Fertility and sterility最新文献

Objective: To determine whether chronodisruption is associated with achieving pregnancy.

Design: Pilot prospective cohort study.

Setting: Academic Medical Center.

Patient(s): One hundred eighty-three women desiring pregnancy were recruited from the local community of an academic medical center located in the Midwest and provided sleep information between February 1, 2015, and November 30, 2017.

Intervention: Sleep and activity data were obtained via actigraphy watches worn continuously for 2 weeks to assess measures of chronodisruption, including sleep period onset, offset, midtime, and duration; as well as variability in each of these measures.

Main outcome measures: Time to becoming pregnant over 1-year of follow-up.

Results: Of the 183 eligible women, 82 became pregnant over a median of 2.8 months of follow-up. Greater interdaily variability in time of sleep onset and variability in sleep duration were associated with a longer time to achieving pregnancy after adjusting for age, body mass index, race, education, income, and smoking status (adjusted hazard ratio [aHR], 0.60; 95% confidence interval [CI], 0.36-0.999 comparing participants with a standard deviation of >1.8 hours to <1.8 hours in daily time of sleep onset; and aHR, 0.58; 95% CI, 0.36-0.98 comparing participants with a standard deviation of >2.3 hours to <2.3 hours in daily sleep duration). In adjusted analyses, no statistically significant associations were observed for average time of sleep onset and offset, midsleep time, and sleep duration, or for variability in time of sleep offset and midtime.

Conclusions: Higher day-to-day variability in time of sleep onset and sleep duration-two measures of chronodisruption-were associated with a longer time to achieving pregnancy over 1 year of follow-up in women desiring pregnancy. If replicated in additional studies, these findings could point to lifestyle interventions to help women achieve a desired pregnancy.

Objective: To study and address the diagnostic, management, and classification challenges of unilocular myometrial cystic lesions adjacent to a normal uterine cavity.

Design: Describe 23 further cases, and undertake a systematic review using Medline, PubMed and Ovid for similar lesions.

Subjects: 23 cases of accessory uterine cavities presenting to pediatric and adolescent gynecologists in Australia and New Zealand.

Main outcome measures: 92 similar cases of cavitated myometrial masses were identified in the literature. The cases in our series and in the literature were examined for age at presentation, site of lesion, pathology, and presence of other anomalies.

Results: All patients in our series were aged ≤ 32 years. All presented with unilocular blood-filled myometrial lesions that did not communicate with the uterine cavity. All were located on the lateral aspect of the uterus in proximity to the round ligament. Of the 22 that have been resected, all were lined by endometrium and smooth muscle. These characteristics are mirrored in the previously described cases in the literature.

Conclusion: The frequency of these myometrial cystic masses is such that they can no longer be considered rare. Nevertheless, their etiology remains unclear. These lesions have often been given names suggesting that they are an early representation of adenomyosis. The alternative possibility of a Müllerian anomaly is supported by consistent anatomical location and young age of presentation in most reported cases. Yet the absence of documented associated anomalies raises concerns about this theory. To progress understanding of these lesions, consistent reporting of features including location and the presence or absence of other anomalies is required. In view of this ongoing uncertainty, we recommend the use of the term "accessory uterine cavity (AUC)." This terminology avoids the implication of either a pathological process or a congenital anomaly.

Objective: To demonstrate the robotic-assisted Davydov technique for neovaginal creation in Mayer-Rokitansky-Küster-Hauser syndrome.

Design: Stepwise demonstration of the technique with narrated video.

Setting: Gynecologic unit of a tertiary center.

Subjects: A 27-year-old patient has been diagnosed with Mayer-Rokitansky-Küster-Hauser syndrome since the age of 18 years. Three months ago, vaginal dilation was attempted at another medical center but was unsuccessful because of intolerance. Pelvic examination revealed a shallow vaginal dimple.

Exposure: After identification of the anatomical structures, the rectovaginal and vesicovaginal spaces were dissected, creating a space for the neovaginal canal and forming anterior and posterior peritoneal flaps. After complete dissection of the rectum from the posterior pelvic peritoneum, the vaginal remnant was bluntly dissected externally under guidance of a blunt-tipped curette handle and connected adequately to the introitus. Subsequently, the created anterior and posterior flaps were individually interrupted with sutures to form the neovaginal entrance. After the neovaginal entrance was established, the robot was used again to continuously suture the uterine remnants to create the anterior neovaginal wall. The uterine remnants, rectal serosa, and internal portions of the flaps were then joined together to form the neovaginal vault.

Main outcome measures: Demonstration of the steps for the robotic management of neovaginal creation in Mayer-Rokitansky-Küster-Hauser syndrome.

Results: The patient was discharged on postoperative day 1 with a soft mold in the vagina. On postoperative day 3, the soft mold was replaced with a medium-sized rigid mold. By postoperative day 6, the patient could insert a full-size rigid mold. The patient achieved full penetration and engaged in sexual activity within 1 month, with no postoperative complications observed. At the 8-month follow-up, the neovaginal cavity measured 13.4 cm in depth and 4.7 cm in diameter.

Conclusions: Creating a neovagina using the robotic-assisted Davydov technique in patients with Mayer-Rokitansky-Küster-Hauser syndrome is a safe, feasible, beneficial, and highly effective method. Although the superiority of robotic systems over laparoscopy has not yet been fully established through extensive publications, the advantages provided by high-image quality, magnification, and maneuverability are highlighted in this study. Robotic technology could be particularly beneficial for patients with obesity or those with complex pelvic anatomy because of prior surgeries.

Objective: To demonstrate the techniques and advantages of targeted gestational sac removal via hysteroscopy in a case of early miscarriage.

Design: Video article.

Subjects: A 41-year-old woman with a missed miscarriage at 7⁺¹ weeks presented with a human chorionic gonadotropin level of 1,070 mIU/mL and an intrauterine gestational sac measuring 3.8 mm, which showed enhanced peripheral echogenicity without a visible yolk sac. Ultrasound identified three additional small hypoechoic areas within the uterine cavity, which were difficult to differentiate by ultrasound. The patient had a strong desire to preserve the chorionic villi for chromosomal analysis. However, the small size of the gestational sac and the presence of multiple hypoechoic lesions were expected to complicate the task of locating chorionic villi within the expelled products of conception after expectant management, medication, or suction aspiration. The patient(s) included in this video gave consent for publication of the video and posting of the video online including social media, the journal website, scientific literature websites (e.g., PubMed, ScienceDirect, and Scopus), and other applicable sites.

Exposure: Non-contact hysteroscopy was conducted without uterine probing or cervical dilation using HEOS-mini hysteroscope (Delmont, France). The true gestational and pseudogestational sacs and submucosal fibroids were identified and removed using a grasper. Intraoperative intravenous oxytocin (10 IU in 500 mL normal saline) was administered to enhance the visualization of fibroids. Surgical skills were discussed in detail. This study was approved by the Ethics Committee of The First Affiliated Hospital, Zhejiang University School of Medicine (IIT2024-0505).

Main outcome measures: Successful targeted removal of the gestational sac and intrauterine lesions.

Results: Cytogenetic analysis of the chorionic villi revealed a 45,XO karyotype. Histopathological findings confirmed the hysteroscopic diagnosis. The postoperative recovery was uneventful.

Conclusion: Targeted removal of the gestational sac in early pregnancy loss via hysteroscopy is both feasible and effective. It offers valuable diagnostic and therapeutic benefits for patients with recurrent pregnancy loss who require precise sampling or those with concurrent intrauterine abnormalities.

Objective: To compare the cost-effectiveness of treatment for patients with absolute uterine factor infertility to achieve one or two singleton births by gestational carrier vs. uterus transplant.

Design: Decision analysis from the US healthcare sector perspective, with time horizons to achieve one or two singleton births.

Subjects: Patients with uterine factor infertility desiring family building.

Exposure: Gestational carrier or uterus transplant.

Main outcome measures: Incremental cost-effectiveness ratios, comparing the costs (2020 US Dollars) and effectiveness (quality-adjusted life years [QALYs] and live births) to achieve one or two births by gestational carrier vs. uterus transplant.

Results: In the base case of one singleton birth, the overall cost using a gestational carrier was $97,712.90 ($56,985.20-$153,084.20) compared with $116,137.20 ($67,142.88-$182,290.86) after uterus transplant. Quality-adjusted life years were higher in the gestational carrier arm (0.93) compared with the uterus transplant (0.90) and overall rates of live birth were also higher in the gestational carrier arm (94%) compared with the uterus transplant arm (77%). Costs of the gestational carrier and uterus transplant recipient were the most significant cost variables in the model. Monte Carlo simulation showed that uterus transplant had a 37% chance of being the cost-effective strategy for a single live birth at a willingness to pay of $150,000/QALY. In the case of two singleton births, the cost using a gestational carrier was $186,278.56 ($103,597.81-$296,010.27) compared with $164,276.84 ($111,961.91-$229,394.43) after uterus transplant. Quality-adjusted life years were again higher in the gestational carrier arm (0.93) than the uterus transplant (0.89). Overall rates of two live births were also higher in the gestational carrier arm (86%) compared with the uterus transplant arm (66%). Monte Carlo simulation showed that uterine transplant has a 62% chance of being the cost-effective strategy for two live births at a willingness to pay $150,000/QALY.

Conclusion: In the United States, treatment of uterine factor infertility with a gestational carrier is likely the most cost-effective approach for patients delivering a single child. However, the absolute costs associated with uterus transplants were 14% less than a gestational carrier for those having two live singleton births.

Objective: To compare the cost-effectiveness of a gestational carrier (GC) to a uterine transplantation (UTX) in the treatment of absolute uterine-factor infertility.

Design: We performed a cost-effectiveness analysis using a decision-tree mathematical model comparing a GC with a UTX.

Subjects: Published literature was used to derive costs for solid organ transplant, immunosuppression, GC obtainment, in vitro fertilization, preimplantation genetic testing, and frozen embryo transfer (FET).

Exposure: Gestational modality: GC or UTX. We assumed graft failures occurred immediately and FETs at least 6 months after transplant.

Main outcome measure(s): The primary outcomes were costs per live birth, number of children born, and quality-adjusted life years for each gestational modality.

Results: Uterine transplantation was more expensive than a GC by $1.4 million with a lower utility by 23.74 quality-adjusted life years using the same average number of children born per 2 FETs. After 10,000 simulated iterations, the GC arm had 2 children born 42% of the time, compared with only 17% of the time in the UTX arm. No children were born 56% of the time in the UTX arm vs. 16% for the GC arm. Deterministic and probabilistic sensitivity variance of all cost parameters by ±75% ($39,292-$275,044 for GC vs. $390,761-$2,735,329 for UTX) and other input parameters by ±20%, including graft failure (21%-31%) and live birth per embryo transfer (29%-78%), produced the same outcomes in >99% of scenarios simulated, as did variation in immunosuppression time (2-18 months) between delivery and subsequent FET. UTX was no longer absolutely dominated if the probability of a live birth per transfer using UTX increased beyond 85%, startup cost for UTX decreased to <$13,646.28, or GC costs increased to >$359,200.

Conclusions: Our model suggests that GC use is currently more cost effective than UTX for treating absolute uterine-factor infertility. However, the desire to carry one's own child is an intangible factor not captured in cost analyses, and improvements in UTX success rates or reduced costs may alter these results in the future.

Assisted reproductive technology has become the primary treatment of infertility. As such, assisted reproductive technology has been regulated by certain authorities and primarily, structured by various scientific organisms through recommendations and guidelines. Yet, these have limits-the topic addressed here-and may at times need to rely on grit for managing the totally unexpected. Doctors should also cope with what is not addressed by these guidelines, including the couple's desire for final family size.