, and the millennial learner

This article, from the "To The Point" series that was prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee, provides an overview of the characteristics of millennials and describes how medical educators can customize and reframe their curricula and teaching methods to maximize millennial learning. A literature search was performed to identify articles on generational learning. We summarize the importance of understanding the attitudes, ideas, and priorities of millennials to tailor educational methods to stimulate and enhance learning. Where relevant, a special focus on the obstetrics and gynecology curriculum is highlighted.

Endometrial BCL6 testing for the prediction of in vitro fertilization outcomes: a cohort study

OBJECTIVE

To evaluate endometrial BCL6 expression as a prognostic biomarker for IVF outcome in women with unexplained infertility (UI) before ET.

DESIGN

Prospective cohort study.

SETTING

University-associated infertility clinic.

PATIENT(S)

Women with UI for >1 year.

INTERVENTION(S)

We studied women with UI who underwent testing for endometrial BCL6, in an LH-timed midluteal phase biopsy and completed an IVF cycle and ET.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rate (PR) and live birth rate per transfer was compared for women positive or negative for BCL6 expression. An abnormal BCL6 result was defined by an histologic score (>1.4).

RESULT(S)

Women with normal and abnormal BCL6 and those who conceived or not had similar characteristics. Women with low levels of BCL6 expression had a significantly higher clinical PR (11/17; 64.7%; 95% confidence interval [CI] 41.3-82.6) compared with women with abnormal (high) BCL6 expression (9/52; 17.3%; 95% CI 9.3-30.8). These results yield a relative risk of 0.267 (95% CI 0.13-0.53; P=.0004) for those with normal BCL6 expression, an absolute benefit of 47.4% (95% CI 22.5-72.0). Live birth rate was also significantly higher in women with low BCL6 expression (10/17; 58.8%; 95% CI 36.0-78.4) compared with women with abnormal BCL6 expression (6/52; 11.5%; 95% CI 5.4-23.0). The relative risk was 0.19 (95% CI 0.08-0.45; P=.0002), yielding an absolute benefit of 47.3% (95% CI 21.8-67.8).

CONCLUSION(S)

Aberrant BCL6 expression (histologic score, >1.4) was strongly associated with poor reproductive outcomes in IVF cycles in women with UI.

Pelvic and breast examination skills curricula in United States medical schools: a survey of obstetrics and gynecology clerkship directors

BACKGROUND

Learning to perform pelvic and breast examinations produces anxiety for many medical students. Clerkship directors have long sought strategies to help students become comfortable with the sensitive nature of these examinations. Incorporating standardized patients, simulation and gynecologic teaching associates (GTAs) are approaches gaining widespread use. However, there is a paucity of literature guiding optimal approach and timing. Our primary objective was to survey obstetrics and gynecology (Ob/Gyn) clerkship directors regarding timing and methods for teaching and assessment of pelvic and breast examination skills in United States medical school curricula, and to assess clerkship director satisfaction with current educational strategies at their institutions.

METHODS

Ob/Gyn clerkship directors from all 135 Liaison Committee on Medical Education accredited allopathic United States medical schools were invited to complete an anonymous 15-item web-based questionnaire.

RESULTS

The response rate was 70%. Pelvic and breast examinations are most commonly taught during the second and third years of medical school. Pelvic examinations are primarily taught during the Ob/Gyn and Family Medicine (FM) clerkships, while breast examinations are taught during the Ob/Gyn, Surgery and FM clerkships. GTAs teach pelvic and breast examinations at 72 and 65% of schools, respectively. Over 60% of schools use some type of simulation to teach examination skills. Direct observation by Ob/Gyn faculty is used to evaluate pelvic exam skills at 87% of schools and breast exam skills at 80% of schools. Only 40% of Ob/Gyn clerkship directors rated pelvic examination training as excellent, while 18% rated breast examination training as excellent.

CONCLUSIONS

Pelvic and breast examinations are most commonly taught during the Ob/Gyn clerkship using GTAs, simulation trainers and clinical patients, and are assessed by direct faculty observation during the Ob/Gyn clerkship. While the majority of Ob/Gyn clerkship directors were not highly satisfied with either pelvic or breast examination training programs, they were less likely to describe their breast examination training programs as excellent as compared to pelvic examination training-overall suggesting an opportunity for improvement. The survey results will be useful in identifying future challenges in teaching such skills in a cost-effective manner.

CREOG In-Training Examination Results: Contemporary Use to Predict ABOG Written Examination Outcomes

BACKGROUND

The in-training examination (ITE) offers formative assessments of residents' developing medical knowledge. Identification of an ITE performance level associated with success on the specialty board examination allows identification of "at risk" residents.

OBJECTIVE

This study sought to identify a threshold score for obstetrics and gynecology residents' performance on the Council on Resident Education in Obstetrics and Gynecology (CREOG) ITE that predicts successful performance on the American Board of Obstetrics and Gynecology (ABOG) written examination.

METHODS

We analyzed ITE and ABOG results of 80 residents who completed 4 years of CREOG ITEs at 2 institutions between 2002 and 2012. We assessed the level of performance associated with successful performance on the ABOG written examination.

RESULTS

Data analyzed included scores for 71 of 80 residents (89%), with an overall pass rate of 82%. A postgraduate year (PGY) 4 score of 200 on the CREOG ITE or twice in any of the PGY training years was associated with a 100% ABOG pass rate. Scoring ≥ 205 in any PGY also was associated with a 100% pass rate. Residents who did not attain a score of 200 had a 35% to 45% chance of failing the ABOG written examination, depending on the PGY of the ITE performance.

CONCLUSIONS

Our findings suggest that a CREOG ITE score of at least 200 twice, or as a PGY-4, offers assurance of successful performance on the ABOG examination. Scores lower than this threshold may be used to identify "at risk" residents for added learning and provide program elements in need of improvement.

Laparoscopic surgery improves pregnancy outcomes in women with suspected endometriosis with or without pathological confirmation

PURPOSE OF THE INVESTIGATION

To verify whether histologic confirmation of endometriosis impacts fertility outcomes.

MATERIALS AND METHODS

Women with unexplained infertility (UI) underwent laparoscopic excision or ablation with CO2 laser or electrocautery of all suspected endometriotic lesions, followed by clinical treatment between January 2007 and December 2013; pregnancy (> 12 weeks) within 12 months of monitored cycles was the main outcome measured.

RESULTS

Women with histological confirmation (n = 74) did not differ from those not confirmed (n = 29) with age, body mass index, gravidity, parity, ovulation induction protocol, and past duration of infertility. Pregnancy outcome was similar in both groups (39/74 vs. 15/29-p = 0.9--Chi-square) and there was no statistical difference in time to conceive/deliver (p = 0.7) between groups.

CONCLUSIONS

There is no difference in fertility outcomes in women with UI, whether or not suspected endometriosis is confirmed pathologically.

To the point: teaching the obstetrics and gynecology medical student in the operating room

This article, from the "To the Point" series that is prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee, is a review of considerations for teaching the medical student in the operating room during the obstetrics/gynecology clerkship. The importance of the medical student operating room experience and barriers to learning in the operating room are discussed. Specific considerations for the improvement of medical student learning and operating room experience, which include the development of operating room objectives and specific curricula, an increasing awareness regarding role modeling, and faculty development, are reviewed.

To the point: obstetrics and gynecology global health experiences for medical students

This article, from the To the Point series prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee, provides educators with an overview of considerations for obstetrics and gynecology global health experiences for the medical student. Options for integration of obstetrics and gynecology global health into undergraduate medical curricula are discussed. Specific considerations for global health clinical experiences for medical students, including choosing a clinical location, oversight and mentorship, goals and objectives, predeparture preparation, and evaluation, are reviewed.

Before the breaking point: reducing the risk of osteoporotic fracture

Osteoporosis is a major cause of morbidity in the United States, resulting in approximately 2 million fractures and contributing to 65,000 deaths annually. Organizations have published guidelines for the diagnosis and management of the disease. However, a degree of conflict exists among some of the recommendations. Several screening tools have been developed to identify fracture risk, and although the Fracture Risk Assessment tool developed by the World Health Organization has been widely adopted, other screening tests are also potentially useful. A range of medications are available for the prevention of osteoporosis in individuals who are at high risk for the disease and for the treatment of individuals who already have osteoporosis. Although some of these medications are highly effective, all have adverse-effect profiles and other caveats that require both familiarity with the characteristics of the medication and detailed knowledge of patient needs and preferences. Effective therapy is only possible with strong patient adherence to the regimen, which in turn requires that the patient have an understanding of the risks and benefits and can participate in the treatment-selection process.

Endometrial receptivity defects during IVF cycles with and without letrozole

BACKGROUND

Our aim was to study ways to improve IVF success rates in women with suspected endometrial receptivity defects.

METHODS

We conducted a retrospective cohort study examining the effect of letrozole (aromatase inhibitor) on integrin expression as a marker of endometrial receptivity. We compared IVF outcomes in 97 infertile women who had undergone ανβ3 integrin assessment by immunohistochemistry in mid-luteal endometrial biopsies. Of 79 women undergoing standard IVF, 29 (36.7%) lacked normal integrin expression. Eighteen other women with low integrin were studied after receiving letrozole during early IVF stimulation. An independent set of ανβ3 integrin-negative patients (n = 15) who had undergone repeat endometrial biopsy for integrin testing while taking letrozole were re-evaluated.

RESULTS

Clinical pregnancy and delivery rates were higher in women with normal ανβ3 integrin expression compared with those who were integrin negative [20/50 (40%) versus 4/29 (13.8%); P = 0.02 and 19/50 (38%) versus 2/29 (7%); P < 0.01, respectively]. In 18 women who received letrozole early in IVF, 11 conceived (61.1%; P < 0.001) compared with integrin-negative patients who did not receive letrozole. In integrin-negative women who were rebiopsied on letrozole, 66.7% reverted to normal integrin expression. Positive endometrial aromatase immunostaining using a polyclonal antibody was a common finding in infertile patients compared with controls.

CONCLUSIONS

Lack of endometrial ανβ3 integrin expression is associated with a poor prognosis for IVF that might be improved with letrozole co-treatment. Prospective studies are needed to confirm and extend these findings but the data suggest that aromatase expression may contribute to implantation failure in some women.

Changes in long luteal protocol affects the number of days of stimulation: evolution of an assisted reproductive technology practice

OBJECTIVE

To determine if the types of drugs used in controlled ovarian hyperstimulation influence the number of days of stimulation.

STUDY DESIGN

This retrospective study of couples presenting at an assisted reproductive technology (ART) facility January 1997 through December 2007 included patients who were < 40 years of age, had a body mass index (BMI) of 20-35, used fresh sperm or oocytes, had > or = 3 embryos available on day 3, never had previous ART, and did not use a gestational carrier. Data analysis was limited to patients treated with long luteal stimulation. Data were separated into two groups: patients stimulated with urinary drugs and those stimulated with recombinant drugs.

RESULTS

The groups were not different in age and day 3 follicle-stimulating hormone values, but were different in BMI, diagnoses, and fertilization methods. There were a significantly greater number of days of stimulation, total number of follicles produced, and peak estradiol level in the recombinant group. The recombinant group had less drug given per day, less endometrial thickness, and fewer embryos transferred.

CONCLUSION

A change in our long luteal stimulation protocol appears to have lengthened the days of stimulation for our patients without altering pregnancy rate.

Creation of a neovagina by the Vecchietti procedure in a patient with corrected high imperforate anus

BACKGROUND

Vaginal atresia is often associated with high imperforate anus. Because the commonly used methods of surgical vaginal creation (eg, McIndoe, intestinal segment interposition) may adversely affect urinary and fecal continence, the less-invasive Vecchietti procedure was selected for a young adult with a successfully corrected high imperforate anus.

METHODS

A 21-year-old was born with a high imperforate anus, vaginal atresia, right hemi-uterus, and left renal agenesis. A colostomy was done at birth, a pull-through procedure at 9 months, and a stoma closure 3 months later. At age 13, an obstructed and dilated right hemiuterus and fallopian tube were resected. A laparoscopic version of the Vecchietti procedure was used for creation of a neovagina.

RESULTS

After the patient had been in the hospital for 2 days, traction was gradually advanced every other day in the office. At 2 weeks postoperatively, the bead was removed revealing a 7-cm vagina. Further elongation was achieved using the Frank method, while continence remained intact.

CONCLUSION

The Vecchietti procedure is an attractive, minimally invasive alternative for creation of a neovagina in patients at risk for compromise to their vesico-anorectal continence.

Effect of short-term diet and exercise on hormone levels and menses in obese, infertile women

OBJECTIVE

To improve serum metabolic and endocrine measures known to influence fecundity.

STUDY DESIGN

Twelve infertile, obese women were enrolled in a 12-week program of diet and exercise. Subjects underwent baseline testing for estrone (E1), estradiol (E2), testosterone (T), luteinizing hormone (LH), follicle-stimulating hormone (FSH), thyroid-stimulating hormone (TSH), prolactin, fasting leptin, dehydroepiandrosterone sulfate (DHEAS), C-reactive protein (CRP) and total cholesterol. Glucose and insulin levels were measured fasting and 2 hours after a 75-g glucose load. Subjects attended three 1-hour exercise sessions per week and received instructions for a 1,200- to 1,300-kcal/day diet. Serum tests and body mass index (BMI) were remeasured after 12 weeks. Intermenstrual intervals were also recorded. At 24 weeks, subjects rated compliance with diet and exercise. Main outcome measures included change in serum variables, BMI and intermenstrual interval.

RESULTS

BMI, total cholesterol and E1/E2 ratio significantly decreased over 12 weeks (mean difference +/- SEM, 2.06 +/- 0.51 kg/m2, 25.91 +/- 4.33 mg/dL and 0.7 +/- 0.22, respectively). No significant differences were noted for all other measures. Ten of the 12 subjects (83%) showed menstrual improvement, with 8 becoming eumenorrheic.

CONCLUSION

Favorable metabolic and menstrual changes are possible in obese, infertile women after 12 weeks of diet and exercise.

Assisted reproductive technology (ART) in the upstate: reducing the risks of multiple births

Multiple pregnancies from ART procedures are all too common. Efforts to reduce high-order multiple pregnancies will require both social and medical reforms. In lieu of a legislative agenda to reduce multiple pregnancies in the United States, efforts must come from the personnel within the individual ART clinics. The approach to the problem includes accepting a lower pregnancy rate than otherwise might be obtainable, if the observed rate of high-order multiple pregnancies is above a certain threshold. Expanding the opportunities for ART reimbursement will ultimately address this problem in the United States, but until then, it is a problem that will not go away without commitment and resolve.

Managing common problems in perimenopausal women

The perimenopause can be a time of many changes in the lives of women. Uncomfortable, nuisance, and sometimes serious symptoms and medical problems often accompany it. Some of these problems include concerns about fertility or contraception (or both), hot flashes, sleep disturbances, urogenital changes, and abnormal uterine bleeding. Common treatment options for perimenopausal problems include hormone replacement therapy with estrogen and progestins and surgical modes of therapy. In addition, many women will notice a change in their health during the perimenopausal years and a strategy for screening and health maintenance needs to be established.