Infertility Procedures Research Articles

(090) DELAYED STENOSIS RATE POST VASECTOMY REVERSAL: A MULTICENTER COHORT

Abstract Introduction Outcomes with vasectomy reversal procedures for infertility have varied widely in the literature, with limited data available on long-term results. The current study objective was to provide data on long-term outcomes, including delayed stenosis rates using a multicenter dataset. Objective To evaluate the rate of long-term stenosis of men undergoing vasectomy reversal. Methods A retrospective study was performed of men undergoing vasectomy reversal for infertility by 14 surgeons from nine institutions. Each of the participating institutions had fellowship-trained andrologists specializing in male infertility and provided the data in an anonymous manner to optimize accuracy of reporting. Two institutions provided only limited datasets. The primary objective of the study was to evaluate the rate of long-term patency. Secondary objectives were to describe sperm concentration at various time points and by surgical team. For clinical variability, clinics without at least 10 data points were excluded from those analyses. Results A combined total of 3589 cases were included in the cohort, with 2838 having at least one test and 893 with at least one semen analysis available beyond 10 months. The percentage of patients with test results >10 months after surgery by clinic ranged from 1.2 to 47.5%, indicating wide discrepancies in follow-up protocols. Overall median sperm concentrations at <2, 2-4, 4-7, 7-10, 10-13, 13-18, and 18-24+ months were 5.8, 6.7, 5.3, 2.5, 1.3, 0, 1.2 million/ml, respectively. All-comer patency (defined as sperm at any point) rates ranged from 60-97%, with median maximal sperm concentration by clinic (any time point) ranging from 2-21 million/ml. Among men with at least two semen analyses, at least one of which was >10 months, 33.4% who initially had sperm went on to experience azoospermia (clinics varying from 2-48%). Overall patency rates at >10 months were 54% for the full cohort (range by clinic 41-93%). When reviewing data by surgeon, statistically significant differences were noted with all variables assessed, including the ratio of VV vs EV, successful completion rates of both sides, sperm concentrations, and short and long-term rates of azoospermia, suggesting notable differences in results based on surgical technique. Conclusions Using data from a combined cohort of 14 surgeons, approximately 54% of men who undergo vasectomy reversal for infertility experience durable patency at 10+ months with results varying significantly by surgeon. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: PathRight Medical.

Prevalence of infertility and barriers to family building among male physicians.

Fertility declines with increasing age and physicians often delay childbearing beyond prime reproductive years for the sake of medical training. However, the risks of infertility in male physicians compared to the general population remain poorly studied. To characterize rates of infertility among male physicians and identify barriers in access to fertility care and family building. Between June 2022 and December 2022, male physicians were invited to complete a questionnaire regarding fertility and family building. Surveys were disseminated electronically via social media and professional medical societies using Qualtrics (Provo, UT). Two hundred thirty-five responses were included in the final analysis. The mean age of respondents was 36.3±7.4 years. Of 151 respondents with children or currently attempting to have children, 66 (43.7%) delayed family building due to their medical training or career. The most influential factors affecting timing of children were lack of flexibility in schedule, lack of time, stress, and financial strain. Forty-three (18.3.%) respondents had seen a doctor for fertility evaluation; an additional 12 (5.1%) said they considered doing so but did not, mostly due to being too busy. Sixty (25.5%) had undergone semen testing in the past. Thirty-one (13.2%) reported a diagnosis of fertility issues in either themselves or their partner. Twenty-seven (11.5%) endorsed either them or their partner having undergone assistive reproductive technologies or other procedures for infertility. A significant proportion of male physicians delayed building their family or seeking fertility evaluation due to their medical career. Around 23.4% of male physicians have either seen or considered seeing a physician for fertility evaluation, suggesting a high prevalence of infertility in this cohort. Our results indicate a need for interventions to support family building and fertility evaluation and treatment among male physicians.

Evaluation and perspectives on hysterosalpingography (HSG) procedure in infertility: a comprehensive study.

Infertility continues to be a common medical problem with significant societal repercussions and psychological and economic effects on families' lives. Hysterosalpingography (HSG) is the preferred method in clinical practice for evaluating the uterine cavity and tubal patency. Our study aims to present a comprehensive perspective on the importance of the HSG procedure in the evaluation of infertile patients, starting with the recommendation of the HSG procedure to the patient, the application of the procedure, and the evaluation of the patient's post-procedure process. This is a prospective evaluation of 323 women who underwent HSG at Kafkas University between 2021-2022. The type and duration of infertility in patients, the source from which the patient received the recommendation for HSG, visual pain score for evaluating pain during the HSG procedure, HSG results, patients' perspectives on the procedure's contribution to the treatment processes, their immediate post-procedure pain, and their pregnancy status within 6 months after the procedure were evaluated. 72.1% of patients had primary, and 27.8% had secondary infertility. 82% of HSG results were reported as normal. Among primary infertility, uterine pathologies were detected in 62.5%. In secondary infertile patients, tubal pathology was detected in 88.4%. There is a statistically significant difference between the infertility types of patients with normal HSG results and those without (p=0.001). There was also a difference between the results of HSG and follow-up types (p<0.001). A statistical difference was also found between the HSG result and the patients' conception status within 6 months after the procedure (p<0.001). When it comes to the cost of the HSG procedure for infertility, as well as potential pain, radiation exposure, and rare allergic reactions to the contrast material, it is important to choose the appropriate circumstances for this procedure. In order to avoid unnecessary interventional procedures, it would be beneficial to discuss the recommendation of HSG for primary infertile patients under 28.5 years of age. Further research is required in this regard. Since tubal factors are most common among secondary infertile women, this group of patients is more likely to benefit from HSG in the evaluation.

O-143 Biopsy-free profiling of the uterine immune system in patients with recurrent pregnancy loss and unexplained infertility

Abstract Study question What are the differences in menstrual blood lymphocytes between controls, patients with recurrent pregnancy loss (RPL) or with unexplained infertility (uINF)? Summary answer Compared with controls, RPL- and uINF patients had a different menstrual blood immune profile, including altered NK-subtypes indicating an altered cytotoxicity in these patients. What is known already T-cells, particularly regulatory T-cells, and uterine natural killer cells play a vital role as they are the main immunological regulators at the feto-maternal interface. However, an endometrial biopsy (EB) is required for the examination of these cells, necessitating an invasive and uncomfortable procedure. Moreover, the small tissue samples are mainly analyzed by immunohistochemistry, limiting the amount of analysable markers and ultimately results in controversial data. Menstrual blood (MB) has been used in proof-of-concept studies to analyse lymphocyte populations. So far, no study has investigated MB lymphocytes in a well-defined cohort of RPL- and uINF patients in comparison to healthy controls. Study design, size, duration In this prospective study, 46 healthy controls, 28 RPL patients and 11 uINF patients were included between 03/2021 and 02/2022. RPL was defined as ≥ 3 consecutive pregnancy losses. For being diagnosed with uINF, all standard-diagnostic procedures for infertility had to provide negative results in couples trying to conceive for &amp;gt;12 months. Participants/materials, setting, methods To establish the procedure, lymphocyte compositions in EB in 7 controls were compared with those in MB during 48h. The first 24h and the second 24h were collected separately. In all other RPL- and uINF-patients, as well as controls, peripheral blood (PB) and MB was collected. Density gradient centrifugation was performed to isolate PB and MB mononuclear cells. Cells were analyzed by flow cytometry focusing on the main lymphocyte populations and NK-cell subsets. Main results and the role of chance The first 24h of MB closely resembled the uterine lymphocyte composition in EB, with were CD3+ T-cells and CD56+ NK-cells being the predominant lymphocyte populations in EB and MB. We therefore based further analyses on the first 24h of menstrual shedding. In comparison to controls, RPL-patients showed significantly higher MB-CD56+-NK-cell numbers (mean±SD: 31.13±7.52 vs. 36.73±5.4; p = 0.002). Furthermore, MB-CD56dimCD16bright NK-cells within the CD56+-NK-cell population were decreased in individuals with RPL and uINF compared to controls (mean±SD: 20.4±11.53;16.34±14.65;15.7±5.91; Ctrl vs. RPL p = 0.011; Ctrl vs. uINF p = 0.02). Further, compared to controls and RPL patients, uINF patients had lower CD3+ T-cell counts (mean±SD Ctrl. vs. uINF: 47.93±11.11 vs. 38.81±5.04, p = 0.013), with decreased CD4+ (mean±SD Ctrl. vs. uINF: 25.78±7.91 vs. 15.66±4.88, p = 0.001) and CD8+ T-cells (mean±SD Ctrl. vs. uINF: 15.32±4.14 vs. 8.43±2.85, p &amp;lt; 0.001). Interestingly, uINF-patients showed higher CD25highCD127dim/neg regulatory T-cell counts than controls (mean±SD Ctrl. vs. uINF: 1.34±0.49 vs. 1.84±0.51, p = 0.009). The cytotoxicity receptors NKp46 and NKG2D were more present in uINF and RPL patients. Furthermore, RPL and uINF patients had significantly higher peripheral CD56+-NK-cell counts as compared to controls (mean±SD: 8.4±3.5;11.42±4.05;12.86±4.29; Ctrl vs. RPL p = 0.021; Ctrl vs. uINF p = 0.009). Limitations, reasons for caution The small sample size of our study limits our ability to extrapolate the findings to other populations, as well as perform further subgroup analyses in controls, RPL and uINF. Future research must concentrate on NK cell subpopulations in larger cohorts, potentially in a multi-center setting. Wider implications of the findings Strengths of this study include well phenotyped participants and that the immunological milieu of the endometrium is directly compared for EB and MB. In future studies, this non-invasive analysis might enable to identify and monitor patients who could profit from (immunomodulatory) medications, and thereby improve live birth rates. Trial registration number not applicable

PD18-11 IMPACT OF STATE IN-VITRO FERTILIZATION MANDATES ON MALE INFERTILITY CARE

You have accessJournal of UrologyCME1 Apr 2023PD18-11 IMPACT OF STATE IN-VITRO FERTILIZATION MANDATES ON MALE INFERTILITY CARE James Dupree, Rodney L. Dunn, Phyllis Yan, David Suh, Erica Marsh, Edward C. Norton, Vanessa Dalton, and Marissa S. Weiss James DupreeJames Dupree More articles by this author , Rodney L. DunnRodney L. Dunn More articles by this author , Phyllis YanPhyllis Yan More articles by this author , David SuhDavid Suh More articles by this author , Erica MarshErica Marsh More articles by this author , Edward C. NortonEdward C. Norton More articles by this author , Vanessa DaltonVanessa Dalton More articles by this author , and Marissa S. WeissMarissa S. Weiss More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003273.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: By 2019, 11 states had passed laws mandating insurance coverage for infertility care, including in-vitro fertilization (IVF). These mandates vary in their coverage for male infertility care, with five states (AR, HI, IL, MD, RI) mandating IVF coverage but not coverage for male infertility care. Our objective was to evaluate the use of IVF and three common male infertility procedures (varicocelectomy, testicular/epididymal biopsy, and vasectomy reversal) in three groups of states: 1) states mandating IVF coverage and male infertility care, 2) states mandating IVF coverage but not male infertility care, and 3) states without IVF mandates. METHODS: We obtained nationwide insurance claims from over 80 million individuals from 2003 to 2019 from Optum® ClinformaticsTM Data Mart. We identified IVF cycles using the Current Procedural Terminology (CPT) code for oocyte retrieval and excluded oocyte retrievals performed for fertility preservation. We identified varicocelectomy, testicular/epididymal biopsy, and vasectomy reversal using their respective CPT codes. States were categorized into three groups: 1) states mandating IVF coverage and male infertility care (CT, MA, NJ, NY, DE 2018-19, UT 2018-19); 2) states mandating IVF coverage but not male infertility care (AR, HI, IL, MD, RI); and 3) all remaining states, including both DE and UT from 2003-2017. Within each group of states, we calculated the use rates and 95% confidence intervals (CIs) of IVF cycles per 100,000 women aged 21-44 and of varicocelectomy, testicular/epididymal biopsy, and vasectomy reversal per 100,000 men. RESULTS: IVF use was highest in Group 1 states and lowest in Group 3 states (Table 1). Varicocelectomy and testicular/epididymal biopsy use was 43% to 89% higher in Group 1 states than in Group 2 and 3 states. Use of vasectomy reversal—a procedure not typically covered by insurance regardless of state mandates—was only 14% higher in Group 1 states than in Group 3 states. The overall use of male infertility procedures was similar in Group 2 and 3 states. CONCLUSIONS: There is decreased use of male infertility procedures in states whose IVF mandates do not include coverage for male infertility care. Policymakers considering new state mandates for IVF should include coverage for male infertility care to facilitate access to effective male infertility treatments. Source of Funding: Eunice Kennedy Shriver National Institute of Child Health & Human Development - 1R01HD103603-01A1 © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e507 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information James Dupree More articles by this author Rodney L. Dunn More articles by this author Phyllis Yan More articles by this author David Suh More articles by this author Erica Marsh More articles by this author Edward C. Norton More articles by this author Vanessa Dalton More articles by this author Marissa S. Weiss More articles by this author Expand All Advertisement PDF downloadLoading ...

Is There Room for Microsurgery in Robotic Surgery?

Robotic surgery opened a new era of minimally-invasive procedures, through its improved precision, elimination of tremors, greater degrees of freedom, and other facilitating aspects. The field of robotic microsurgery showed great growth in recent years in particular, since robotics offers a potentially-ideal configuration to perform the sensitive manipulations required in microsurgery. We conducted a systematic review to assess the benefits of robotic surgery and its contributions to microsurgery, comparing it with other surgical techniques used in patients of all age groups. We assessed 25 articles found in the PubMed and Cochrane databases using the terms ' robotic surgery ' AND microsurgery , with a filter for studies published in the last five years, and studies conducted in humans and published in English or Portuguese. We concluded that there is plenty of room for robotic surgery in microsurgery, such as in male infertility procedures, neurological microsurgery, ocular and otological surgeries, and transoral, hepatobiliary, microvascular, plastic and reconstructive surgeries.

The impact of male infertility faculty on urology residency training.

The objective of this study was to determine the impact of having male infertility on urology residents' infertility training experience, surgical confidence, and In‐Service‐Exam Infertility/Sexual Medicine subscores. We electronically surveyed urology residents throughout the United States querying exposure to infertility faculty and fertility knowledge. Univariable and multivariable analysis was performed to determine predictors of higher In‐Service Exam Infertility/Sexual Medicine sub‐scores and self‐rated infertility competency. Fifty‐four of 72 respondents (75%) reported that male infertility comprises ≤10% of their training. Of the 63 residents who have a reproductive urologist on faculty, 66.7%, 47.6%, and 49.2% have scrubbed/observed a microsurgical varicocelectomy, vasectomy reversal and testicular sperm extraction, respectively. Residents exposed to infertility faculty are more likely to self‐rate their infertility understanding as “excellent” or “good” (p = 0.04 and p = 0.02, respectively), and 14.4× more likely to feel confident performing infertility procedures, versus residents lacking faculty (p < 0.001). Residents having formal microsurgical training have better self‐rated infertility understanding (p < 0.001), non‐obstructive azoospermia management (p = 0.01), and competency performing infertility procedures (p < 0.001). Residents exposed to fertility faculty are more likely to feel confident performing fertility procedures after residency (p = 0.001). In conclusion, infertility comprises a minority of residency training. Most residents anticipate performing infertility procedures in practice, despite two‐thirds lacking confidence performing these. Having an infertility faculty and formal microsurgical training improves residents' surgical confidence, non‐obstructive azoospermia management, and global male infertility understanding. A structured educational curriculum may improve resident infertility training.

MP21-12 THE IMPACT OF MALE INFERTILITY FACULTY ON UROLOGY RESIDENCY TRAINING: WHAT ARE THE EFFECTS ON FERTILITY KNOWLEDGE, IN-SERVICE EXAM SCORES, AND SURGICAL CONFIDENCE?

You have accessJournal of UrologyInfertility: Epidemiology & Evaluation I (MP21)1 Sep 2021MP21-12 THE IMPACT OF MALE INFERTILITY FACULTY ON UROLOGY RESIDENCY TRAINING: WHAT ARE THE EFFECTS ON FERTILITY KNOWLEDGE, IN-SERVICE EXAM SCORES, AND SURGICAL CONFIDENCE? Kian Asanad, David Nusbaum, John Rodman, Gerhard Fuchs, and Mary Samplaski Kian AsanadKian Asanad More articles by this author , David NusbaumDavid Nusbaum More articles by this author , John RodmanJohn Rodman More articles by this author , Gerhard FuchsGerhard Fuchs More articles by this author , and Mary SamplaskiMary Samplaski More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002006.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Given the lack of consistent male infertility faculty exposure in urology residency programs, we sought to understand the impact of having a dedicated reproductive urologist (RU) faculty on resident male infertility training. We surveyed urology residents to determine the effects on self-competence in male infertility knowledge, procedures, and In-Service Exam scores. METHODS: A 42-question anonymous survey was emailed to American urology residencies assessing exposure to RU faculty in the clinic and operating room, fertility knowledge in management of non-obstructive azoospermia (NOA), and self-competence in performing infertility procedures. Fisher’s Exact test was performed to examine the association between formal microsurgical training and self-reported male infertility knowledge and procedural competence. Multivariable linear regression analysis was used to identify significant predictors of higher In-Service Exam Infertility/Sexual Medicine subscores. RESULTS: Infertility comprises ≤10% of training in 75% of respondents. Residents exposed to RU faculty are more likely to self-rate their infertility understanding as “excellent” or “good” (p=0.04 and p=0.02, respectively) and 14.4-times more likely to feel confident performing infertility procedures, versus residents lacking faculty (p<0.001). Residents with formal microsurgical training have better self-rated global infertility understanding (p<0.001), NOA management (p=0.01), and competency performing infertility procedures (p<0.00). Those that rate their knowledge of NOA management as ‘excellent’ scored, on average, 65.8 points higher on the 2019 In-Service Exam Infertility/Sexual Medicine section than those that rate their knowledge as ‘awful’ (p-value=0.007 and <0.001, respectively). CONCLUSIONS: Infertility comprises a minority of urology residency training. Most residents (80.8%) plan to perform infertility procedures in practice, despite two-thirds lacking confidence performing these. Having an RU faculty and formal microsurgical training significantly improves residents’ surgical confidence, NOA management, and global understanding of male infertility. Better knowledge in management of NOA correlates with higher In-Service Exam Infertility/Sexual Medicine subscores. A structured educational curriculum may improve resident male infertility training. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e350-e351 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kian Asanad More articles by this author David Nusbaum More articles by this author John Rodman More articles by this author Gerhard Fuchs More articles by this author Mary Samplaski More articles by this author Expand All Advertisement Loading ...

A Case of Ovarian Hyperstimulation Syndrome with Diffuse Cortical Necrosis

Ovarian hyperstimulation syndrome is an iatrogenic, serious complication of controlled ovarian hyperstimulation, usually self-limited, but occasionally life threatening and typically occurs with gonadotropin. A 32-year-old married female [Para 0+1, 30 weeks (intra-uterine death)—2016], who underwent ovum pick up procedure for secondary infertility, presented to the Department of Nephrology, Apollo Hospital, Guwahati with the complaints of pain in the abdomen, anuria, breathing difficulty, bleeding per vagina on the next day. On investigating the case, the patient had thrombocytopenia, leucocytosis, anemia, normal morphology in peripheral blood smear, raised inflammatory markers, hepatic transaminases, lactate dehydrogenase, and rapidly progressive renal failure, metabolic acidosis with negative serological markers for connective tissue disease. Radio imaging suggested bilaterally enlarged ovaries with multiple hemorrhagic cysts, pleural effusion, and ascites. Ultrasound showed normal sized kidneys with increased echotexture and hypoechoeic cortical rim. Renal biopsy showed diffuse renal cortical necrosis. Supportive management started with a target to correct volume depletion, monitoring, and electrolyte abnormalities. Patient was hemodynamically stabilised and discharged on thrice weekly maintenance dialysis.

Surgical procedures for male infertility: an update.

The aim of this review is to provide an overview of surgical treatment options for male infertility including varicocelectomy, treatment of ejaculatory duct obstruction, vasovasostomy, and sperm extraction, and to review recent advances in techniques and technologies that may improve operative outcomes. Microscopic subinguinal varicocelectomy has been shown to have the highest success rates with lowest rates of complications, and may be facilitated by the use of Doppler, indocyanine green angiography, and the 4K3D operating video microscope. The standard treatment for ejaculatory duct obstruction by transurethral resection of the ejaculatory ducts has changed little over time, but vesiculoscopy may allow for temporary dilation of an obstruction to allow for natural conception, while also offering diagnostic capabilities. Use of the robotic platform has gained popularity for vasectomy reversals but controversy remains regarding the cost-effectiveness of this option. Recently, a reinforcing suture technique has been described for vasovasostomy to minimize anastomotic breakdown and reversal failure. Finally, gray-scale and color-enhanced ultrasound may improve ability to predict successful sperm retrieval during extraction procedures. Though the fundamentals of surgical treatment options for male infertility have changed little with time, technological advancements have contributed to improved surgical outcomes over recent years.

Tehnologije asistirane reprodukcije u centrima za biomedicinski potpomognutu oplodnju u planu mreže i van plana mreže u Republici Srbiji i njihovo finansiranje

INTRODUCTION: Assisted reproduction technologies (ART) are technologies that are used today, in the treatment of infertility, on human germ cells (oocytes and sperm) and embryos. Currently in the Republic of Serbia, there are various procedures of assisted reproduction technologies that are used to treat infertility in patients depending on medical indications. The availability of assisted reproduction technologies has been evolving over the years, and their application differs in biomedically assisted fertilization centers that are in the Network Plan (state institutions) and outside the Network Plan (private institutions). The aim of this article is to analyze available ART methods in Fertility centers within and outside the Network plan regulated by the Law on the Treatment of Infertility Procedures of Biomedical Assisted Fertilization (Official Gazette of the Republic of Serbia", No. 72/2009), their financing and availability to patients in the Republic of Serbia. METHOD:This article is assembled upon seeking documents using the Internet and based on analyzed literature available on the Internet. RESULTS: The results were gathered by analyzing official ART centers' websites and analyzing available external secondary data from the National health insurance fund and the Institute for public health "Dr Milan Jovanovic Batut". Fertility clinics in the Republic of Serbia have access to all the important technologies for ART. ART technologies funded by National health insurance fund include in vitro fertilitation, intracytoplasmic sperm injection and frozen embryo transfer. Patients whose medical indications require for some other technology may approach Fertility Centers outside the Network plan on their own budget. CONCLUSION: Based on the available and updated data we can conclude that Fertility centers in the Republic of Serbia have access to all the important technologies for ART. Fertility centers within the Network plan can implement only the technologies financed and invoiced by the Fund.

THE PROVIDER LANDSCAPE OF MALE INFERTILITY CARE IN THE UNITED STATES

Recent studies have demonstrated that reproductive endocrinologists perform sperm extraction procedures for male infertility, yet the overall proportion of male infertility care provided by non-urologists is unknown. Using a nationally representative cohort, we sought to assess male infertility visits to examine provider specialization and patient characteristics across the United States.

Anesthetic Techniques for Gynecological Surgeries in Benue State University Teaching Hospital (BSUTH), Makurdi, Nigeria

Background: Gynecological surgery refers to surgery on the female reproductive system usually performed by gynecologists. It includes procedures for benign conditions, cancer, infertility and incontinence. Gynecological conditions are seen in the non-pregnant and early pregnant state up to 20 weeks gestation. . Just like every other surgery, they require anesthesia for the elimination of surgical pain and the surgical methods to a great extent, determine the choice of anesthesia employed. Anesthesia is usually in the form of regional, especially the neuroaxial type, or general anesthesia. This study was conducted to ascertain the anesthetic techniques employed for gynecological surgeries in the Benue State University Hospital (BSUTH), Makurdi, Nigeria and complications arising there from.&#x0D; Methodology: A retrospective and descriptive study of case files of patients that underwent gynecological surgeries between January 2016 and December 2018 in BSUH, Makurdi was carried out.&#x0D; A total of 156 case files of eligible patients were retrieved from the records department of BSUTH after approval from relevant authorities. Relevant information were extracted from the patients’ folders and transferred into a prepared proforma. The data collected were analyzed using SPSS version 25 using simple statistics.&#x0D; Result: A total of 156 cases were evaluated. The age bracket with the most number is that between 21 and 30 years which recorded 54 (34.6%). This was followed by the age group between 31 and 40 years which were 51, making up 32.7% of the study population. Uterine fibroid was the most recorded diagnosis with 36 cases accounting for 23.1% of the study population. This was followed by ruptured ectopic gestation which was observed to 23, representing 14.7% of the study group. Cancer (Ca) of the cervix recorded 22, amounting to 14.1% of the study group. Exploratory laparotomy was carried out 44 times accounting for 28.2% of the procedures. This was followed by myomectomy and examination under anesthesia (EUA) with 26, representing 14.7% of the variables each. Of the 156 anesthetic procedures undertaken, 56 (35.9%) were sub-arachnoid block (SAB). This was followed closely by general anesthesia with endotracheal intubation (GA/ETT) with 55 (35.3%). General anesthesia with face mask (GA/FM) came third with 35 (22.4%). Twenty-four episodes of complications were observed out of which pain occurred 10 times accounting for 41.7% of the variables. Hypotension occurred 8 times representing 33.3% of the variables. Accordingly, 24 modalities were employed for the management of complications of anesthetic techniques of which IV administration of ephedrine was done 8 times representing 33.3% of the variables. This was followed by IV administration of pentazocine that was done 5 times accounting for 20.9% of the variables.&#x0D; Conclusion: As a result of the vast array of gynecological diseases observed in this study, GA with tracheal intubation and GA with face mask together make up the anesthetic technique of choice for gynecological surgeries. The prominence of SAB as an anesthetic technique is not unexpected because many gynecological lesions are sub-umbilical in location, thus making them amenable to the technique which also possesses a lot of advantages. In addition, complications observed were few and included mainly pain and hypotension, none of which was life-threatening.&#x0D;

AGENCY THROUGH OBJECTIFICATION: SUBJECTIVITY AND TECHNOLOGY

The article turns to the ethnography of infertility clinics to answer the question: To what extent and in what situations do the technologies that objectify the bodies of patients in these clinics in fact not reduce the agency and selfhood of the patients but, on the contrary, enable them to reveal their capacities? The author engages in an argument with the tradition in feminist studies of regarding those technologies as harmful and as an objectification of the patients and their bodies. On the basis of her fieldwork (participant observation of pelvic exams, ultrasound procedures, surgical operations, etc.), the author cogently shows that certain forms of objectification that are expressed in the patient’s submitting to technical procedures and to epistemological and bureaucratic discipline in fact enable activation of capacities of parts of the body and self that cannot be exhibited outside the clinic. However, these forms of objectification are applicable and relevant for women patients only to the extent that they are in line with an overall progression of the patients from infertility to restoration of fertility. Otherwise, they turn into mechanization and alienation of the patient’s body and self. The author’s conceptual and political aim in this article is to point out the possibility of preserving compatibility between the objectified body parts or selfhood of the patient, the tools and reproductive technologies, the bureaucratic and epistemological discipline inside the IVF clinics, and the “I” of the patient with which she will live before and after the infertility procedures regardless of the outcome. The process of arranging a functional zone where this compatibility is possible is what the author calls ontological choreography.

Role of Transvaginal Ultrasound in Infertility: Experience at a Tertiary Care Hospital in Dhaka City

Background: Infertility problem is a global problem and now infertile couples are more aware for the treatment of infertility. Transvaginal sonography since 1995 has expanded the scope of use of ultrasonography in assessment of endometrial thickness, ovarian volume, follicular development in response to hormone in different phase of menstrual cycle in relation to infertility management. In this study it may be assumed that present study may help to establish transvaginal sonography as a new and reliable diagnostic method by which we will be able to proceed accurately with more confidence in diagnosing infertility.Objectives: The purpose of the present study was to assess the role of TVS in diagnosing&amp; evaluating causes of infertility and the comparison between clinical correlation and TVS findings in infertility.Methodology: It is a Hospital based cross sectional study conducted in outdoor department of Obstetrics and Gynecology in Sir Salimullah Medical College (SSMC) and Mitford Hospital, Dhaka, Bangladesh and in a infertility clinic in Dhaka, from March 2009 to August 2009. Sample size was 98 cases of infertile women.Result: Amongst 98 women, 64 cases were represented with primary infertility and 34 patients came with secondary infertility; common age group is 29-35 years; most frequent TVS finding is PCOD with its various presentation and ovarian volume.Conclusion: Transvaginal sonography is painless, quicker, costeffective and can be done as a out door patient in the department. It can be used as a first-line diagnostic procedure for infertility in Bangladesh.But it demands costly equipments, special TVS probe as well as expertise of the operator. At present there are few number of IVF centres in some districts of Bangladesh where transvaginal sonography is the most useful procedure and they play an important role in the diagnosis of causes of infertility.Journal of Science Foundation, July 2017;15(2):41-47

Changes in practice patterns in male infertility cases in the United States: the trend toward subspecialization

To assess changes in the practice patterns of urologists performing male infertility procedures (vasal reconstruction, sperm retrieval, varicocelectomy) from 2004 to 2015 in the United States. Examination of self-reported procedural volumes from urologists undergoing certification and recertification using case log data provided by the American Board of Urology. The study period was stratified into early (2004-2007) and recent (2012-2015) time periods. Not applicable. None. None. Temporal variations in male infertility practice patterns among different urologic subspecialties between the early and recent time periods. The overall proportion of total male infertility procedures performed by andrologists significantly increased between the early and recent groups (23% to 26%). This growth was driven by a significant increase in the proportion of varicocele repairs being performed by andrologists between the early and recent periods (19% to 25%). Most notably, an assessment of total number of male infertility procedures performed by newly certifying urologists showed that there was a significant increase in the overall proportion of all male infertility procedures being performed by recently trained andrologists (24% to 35%). This significant increase was seen individually among all three types of male infertility procedures. With the increased trend in urologists obtaining fellowship training, male infertility surgical volume is beginning to shift from general urologists to subspecialized andrologists.

Office-based andrology and male infertility procedures-a cost-effective alternative.

BackgroundFrom 2014–2016, our clinical practice progressively incorporated several male infertility and andrology procedures performed under local anesthesia, including circumcision, hydrocelectomy, malleable penile prostheses, orchiectomy, penile plication, spermatocelectomy, testicular prostheses, varicocelectomy, vasectomy reversal (VR), and testicular and microepididymal sperm aspiration (TESE/MESA). Given the observed outcomes and potential financial and logistical benefits of this approach for surgeons and patients, we sought to describe our initial experience.MethodsA retrospective analysis was performed of all andrologic office-based (local anesthesia only) and select OR (general or monitored anesthesia care) procedures performed from 2014–2016. Financial and outcomes analyses were performed for infertility cases due to the homogeneity of payment modalities and number of cases available. Demographic, clinicopathologic, and procedural costs (direct and indirect) were reviewed and compared.ResultsA total of 32 VRs, 24 hydrocelectomies, 24 TESEs, 10 circumcisions, 9 MESA/TESEs, 4 spermatocelectomies, 3 orchiectomies (1 inguinal), 2 microTESEs, 2 testicular prostheses, 1 malleable penile prosthesis, 1 penile plication, and 1 varicocelectomy. Compared to the OR, male infertility procedures performed in the clinic with local anesthesia were performed for a fraction of the cost: MESA/TESE (78% reduction), TESE (89% reduction), and VR (62% reduction). All office-based procedures were completed successfully without significant modifications to technique. Outcomes were similar between the office and OR including operative time (VR: 181 vs. 190 min, P=0.34), rate of vasoepididymostomy (VE) (23% vs. 32%, P=0.56), total sperm counts (72.2 vs. 50.9 million, P=0.56), and successful sperm retrieval (MESA/TESE 100% vs. 100%, P=1.00; TESE 80% vs. 100%, P=0.36). To our knowledge, the current study also represents the first report of office-based VE under local anesthesia alone. For hydrocelectomy procedures, recurrence (4%) and hematoma (4%) rates were low (mean 4.2 months follow-up), although this likely relates to modifications with technique and not the anesthesia or operative setting. Overall, when given the choice, 86% of patients chose an office-based approach over the OR.ConclusionsOffice-based andrology procedures using local anesthesia may be successfully performed without compromising surgical technique or outcomes. This approach significantly reduces costs for patients and the overall healthcare system and has become our treatment modality of choice.

Impact of uterus transplant on fetuses and resulting children: a response to Daar and Klipstein.

In assessing the safety of uterine transplant, the effects of gestation on mother, fetus, and resulting child need close attention. Data from current and future clinical studies should provide helpful information about those concerns. Unless the risks to mother and child are acceptable, uterus transplant will not become an accepted procedure for uterine infertility. Professor Judith Daar and Dr Sigal Klipstein in a trenchant yet generously toned comment critique my article on uterus transplant (and those of previous commentators) for a lack of focus on those risks.1 They argue that the safety record of gestational surrogacy2 in the United States is so much better than the vascular and teratogenic problems that are likely to arise with uterus transplants that women have an obligation to use surrogacy rather than transplant.3 I am very grateful for their Comment (as should be others working on uterus transplant) for they raise important questions about the effects of gestation in a donor uterus thatneedansweringduring the current experimental phaseof uterus transplant.4 If their empirical suspicions stand, uterine transplantmay notmeet the high standards of safety and efficacy required to become a routine therapy.

Open-label, Prospective, Investigator Initiated Study to Assess the Clinical Role of Oral Natural or Synthetic Progesterone During Stimulated IUI Cycles for Unexplained Infertility.

Unexplained infertility remains as one of the important subtype of infertility that follows expectant management with Intrauterine Insemination (IUI) in most cases. To evaluate the clinical role of progesterone supplement as luteal phase support for women with unexplained infertility following stimulation protocol with Clomiphene Citrate (CC)/Human Menopausal Gonadotropin (HMG). An investigator initiated study to survey the success rate for first cycle of IUI following stimulation protocol with CC/HMG & luteal phase support with oral natural or synthetic progesterone was conducted. 120 patient records between observation period of Jan to May '14 were retrieved especially for subjects undergoing IUI procedure for Unexplained infertility. Patients with baseline Serum (Sr). progesterone records who received Oral Natural Micronized Progesterone Sustained Release (Oral NMP SR) (N=45) or Dydrogesterone (n=33) following CC/HMG induction protocol and human Chorionic Gonadotropin(HCG) Inj., were further analysed following Luteal Phase Support(LPS) with oral natural or synthetic progesterone. Baseline demographics showed 78 patients with mean age, weight and cycle duration of 29.5 yrs, 57.3 kg & 28.6 days respectively. Progesterone was supplemented as Oral NMP SR 200/300 mg OD or Dydrogesterone 10 mg bid in 22, 23 and 33 patients respectively. In all cases ovulation was triggered with HCG inj., followed by IUI within the next 48 hours while baseline sr. progesterone levels were being assessed. Medicines and Healthcare Products Regulatory Agency (MHRA) UK recommended therapeutic compliance to suggest sr. progesterone levels of ≥14ng/ml were recorded as Mid-luteal levels in all of these patients. This therapeutic compliance was noted in 82.2% & 78.8% of the patients treated with oral NMP SR or Dydrogesterone respectively. Pregnancy was observed amongst 5 and 10 patients treated with oral NMP SR and Dydrogesterone respectively at the end of 'First' IUI cycle. Both the groups were well tolerated with drowsiness documented in three cases for Oral NMP SR. Clinical supplementation with ONMPSR suggests therapeutic compliance and alternative strategy to conventional formulations while offering dosing convenience with minimal side effects.

Sonographic appearances of the postoperative testis

To describe the sonographic findings observed in the testis in patients who have undergone testicle-sparing surgery and surgical biopsies. We reviewed the color Doppler sonographic findings from 14 patients after testicular interventions: 2 open biopsy procedures for infertility and 12 testicle-sparing surgical procedures (1 for spontaneous intratesticular hemorrhage and 11 for small tumors). Ten patients had benign tumors; one had a malignancy. Three patients were symptomatic; all others were studied as follow-up. Hypoechoic and hypovascular lesions at site of surgery were seen in 10 of the 11 patients after tumorectomy; no changes were observed in one patient. The lesions were either linear or an irregularly triangular shape, located at the surgical site, and interpreted as scars. Retraction of the testicular surface was detected in two cases. In the eight patients who underwent follow-up, lesions disappeared in one case, became smaller in two, and remained stable in five. Of the two patients who underwent biopsy, one developed peritesticular hematoma, and both had late hypoechoic scars in the testis. Hypoechoic and hypovascular scars are a "normal" postoperative pattern after testicle-sparing surgery. They are either linear or triangular, with rectilinear margins. Such findings need to be correctly interpreted and not misinterpreted as recurrences.