Khan, Zaraq

Endometriosis is a common, chronic inflammatory condition characterized by the presence of endometrium-like tissue outside of the uterus that can impact fertility through multiple mechanisms. In this review, the diagnosis, classification, staging, and surgical management of endometriosis for fertility enhancement is discussed. Surgery for patients seeking to optimize fertility or for whom infertility is the only symptom is complex. In patients with superficial endometriosis, laparoscopy may enhance fertility for unassisted pregnancy, but current guidelines recommend against routine surgery prior to ART. In patients with deep endometriosis, surgical intervention depends on multiple factors, including patient age, ovarian reserve, fertility goals, and the presence of other infertility factors. While there may be potential improvements in fertility-related outcomes, this must be weighed against potential impacts to ovarian reserve. Surgical techniques that minimize damage to the ovaries, fallopian tubes, and uterus are essential when fertility is the goal. While there is increasing interest in regenerative therapies for treatment of endometriosis (e.g., stem-cell based therapies, platelet-rich plasma, or extracellular vesicles), these remain investigational and are not yet utilized clinically for fertility enhancement in patients with endometriosis.

Abstract STUDY QUESTION What is the fertility preservation (FP) utilization rate among transgender and gender diverse (TGD) patients at the Transgender and Intersex Specialty Care Clinic (TISCC) within the Mayo Clinic? SUMMARY ANSWER The rate of utilization of FP services by TGD patients at Mayo Clinic’s TISCC was determined to be 6.62%. WHAT IS KNOWN ALREADY TGD patients encounter several barriers when pursuing FP, which may contribute to a lower utilization rate of these services. These barriers include financial constraints and lack of insurance coverage, as well as societal and healthcare provider attitudes; TGD individuals face discrimination or lack of understanding, making it uncomfortable or difficult to discuss FP options. Additionally, there continues to be a lack of inclusive policies and support within healthcare systems that can further impede access to FP services for TGD individuals. STUDY DESIGN, SIZE, DURATION The study was executed in two phases. In the first phase, a retrospective cohort study was completed with TGD patients who provided electronic health record (EHR) research authorization from Mayo Clinic’s TISCC in Rochester, MN between 1 January 2015 and 30 July 2021. Search terms related to FP were used to determine the FP utilization rate among this patient population. In the second phase of the study, two sets of patients, (i) patients who were included in the cohort study in Phase 1, and (ii) members of JASMYN, a community organization specializing in care and wellness coordination for Lesbian, Gay, Bisexual, and Transgender (LGBT) teens and young adults in North Florida. Individuals were invited to participate in a qualitative interview exploring their cumulative healthcare experiences accessing gender-affirming care. Interviews were conducted from January 2023 to June 2023. Interviews examined participants’ perceptions of FP options, motivations for pursuing FP, and barriers to accessing both gender and fertility care. When applicable, participants also discussed their experiences pursuing FP and reflected on their satisfaction with their fertility and family planning decisions. PARTICIPANTS/MATERIALS, SETTING, METHODS In phase 1, a total of N = 1189 patients sought care from Mayo Clinic’s TISCC in Rochester, MN. Out of these patients, N = 589 patients provided research authorization and were included in the retrospective cohort study. The study team assessed whether FP terms were mentioned in each patient’s EHR, and whether patients scheduled and attended appointments with either the Department of Reproductive Endocrinology or the Department of Urology. FP search terms included sperm cryopreservation, sperm extraction, sperm aspiration, testicular tissue cryopreservation, oocyte cryopreservation, embryo cryopreservation, and ovarian tissue cryopreservation. In phase 2, N = 36 participants were interviewed, with N = 25 participants recruited from Mayo Clinic’s TISCC in Rochester, MN, and N = 11 participants recruited from JASMYN in Jacksonville, FL. Participants recruited from the Mayo Clinic participated in a video-call-based interview and those enrolled from JASMYN were interviewed in person. MAIN RESULTS AND THE ROLE OF CHANCE The study team observed a 6.62% utilization rate of FP services among N = 589 patients (median age: 28 years; age range: 8–78 years) included in the retrospective cohort study. N = 39 patients completed FP, with N = 14 receiving these services at other institutions before seeking care with the TISCC at Mayo Clinic. N = 25 patients pursued FP services within the Mayo Clinic. Patients with testes were more likely to complete FP via sperm cryopreservation when compared to the utilization of egg cryopreservation among patients with ovaries. Participants who completed an interview in Phase 2 (median age 27 years; age range: 22–80 years) reflected on their decision on whether to preserve their fertility and what factors influenced these decisions, and how their satisfaction with this decision has changed over their lifespan. The major themes reported here include the desire for biological children, planning gender care around fertility desires, conversations about FP options, physical and psychosocial barriers to pursuing FP, reflections on personal FP decisions, and reflections on having to make decisions about FP at a young age. LIMITATIONS, REASONS FOR CAUTION All participants who completed an interview have done so voluntarily; as such, there is a possibility of selection and recall bias. WIDER IMPLICATIONS OF THE FINDINGS Findings suggest that there is a need for more structured conversations around FP when TGD patients seek medical and surgical gender-affirming care. Accessibility, including financial barriers and limited insurance coverage, continues to limit the utilization of FP services among TGD patients. Increased affordability through insurance coverage may additionally improve FP utilization. STUDY FUNDING/COMPETING INTEREST(S) This project was funded by the Mayo Clinic Department of Obstetrics and Gynecology and the Mayo Clinic Center for Clinical and Translational Science (CCaTS), grant number UL1TR002377. This project was also supported by Clinical and Translational Science Award (CTSA) Grant Number TL1TR002380 from the National Center for Advancing Translational Sciences (NCATS). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. Felicity Enders reports grants from the National Institutes of Health and the Agency for Healthcare Research and Quality paid to her institution; speakers’ fees for lectures or presentations from Mount Sinai, University of Washington, University of Minnesota, University of Rochester, Cincinnati University, the National Institutes of Health, Duke University, Wake Forest University, the Patient Centered Outcomes Research Institute, Johns Hopkins University; travel support from the Association for Clinical and Translational Science and Cold Spring Harbor Laboratory; and an unpaid leadership role on the Board of Directors of the Association for Clinical and Translational Science. All other authors declare no conflicts of interest. TRIAL REGISTRATION NUMBER N/A.

Abstract Objective To compare the long‐term risk of subsequent abdominopelvic surgery in women who underwent hysterectomy with ovarian conservation (H‐OC) versus referent women, and in women who underwent abdominal H‐OC versus vaginal H‐OC. Methods We conducted a population‐based cohort study in Olmsted County, Minnesota, USA including 1573 women who underwent H‐OC for a benign indication at age 18–44 years between January 1, 1980, and December 31, 2002, and 1573 age‐matched (±1 year) referent women who had not undergone hysterectomy or any oophorectomy as of the matching date. For both the H‐OC women and the referent women, we defined the index date as the H‐OC or matching date plus 6 months. The index date served as the starting point for follow‐up. Results Overall, we found an increased risk of subsequent lysis of adhesions in women who underwent H‐OC compared to referent women (hazard ratio [HR], 1.57 [95% confidence interval [CI]: 1.09–2.27]). Women undergoing H‐OC also had an increased risk of subsequent gastrointestinal tract procedures (HR, 1.18 [95% CI: 1.05–1.31]) compared to referent women. When comparing surgical route of H‐OC, we identified an increased risk of subsequent adnexal surgeries in women undergoing abdominal compared with vaginal H‐OC (HR, 1.91 [95% CI: 1.40–2.61]). Conclusion Women who underwent H‐OC have an increased risk of subsequent abdominopelvic surgeries compared to referent women. In addition, women who underwent abdominal H‐OC have an increased risk of subsequent adnexal procedures compared to women who underwent vaginal H‐OC.

Objectives: To determine the risk of developing de novo carpal tunnel syndrome (CTS), arthritis, or rheumatoid arthritis in women who underwent hysterectomy with bilateral ovarian conservation (H-OC) before reaching spontaneous menopause. Methods: We identified 1,573 women undergoing H-OC for a benign indication at age 18 to 44 years between 1980 and 2002 in Olmsted County, Minnesota. Each woman was age-matched (±1 y) to a referent woman who had not undergone hysterectomy or oophorectomy before the matching date (index date). Diagnostic codes for CTS and arthritis were extracted from the Rochester Epidemiology Project medical records-linkage system through 2019. Hazard ratios (HRs) and 95% CIs were estimated using Cox proportional hazards models and the two cohorts were balanced for 19 chronic conditions and for several potential confounders present at index date. Results: Over a median 25.8-year follow-up, women undergoing H-OC had an increased risk of developing CTS (HR: 1.33; 95% CI: 1.13-1.56) compared with referent women. The risk was similar in strata by age at H-OC and was higher for women with endometriosis and menstrual disorders indications. Women undergoing H-OC also had an increased risk of developing arthritis (HR: 1.34; 95% CI: 1.23-1.47). The risk was similar in strata by age at H-OC and by indication. Rheumatoid arthritis considered separately was also associated with H-OC (HR: 1.55; 95% CI: 1.05-2.30). Conclusions: H-OC was associated with an increased risk of de novo CTS, arthritis (all types), and rheumatoid arthritis. Further studies are needed to confirm these associations and to explore potential biological mechanisms.

Abstract Background: Rectosigmoid endometriosis (RSE) presents with a diverse array of MRI findings that impact surgical planning. No standardized reporting and data system has been established for RSE. Purpose: We propose a novel MRI scoring system designed to predict the likelihood of muscularis propria (MP) involvement in RSE, which would, in turn, influence surgical planning. Material and Methods: The records of patients with bowel endometriosis treated surgically from May 2018 to June 2022 were retrieved. Surgery was classified as partial thickness discoid, full thickness discoid, or segmental resection. Each pre-treatment MRI was scored based on the mutual agreement of two abdominal radiologists (reference score). The MRI score was defined as (1) score 0: no evidence of RSE, (2) score 1: minimal tethering involving the serosal surface without MP involvement, (3) score 2: intermediate soft tissue thickening involving the rectosigmoid colon with indeterminate MP involvement, or (4) score 3: definite mushroom cap sign or definite MP involvement. In the reader study, two radiologists independently scored each exam. The area under the curve (AUC) was evaluated for predicting the need for segmental or full thickness discoid resection. Results: The cohort consisted of 95 patients (median age: 36 years); 16, 14, 30, and 35 patients had MRI score 0, 1, 2, and 3, respectively. Patients with MRI scores 3 and 2 underwent partial thickness discoid (6% vs 50%), full thickness discoid (6% vs 17%), and segmental resection (89% vs 33%), respectively. All patients with MRI scores 1 or 0 either underwent partial thickness discoid resection or did not undergo rectosigmoid surgery. The AUCs were 92.2%, 84.5% and 93.9% for MRI scores of the reference, reader 1, and 2, respectively. Conclusion: Our MRI scoring system based on suspected depth of bowel invasion showed good diagnostic performance to predict the type of surgical intervention needed. Summary Statement This novel MRI scoring system for rectosigmoid endometriosis is a concise and qualitative scale based on suspected depth of bowel wall invasion to best guide operative planning.

Abstract Introduction Microdissection testicular sperm extraction (microTESE) is performed in men with nonobstructive azoospermia who desire sperm retrieval for use in IVF. This procedure can be performed in the operating room or in the clinic with local analgesic. Objective To report office-based microTESE sperm retrieval, fertilization, and livebirth rates. Methods A review was conducted of all patients who underwent office-based microTESE for nonobstructive azoospermia with a partner that who underwent concurrent oocyte retrieval for an intended in-vitro fertilization (IVF) intracytoplasmic injection (ICSI) cycle 2022-2024. All male partners underwent Y chromosome microdeletion testing, karyotype analysis, and hormonal testing preoperatively. Patients with a diagnosis of hypogonadism were offered medical therapy and those diagnosed with a varicocele were offered varicocelectomy prior to microTESE. Office-based microTESE was performed using a surgical operating microscope, spermatic cord block, and oral anxiolytic. Female partners underwent oocyte retrieval with oocyte cryopreservation prior to microTESE. Oocyte warming and ICSI was performed only following the collection of motile sperm from the fresh microTESE samples. Relevant demographic and clinical data were collected for patients and their partners. Descriptive data analysis was performed and reported as mean ± standard deviation. Results Ten patients underwent 11 office-based microTESE procedures. One patient had repeat microTESE following an unsuccessful IVF/ICSI cycle. Overall sperm retrieval rate was 70% for first time microTESE with mean search time 197.2 ± 96.5 min. Amongst couples with successful sperm retrieval, normal fertilization rate was 42%. Early cleavage arrest was seen in 84% of normally fertilized oocytes with a 16% blastocyst rate. Embryo development arrested entirely in two couples, while the remaining five couples had at least one blastocyst on day 5 and underwent embryo transfer. Of these, four resulted in a clinical pregnancy (36%). Three couples had a successful live birth and one has an ongoing pregnancy with ultrasound-confirmed fetal heartbeat. Conclusions Our small series demonstrates high sperm retrieval rates from office-based microTESE. Fertilization rates, clinical pregnancies and live birth rates are comparable with those reported in the literature. Given the financial cost associated with microTESE and IVF/ICSI for nonobstructive azoospermia patients, office-based microTESE may be a solution to make the process more financially accessible for couples. Disclosure No.

Linked article: This Correspondence comments on Deslandes and Leonardi. Click here to view the article.