Novel do-it-yourself low-cost abdominal laparoscopy entry simulator for gynaecology trainees

The COVID-19 pandemic has affected gynaecology trainees in the United Kingdom by reducing operating theatre experience. Simulators are widely used for operative laparoscopy but not for practising laparoscopic-entry techniques. We devised a low-cost simulator to help trainees achieve the skill. Our aim was to pilot this low-cost simulator to perform Royal College of Obstetricians and Gynaecologists (RCOG) supervised learning events.A single-centre pilot study involving six gynaecology trainees in a structured training session. Interactive PowerPoint teaching was followed by trainees’ demonstration of laparoscopic entry for a supervised learning event and personalized feedback. Participants completed pre- and post-course questionnaires.All the trainees found the training useful to the score of 10 (scale of 1–10) and recommended this to be included in Deanery teaching. Personalized feedback was described as the most useful. The simulator was rated as good as a real-life patient relative to the skill being taught.Gynaecology trainees are affected by lack of hands-on experience in the operating theatre for performing laparoscopic entry. A low-cost abdominal laparoscopy entry simulator can help deliver the RCOG curriculum, enabling trainees to achieve required competencies.

Antiphospholipid antibodies and combined pathology of small pelvis in women with tumors and tumoroid ovary formations, who suffer with infertility, and correction of revealed disorders

It is given in an article the obtained investigation results in studying antiphospholipid antibodies contains and combined pathology of small pelvis organs in 32 women with tumors and timorous ovary formations, who suffered with infertility. Analysis of anamnesis and clinic-laboratorial data, echography, operative laparoscopy and histological investigation is presented.

RURAL HOSPITAL CORRELATION OF CLINICAL PRESENTATION, HISTOPATHOLOGY, AND POLYMERASE CHAIN REACTION FOR GENITAL TUBERCULOSIS DIAGNOSIS

In India, vaginal tuberculosis (FGTB) is a common cause of infertility, but diagnosis is difficult because of the form of the disease of people in need. Traditional diagnostic methods include the detection of rapid bacilli acid in endometrial or peritoneal biopsy, epithelioid granuloma biopsy, or a positive Expert type in biopsy, although this is only available in a small percentage of cases, leaving patients many are not available. Diagnosis of GTB by PCR along with histopathological findings leads to high sensitivity and specificity. So, both diagnostic and operative laparoscopy and hysteroscopy are the modalities essential for management of genital TB in infertile women. This review discusses various diagnostic modalities including endometrial or peritoneal biopsy to detect epithelioid granuloma on microscopy, role of PCR for GTB and correlation of two for early diagnosis of genital tuberculosis so that management will be started at early stage which can prevent patient from getting permanent damage to organs. Tuberculosis being endemic in counties likes India; it is often a leading cause of infertility. Early diagnosis is crucial because, by the time patient reports with infertility, already the damage has started and reverting tubal patency is almost impossible. Early diagnosis typically fails in developing countries, primarily because there are no pathognomonic signs of the disease and either poor sensitivity or procedurally invasive diagnostic methods are in use.

Impact of endometriosis on female fertility and the management options for endometriosis-related infertility in reproductive age women: a scoping review with recent evidences

Background Endometriosis is a chronic inflammatory condition with varied presentation, which ultimately leads to chronic pelvic pain and infertility. It is a psychological and economic burden to the women and their families. Main body of abstract The literature search was performed on the following databases: MEDLINE, Google Scholar, Scopus, EMBASE, Global health, the COCHRANE library, and Web of Science. We searched the entirety of those databases for studies published until July 2020 and in English language. The literature search was conducted using the combination of the Medical Subject heading (MeSH) and any relevant keywords for “endometriosis related infertility and management” in different orders. The modalities of treatment of infertility in these patients are heterogeneous and inconclusive among the infertility experts. In this article, we tried to review the literature and look for the evidences for management of infertility caused by endometriosis. In stage I/II endometriosis, laparoscopic ablation leads to improvement in LBR. In stage III/IV, operative laparoscopy better than expectant management, to increase spontaneous pregnancy rates. Repeat surgery in stage III/IV rarely increases fecundability as it will decrease the ovarian reserve, and IVF will be better in these patients. The beneficial impact of GnRH agonist down-regulation in ART is undisputed. Dienogest is an upcoming and new alternative to GnRH agonist, with a better side effect profile. IVF + ICSI may be beneficial as compared to IVF alone. Younger patients planned for surgery due to pain or any other reason should be given the option of fertility preservation. Short conclusion In women with endometriosis-related infertility, clinician should individualize management, with patient-centred, multi-modal, and interdisciplinary integrated approach.

A comparison of laparoscopy versus laparotomy for the management of adnexal masses during pregnancy over the last 16 years: retrospective study

Background Adnexal masses during pregnancy is not rare. More and more evidences imply that operative laparoscopy for adnexal masses performed during pregnancy could be safe and feasible. We procured and evaluated the surgical, obstetric outcomes between laparoscopy and laparotomy for the management of adnexal masses during first and second trimester period in our hospital. Results 117 pregnant women with adnexal masses were treated by laparoscopy (69 cases) or laparotomy (48 cases) between July 2003 and March 2019. The laparoscopy group had a significantly lower blood loss (22.0 ± 3.4ml vs 41.7 ± 4.3ml, P = 0.0004), a shorter onset of flatus after operation (24.2 ± 0.1h vs 41.6 ± 1.9h, P < 0.0001) and a shorter hospital stay (3.5 ± 0.2 days vs 6.6 ± 0.2 days, < 0.0001) than the laparotomy group. No patient from either group required a blood transfusion. There is no significant difference in obstetric outcomes, including preterm labor and fetal loss. The median follow-up time was 3.5 years (range, 1.5–11.5 years) after surgery. The median age of the children was 2.5 years (range, 1-9.5 years). No notable abnormality was found. Conclusions In this retrospective study, compared with laparotomy, laparoscopy has successful outcome with lower blood loss, shorter onset of flatus after surgery, and shorter hospital stay, all of those suggest that operative laparoscopy could be promising for adnexal masses performed during pregnancy.

The effect of subcutaneous and intraperitoneal anesthesia on post laparoscopic pain: a randomized controlled trial

A few modes of perioperative local analgesia have been studied in order to reduce postoperative pain after laparoscopy, including preemptive local anesthetics in the trocar sites and intraperitoneal anesthetics administration at the end of the surgery. However, the evidence regarding their efficacy are conflicting. In addition, the combination of both aforementioned methods has been rarely studied. Our aim was to evaluate whether subcutaneous trocar site and/or intraperitoneal analgesia reduce pain after gynecologic operative laparoscopy. This was a single-centered, randomized, controlled, double-blinded trial. The patients were randomly assigned to one of four equally sized groups: group 1—subcutaneous and intraperitoneal analgesia; group 2—subcutaneous analgesia and intraperitoneal placebo; group 3—subcutaneous placebo and intraperitoneal analgesia; Group 4—subcutaneous and intraperitoneal placebo. The patients, the surgeons, and the pain evaluators were all blinded to the patient’s allocation. Included were patients who underwent elective operative laparoscopy. Exclusion criteria were: active infection, pregnancy, known sensitivity to Bupivacaine-Hydrochloride, chronic pelvic pain, surgeries with additional vaginal procedures, conversion to laparotomy, and malignancy. A total of 9 ml of Bupivacaine-Hydrochloride (Marcaine) 0.5%, or Sodium-Chloride 0.9%, as a placebo, were injected subcutaneously to the trocar sites (3 ml to each trocar site), prior to skin incision. In addition, 10 ml of Bupivacaine-Hydrochloride 0.5%, diluted with 40 ml of Sodium-Chloride 0.9% (a total of 50 ml solution), or 50 ml of Sodium-Chloride 0.9%, as a placebo, were injected intraperitoneally at the end of the surgery. By utilizing the 10 cm Visual-analogue-scale (VAS) we assessed post-operative pain at rest at 3, 8, and 24 h, and during ambulation at 8 and 24 h. The study was approved by the local Institutional Review Board and has been registered at clinicaltrials.gov. We conformed to the CONSORT recommendations. Between December 2016 and July 2019, a total of 119 patients were included in the study. Demographic and interventional characteristics were similar among the groups. The level of postoperative pain, either at rest or with change of position, was not significantly different between the groups, at all-time points. Application of subcutaneous and/or intraperitoneal analgesia is not effective in reducing pain after gynecologic operative laparoscopy.Clinical trial identification number: NCT02976571. Date of trial registration 11/29/2016. URL of the registration site: https://clinicaltrials.gov.

Implantation capacity of endometry of veteran women, with contusion in anamnesis, with unrealized reproductive function

The objective: improving the efficiency of diagnosis and treatment of pathology and implantation ability of the endometrium in women of reproductive age who took part in hostilities and received concussions. Materials and methods. The study of endometrial pinopodia was carried out in 35 women of reproductive age who took part in hostilities and received concussions, who on the 21st day of the MC underwent operative laparoscopy and hysteroscopy with endometrial sampling for histological examination and scanning electron microscopy. Of these women, 22 patients – a comparison group – of reproductive age with a history of trauma without post-concussion syndrome and 13 in the main group, women of reproductive age, have the consequences of contusion in the form of post-concussion syndrome. Served as control 10 samples of endometrium from civilian women of reproductive age. The average age of the surveyed was 27.08±4.23 years. The period of stay in the combat zone was 29.34±9.21 months, the time from the moment of receiving a slight traumatic brain injury (contusion) was 18.8±9.2 months. Results. In combatant-women with contusion in history, there are disturbances in the receptivity of the endometrium, manifested by abnormalities in the development of pinopodia and their microvilli during the implantation window: areas without pinopodia in 47.50% of cases (p<0.006), pinopodia of sizes – in 77.50% (p<0.01) and abundant microvilli – in 37.50% (p<0.02); a decrease in the frequency of the presence of developed pinopodia by 2.12 times (p<0.01), large pinopodia by 2.29 (p<0.01), and a small number of microvilli by 4.00 (p<0.0001), an increase in the occurrence of medium-sized pinopodia by 3.00 (p<0.02) times, and a moderate number of microvilli by 4.00 (p<0.0001). A characteristic feature of endometrial pinopodia in the above patients is the presence of mosaicism of their shape (65.00%) and size (67.50%). Conclusions. Women in the military who have been injured in combat are diagnosed with reproductive health problems caused by both the traumatic brain injury itself and the stressors associated with military service. Keywords: reproductive health, female veterans, post-contusion syndrome, receptive endometrial enlargement, office hysteroscopy.

Estimation of the Endometriosis Fertility Index prior to operative laparoscopy

STUDY QUESTION Can the Endometriosis Fertility Index (EFI) be estimated accurately before surgery? SUMMARY ANSWER The EFI can be estimated accurately based on mere clinical/ultrasound information, with some improvement after adding data from diagnostic laparoscopy. WHAT IS KNOWN ALREADY The EFI is a validated clinical instrument predicting the probability of pregnancy after endometriosis surgery without the use of ART. Being an end-of-surgery-score, it implies the decision for operative laparoscopy to be made in advance—hence, its role in the pre-surgical decision-making process remains to be established. STUDY DESIGN, SIZE, DURATION Single-cohort prospective observational study in 82 patients undergoing complete endometriosis excision (between June and December 2016). Two methods were used to estimate the final EFI: type A based on non-surgical clinical/ultrasound findings only, and type B based on the combination of non-surgical clinical/ultrasound findings and diagnostic laparoscopy data. To calculate EFI type A, an algorithm was created to translate non-surgical clinical/imaging information into rASRM (revised American Society of Reproductive Medicine)—and EFI points. EFI type A and type B estimates were assessed for their clinical and numerical agreement with the final EFI score. Agreement was defined as clinical if EFI scores were within the same range (0–4, 5–6, 7–10), and numerical if their difference was ≤1. PARTICIPANTS/MATERIALS, SETTING, METHODS All 82 patients underwent complete laparoscopic CO2-laser excision of any rASRM stage of endometriosis in the Leuven University Fertility Centre (LUFC) of University Hospitals Leuven, a tertiary referral centre for both endometriosis and infertility. An anonymized clinical research file was created. For each patient, three different data sets were created, in order to allow the estimation of the (surgical part) EFI and of the rASRM scores, defined as follows: ‘Estimated type A’ contained only non-surgical clinical/imaging data, ‘Estimated type B’ included type A information plus the information of the diagnostic laparoscopy and ‘Final EFI’ included information of type A, type B and all intra-operative information required to calculate the final EFI. To calculate EFI type A without surgical information, a set of rules was used to translate pre-surgical clinical/imaging information into (rASRM and EFI points). Scoring was done by one person (C.T.), with a time interval of 4 weeks between sessions for each EFI type. Next to the EFI, also rASRM score and stage were calculated. MAIN RESULTS AND THE ROLE OF CHANCE Agreement rate between estimated EFI type A and final EFI was high for both the clinical (0.915; 95% CI 0.832–0.965) and numerical definition (0.878; 95% CI 0.787–0.940). Agreement rates between estimated EFI type B and final EFI were even higher (clinical (0.988; 95% CI 0.934–1.000), numerical (0.963; 95% CI 0.897–0.992)). LIMITATIONS, REASONS FOR CAUTION Type A estimation is dependent on high-level gynaecological ultrasound expertise, which may not be available in all clinics. A small number of patients had no prior clinical, ultrasound (hard markers) or surgical confirmation of the diagnosis of endometriosis. When applying the estimated EFI type A in clinical practice, a priori assumptions of the presence or absence of endometriosis will need to be made in adjunct to the estimation of the estimated type A EFI when counselling patients on the potential benefit of an (at least diagnostic) laparoscopy. The level of agreement for type A or B should also be taken into account when counselling patients on the type of efforts undertaken to attempt to diagnose or rule out endometriosis. WIDER IMPLICATIONS OF THE FINDINGS As this study reports, the EFI can be estimated accurately based on clinical/ultrasound data only without the need for any surgical data. This means that the EFI could be used as an instrument to guide joint physician–patient decision-making between surgery, ART or other fertility management options for the individualized treatment of women with endometriosis-related infertility. STUDY FUNDING/COMPETING INTEREST(S) During this study period, C.T. was supported by FWO (Research Fund Flanders, Grant number 1700816N) and UZ Leuven KOF (University Hospitals Leuven, Klinisch Onderzoeksfonds). The LUFC received unrestricted research grants from Ferring Pharmaceuticals and Merck SA. Gedeon Richter and MSD sponsored travel to and attendance at scientific meetings. C.M. received consultancy fees from Lumenis (paid to KU Leuven, no private revenue). T.D. has been vice-president and head of global medical affairs infertility for the multinational pharmaceutical company Merck (Darmstadt, Germany) since 1 October 2015. He continues his academic appointment on a part-time basis as Professor of Reproductive Medicine at the University of Leuven (KU Leuven). T.D. has been vice-president and head of global medical affairs infertility for the multinational pharmaceutical company Merck (Darmstadt, Germany) since October 2015. He is also a Guest Professor in Reproductive Medicine and Biology at the Department of Development and Regeneration, Group Biomedical Sciences, KU Leuven (University of Leuven), Belgium, and an Adjunct Professor at the Department of Obstetrics and Gynecology in the University of Yale, New Haven, USA. This work was initiated before he joined Merck KGaA in October 2015, and completed during the subsequent years. TRIAL REGISTRATION NUMBER study registration number at UZ Leuven Clinical Trial Centre: S59221.

Study of hundred cases of infertility in polycystic ovarian syndrome and its management outcome

Background: Polycystic ovarian syndrome (PCOS) is relatively common endocrine disorder in reproductive aged women, which leads to reproductive, metabolic and endocrine abnormality. About 70 to 80% patients with PCOS have complained of infertility due to anovulation. Due to advanced diagnostic facility by endoscopic evaluation in infertility, incidence of PCOS has increased now a days.Methods: This is study of 100 cases of infertility with polycystic ovarian syndrome and its pregnancy outcome. In this study, from May 2019 to April 2020, 100 cases of infertility with PCOS were studied at tertiary care hospital. Hormonal assay, ultrasound and laparoscopy were used as diagnostic technique. Clomiphene citrate, letrozole, metformin, and laparoscopic ovarian drilling were used as treatment modalities.Results: The maximum number of patients in the study group are seen in the age group of 21-25 years. Menstrual irregularities are the most common presenting symptom affecting 70% females. Primary infertility is most commonly associated with PCOS. In PCOS, there is increased LH:FSH ratio. On USG examination, there are enlarged ovaries in 82% cases.Conclusions: PCOS is an emerging disease of new generation with high prevalence in infertile women. After proper diagnosis, management with lifestyle modification, pharmacotherapy with clomiphene citrate, letrozole and metformin are used as per necessities. Operative laparoscopy with ovarian drilling is the main treatment which results in good conception rate.