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ObjectiveTo compare success rates, associated risks and cost-effectiveness between intrauterine insemination (IUI) and in vitro fertilisation (IVF).DesignRetrospective observational study.SettingThe UK from 2012 to 2016.ParticipantsData from Human Fertilisation and Embryology Authority’s freedom of information request for 2012–2016 for IVF/ICSI (intracytoplasmic sperm injection)and IUI as practiced in 319 105 IVF/ICSI and 30 669 IUI cycles. Direct-cost calculations for maternal and neonatal expenditure per live birth (LB) was constructed using the cost of multiple birth model, with inflation-adjusted Bank of England index-linked data. A second direct-cost analysis evaluating the incremental cost-effective ratio (ICER) was modelled using the 2016 national mean (baseline) IVF and IUI success rates.Outcome measuresLB, risks from IVF and IUI, and costs to gain 1 LB.ResultsThis largest comprehensive analysis integrating success, risks and costs at a national level shows IUI is safer and more cost-effective than IVF treatment.IVF LB/cycle success was significantly better than IUI at 26.96% versus 11.49% (pIn 2016, IVF maternal and neonatal cost was £115 082 017 compared with £2 940 196 for IUI and this MGP-related perinatal cost is absorbed by the National Health Services. At baseline tariffs and success rates IUI was £42 558 cheaper than IVF to deliver 1LB with enhanced benefits with small improvements in IUI. Reliable levels of IVF-related MGP, OHSS (ovarian hyperstimulation syndrome), fetal reductions and terminations are revealed.ConclusionIUI success rates are much closer to IVF than previously reported, more cost-effective in delivering 1 LB, and associated with lower risk of complications for maternal and neonatal complications. It is prudent to offer IUI before IVF nationally.

OBJECTIVES: To evaluate whether the Morphological Uterus Sonographic Assessment (MUSA) features of adenomyosis need to be better defined and, if deemed necessary, to reach consensus on the updated definitions. METHODS: A modified Delphi procedure was performed among European gynecologists with expertise in ultrasound diagnosis of adenomyosis. To identify MUSA features that might need revision, 15 two-dimensional (2D) video recordings (four recordings also included three-dimensional (3D) still images) of transvaginal ultrasound (TVS) examinations of the uterus were presented in the first Delphi round (online questionnaire). Experts were asked to confirm or refute the presence of each of the nine MUSA features of adenomyosis (described in the original MUSA consensus statement) in each of the 15 videoclips and to provide comments. In the second Delphi round (online questionnaire), the results of the first round and suggestions for revision of MUSA features were shared with the experts before they were asked to assess a new set of 2D and 3D still images of TVS examinations and to provide feedback on the proposed revisions. A third Delphi round (virtual group meeting) was conducted to discuss and reach final consensus on revised definitions of MUSA features. Consensus was predefined as at least 66.7% agreement between experts. RESULTS: Of 18 invited experts, 16 agreed to participate in the Delphi procedure. Eleven experts completed and four experts partly finished the first round. The experts identified a need for more detailed definitions of some MUSA features. They recommended use of 3D ultrasound to optimize visualization of the junctional zone. Fifteen experts participated in the second round and reached consensus on the presence or absence of ultrasound features of adenomyosis in most of the still images. Consensus was reached for all revised definitions except those for subendometrial lines and buds and interrupted junctional zone. Thirteen experts joined the online meeting, in which they discussed and agreed on final revisions of the MUSA definitions. There was consensus on the need to distinguish between direct features of adenomyosis, i.e. features indicating presence of ectopic endometrial tissue in the myometrium, and indirect features, i.e. features reflecting changes in the myometrium secondary to presence of endometrial tissue in the myometrium. Myometrial cysts, hyperechogenic islands and echogenic subendometrial lines and buds were classified unanimously as direct features of adenomyosis. Globular uterus, asymmetrical myometrial thickening, fan-shaped shadowing, translesional vascularity, irregular junctional zone and interrupted junctional zone were classified as indirect features of adenomyosis. CONCLUSION: Consensus between gynecologists with expertise in ultrasound diagnosis of adenomyosis was achieved regarding revised definitions of the MUSA features of adenomyosis and on the classification of MUSA features as direct or indirect signs of adenomyosis. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology. ispartof: ULTRASOUND IN OBSTETRICS & GYNECOLOGY vol:60 issue:1 pages:118-131 ispartof: location:England status: published

BackgroundAdenomyosis commonly occurs with abnormal uterine bleeding (AUB) and is associated with subfertility and a higher miscarriage rate. Recent evidence showed abnormal vascularization in the endometrium in patients with adenomyosis, suggesting a role of angiogenesis in the pathophysiology of AUB and subfertility in adenomyosis and providing a possible treatment target.Objective and rationaleWe hypothesized that the level of abnormal vascularization and expression of angiogenic markers is increased in the ectopic and eutopic endometrium of adenomyosis patients in comparison with the endometrium of control patients. This was investigated through a search of the literature.Search methodsA systematic search was performed in PubMed and Embase until February 2019. Combinations of terms for angiogenesis and adenomyosis were applied as well as AUB, subfertility or anti-angiogenic therapy. The main search was limited to clinical studies carried out on premenopausal women. Original research articles focusing on markers of angiogenesis in the endometrium of patients with adenomyosis were included. Studies in which no comparison was made to control patients or which were not published in a peer-reviewed journal were excluded. A second search was performed to explore the therapeutic potential of targeting angiogenesis in adenomyosis. This search also included preclinical studies.OutcomesA total of 20 articles out of 1669 hits met our selection criteria. The mean vascular density (MVD) was studied by quantification of CD31, CD34, von Willebrand Factor (vWF) or factor-VIII-antibody-stained microvessels in seven studies. All these studies reported a significantly increased MVD in ectopic endometrium, and out of the six articles that took it into account, four studies reported a significantly increased MVD in eutopic endometrium compared with control endometrium. Five articles showed a significantly higher vascular endothelial growth factor expression in ectopic endometrium and three articles in eutopic endometrium compared with control endometrium. The vascular and pro-angiogenic markers α-smooth muscle actin, endoglin, S100A13, vimentin, matrix metalloproteinases (MMPs), nuclear factor (NF)-kB, tissue factor (TF), DJ-1, phosphorylated mammalian target of rapamycin, activin A, folli- and myostatin, CD41, SLIT, roundabout 1 (ROBO1), cyclooxygenase-2, lysophosphatidic acid (LPA) 1,4-5, phospho signal transducer and activator of transcription 3 (pSTAT3), interleukin (IL)-6, IL-22 and transforming growth factor-β1 were increased in ectopic endometrium, and the markers S100A13, MMP-2 and -9, TF, follistatin, myostatin, ROBO1, LPA1 and 4-5, pSTAT3, IL-6 and IL-22 were increased in eutopic endometrium, compared with control endometrium. The anti-angiogenic markers E-cadherin, eukaryotic translation initiation factor 3 subunit and gene associated with retinoic-interferon-induced mortality 19 were decreased in ectopic endometrium and IL-10 in eutopic endometrium, compared with control endometrium. The staining level of vWF and two pro-angiogenic markers (NF-κB nuclear p65 and TF) correlated with AUB in patients with adenomyosis. We found no studies that investigated the possible relationship between markers of angiogenesis and subfertility in adenomyosis patients. Nine articles reported on direct or indirect targeting of angiogenesis in adenomyosis—either by testing hormonal therapy or herbal compounds in clinical studies or by testing angiogenesis inhibitors in preclinical studies. However, there are no clinical studies on the effectiveness of such therapy for adenomyosis-related AUB or subfertility.Wider implicationsThe results are in agreement with our hypothesis that increased angiogenesis is present in the endometrium of patients with adenomyosis compared with the endometrium of control patients. It is likely that increased angiogenesis leads to fragile and more permeable vessels resulting in adenomyosis-related AUB and possibly subfertility. While this association has not sufficiently been studied yet, our results encourage future studies to investigate the exact role of angiogenesis in the etiology of adenomyosis and related AUB or subfertility in women with adenomyosis in order to design curative or preventive therapeutic strategies.

Study question Are IVF clinics collecting too many oocytes per retrieval procedure? Summary answer IVF cycles performed in the UK appear to be retrieving far too many oocytes, most of which may never be used and are probably discarded. What is known already For justifying IVF with low AMH, older women, poor responders, the Bologna and POSEIDON consensuses were developed. The positive linear correlation between cumulative live birth rates and numbers of oocytes collected is well established, thereby focussing intensely on stimulation regimes and the growth of FER cycles and oocyte freezing activities. The associated risk of OHSS is well-known. However, over-stimulation practices and numbers of oocytes retrieved within IVF remain unknown as is the impact on patients’ health, emotional and financial welfare. This UK dataset uniquely reveals numbers of oocytes retrieved against IVF cycles undertaken, and which may well reflect global practices. Study design, size, duration This is a retrospective observational cohort study of oocyte retrieval procedures for non-donor IVF cycles in the UK between 2015 and 2018. Data were obtained from UK HFEA under the Freedom of Information Act 2000. For fresh oocytes, data were obtained for the number of cycles retrieving 1-5, 6-15, 16-25, 26-49, 50-59, and 60+ oocytes. The number of cycles that led to no oocytes was obtained as well as data on the utilisation of oocytes. Participants/materials, setting, methods The data from the HFEA covers up to 86 UK IVF clinics undertaking non-donor IVF. IVF clinics are legally obliged to provide IVF dataset as part of the licence requirement. The unbiased data was gathered independently by HFEA staff under the Freedom of Information Act 2000. Specifically, the number of treatment cycles with; 0, 1-5, 6-15,16-25, 26-49, 50-59, and 60+ oocytes retrieved for each year was requested. Additional limited data could be gained. Main results and the role of chance For 2015-2018 there were 172341 fresh oocyte retrieval cycles, where 10148 (5.9%) cycles from 9439 patients did not yield any oocytes. In this period, 42574 cycles (24.7%), 91797 cycles (53.3%), 23794 cycle (13.8%) and 3970 cycles (2.3%) yielded 1-5 oocytes, 6-15 oocytes, 16-25 oocytes, 26-49 oocytes respectively, while 58 cycle (0.033%) yielded over 50 oocytes. The data was accountable by 5-85 clinics and the outcomes and patterns remained uniform across the 4 years. The main desired oocyte yield of 6-15 oocytes occurred in 53.3% of IVF cycles distributed evenly across the clinics. However, 16.1% of cycles were associated with 16-49 oocytes retrieved per IVF cycle, while 58 (0.03%) cycles led to greater than 50 oocytes retrieved. The maximum number of oocytes collected was not provided by the HFEA due to technical reasons. The total number of oocytes collected over 4-years numbered 1,624,912 oocytes from 147274 women yielding on average 11 oocytes per patient. These oocytes were fertilised to yield 931,265 embryos (57.3% converted). The fate of 42.7% oocytes remains unknown. Of the embryos created, 209,080 (22.4%) were transferred over 172,333 cycles, while 219,563 (23.6%) embryos frozen and the fate of 53.97% of embryos remained unaccounted for. Limitations, reasons for caution This retrospective analysis spans 4 years in which stimulation regimes, patient characteristics, or outcomes were unavailable. Only a qualitative analysis is possible with the HFEA dataset, but the corresponding data is unique and of public interest. The outcome of unaccounted oocytes appears a limitation in the regulatory body data set. Wider implications of the findings This unique observation on IVF clinics practices suggests that the high oocyte number per retrieval procedure needs re-evaluation. In particular, this needs to focus on the side-effects, including OHSS and procedure-related complications. In addition, the outcome and cost of unused frozen oocytes need to be established. Trial registration number not applicable

Research question: Is there vertical transmission (from mother to baby antenatally or intrapartum) after SARS-CoV-2 (COVID-19) infected pregnancy?\ud \ud Study design: A systematic search related to SARS-CoV-2 (COVID-19), pregnancy, neonatal complications, viral and vertical transmission. The duration was from December 2019 to May 2020.\ud \ud Results: A total of 84 studies with 862 COVID positive women were included. Two studies had ongoing pregnancies while 82 studies included 705 babies, 1 miscarriage and 1 medical termination of pregnancy (MTOP). Most publications (50/84, 59.5%), reported small numbers (

Objective: To compare the effect of a hysteroscopic niche resection with a Levenorgestrel-releasing intrauterine device (LNG-IUD) on postmenstrual spotting in women with a symptomatic niche in the uterine cesarean scar. Design: Single center, prospective cohort study. Setting: A hospital affiliated to a medical college in China. Population: Women diagnosed with a niche by MRI scan and postmenstrual spotting of at least two days. Method: Women were allocated to two groups based on the shared medical decision-making approach, and were followed up for 1 year after treatment. Main outcome measures: The primary outcome was effectiveness in reducing postmenstrual spotting. Secondary outcomes were menstrual characteristics, direct medical costs, complications and side effects. Results: Effectiveness of LNG-IUD was significantly higher than a hysteroscopic niche resection during the first year, based on linear mixed models (P=0.009), and the effectiveness increased overtime within 1 year. Postmenstrual spotting reduced statistically in both groups. More slight side effects, although not statistically significant, were reported in LNG-LUD group at obviously lower direct medical costs. Conclusion：LNG-IUD is more effective in the treatment of postmenstrual spotting from the 6th month onwards than a hysteroscopic niche resection in women with a symptomatic niche at lower direct costs. Key Words：Niche, uterine cesarean scar, hysteroscopy niche resection, LNG-IUD, postmenstrual spotting, amenorrhea Tweetable abstract: LNG-IUD is more effective in the treatment of postmenstrual spotting related to a niche than hysteroscopic niche resection.

Caesarean section can result in an indentation of the myometrium at the site of the Caesarean scar, called a niche. Niches can cause symptoms of abnormal uterine blood loss, dysmenorrhoea, chronic pelvic pain and dyspareunia and are possibly related to subfertility. Various other explanations for the cause of subfertility after Caesarean section have been proposed in the literature, such as uterine pathology, intra-abdominal adhesions and women’s reproductive choices. Not all niches cause symptoms and the relation with subfertility and a niche in the uterine scar still needs further study since direct evidence is lacking so far. Based on the limited available evidence, and in combination with observations made during sonographic hysteroscopic evaluations and laparoscopic niche repair, we propose and discuss three hypothetical mechanisms: (i) the environment for sperm penetration and implantation may be detrimental; (ii) there could be a physical barrier to embryo transfer and implantation; and (iii) psychogenic factors may reduce the likelihood of pregnancy. Several innovative surgical treatments have been developed and are being implemented for niche-related problems. Promising results are reported, but more evidence is needed before further implementation in daily practice. The additional value of niche resections should be compared to expectant management or fertility therapies, such as ART, in randomized controlled trials. Therefore, our suggested hypotheses should, for the time being, not be used for justification of any specific procedures outside clinical trials.

The question of whether SARS-CoV-2 (severe acute respiratory syndrome-related coronavirus-2 [SARS-CoV or SARS-CoV-2], leading to the COVID-19 infection) can be harboured in the testes and/or semen is currently unanswered. It is essential to understand the limitations of both antibody and real-time PCR tests in interpreting SARS-CoV-2 data in relation to analyses of semen and testicular tissue without appropriate controls. This article critically analyses the evidence so far on this, and the possible implications. The limitations of diagnostic tests in both sampling and testing methodologies, their validation and their relevance in interpreting data are also highlighted.

Background: Masculinizing mastectomy is the most requested gender affirming surgery (GAS) in trans men, followed by genital GAS. Mastectomy and total laparoscopic hysterectomy, with or without bilateral salpingo-oophorectomy (TLH ± BSO), can both be performed in one single operation session. However, data on complication rates of the combined procedure is scarce and no consensus exists on the preferred order of procedures. Aims: To compare safety outcomes between mastectomy performed in a single procedure with those when performed in a combined procedure and assess whether the order of procedures matters when they are combined. Methods: A retrospective chart review was performed of trans men who underwent masculinizing mastectomy with or without TLH ± BSO in a combined session. The effects of the surgical procedure on complication and reoperation rate of the chest were assessed using logistic regression. Results: In total, 480 trans men were included in the study. Of these, 212 patients underwent the combined procedure. The gynecological procedure was performed first in 152 (71.7%) patients. In the total sample, postoperative hematoma of the chest occurred in 11.3%; 16% in the combined versus 7.5% in the single mastectomy group (p = 0.001). Reoperations due to hematoma of the chest were performed in 7.5% of all patients; 10.8% in the combined versus 4.9% in the single mastectomy group (p = 0.017). The order of procedures in the combined group had no significant effect on postoperative hematoma of the chest (p = 0.856), and reoperations (p = 0.689). Conclusion: Combining masculinizing mastectomy with TLH ± BSO in one session was associated with significantly more hematoma and reoperations compared with separately performing mastectomy. This increased risk of complications after a combined procedure should be considered when deciding on surgical options. The order of procedures in a combined procedure did not have an effect on safety outcomes.

BACKGROUND: Instructing and guiding patients after surgery is essential for successful recovery. However, the time that health-care professionals can spend with their patients postoperatively has been reduced because of efficiency-driven, shortened hospital stays. We evaluated the effect of a personalised e-health-care programme on return to normal activities after surgery.METHODS: A multicentre, single-blind, randomised controlled trial was done at seven teaching hospitals in the Netherlands. Patients aged 18-75 years who were scheduled for laparoscopic cholecystectomy, inguinal hernia surgery, or laparoscopic adnexal surgery for a benign indication were recruited. An independent researcher randomly allocated participants to either the intervention or control group using computer-based randomisation lists, with stratification by sex, type of surgery, and hospital. Participants in the intervention group had access to a perioperative, personalised, e-health-care programme, which managed recovery expectations and provided postoperative guidance tailored to the patient. The control group received usual care and access to a placebo website containing standard general recovery advice. Participants were unaware of the study hypothesis and were asked to complete questionnaires at five timepoints during the 6-month period after surgery. The primary outcome was time between surgery and return to normal activities, measured using personalised patient-reported outcome measures. Intention-to-treat and per-protocol analyses were done. This trial is registered in the Netherlands National Trial Register, number NTR4699.FINDINGS: Between Aug 24, 2015, and Aug 12, 2016, 344 participants were enrolled and randomly allocated to either the intervention (n=173) or control (n=171) group. 14 participants (4%) were lost to follow-up, with 330 participants included in the primary outcome analysis. Median time until return to normal activities was 21 days (95% CI 17-25) in the intervention group and 26 days (20-32) in the control group (hazard ratio 1·38, 95% CI 1·09-1·73; p=0·007). Complications did not differ between groups.INTERPRETATION: A personalised e-health intervention after abdominal surgery speeds up the return to normal activities compared with usual care. Implementation of this e-health programme is recommended in patients undergoing intermediate-grade abdominal, gynaecological, or general surgical procedures.FUNDING: ZonMw.

BackgroundThe aim of this study was to determine growth in trainee laparoscopic skill as recorded by the TrEndo laparoscopic simulator during a laparoscopic training course, compared to an expert level.MethodsA prospective observational cohort study was conducted between February 1 and November 31, 2010. Trainees in laparoscopic surgery completed a basic laparoscopic suturing task on a laparoscopic box trainer at three successive assessment points during a laparoscopic training course. Experts were assessed only once to define an expert level. The TrEndo recorded four motion analysis parameters (MAPs) individually for each hand and the amount of time taken to complete the suturing task.ResultsSeventy-two residents and 56 experts were included in this study. Overall, the amount of time taken on the suturing task and seven out of eight MAPs significantly increased toward an expert level during the course, representing an improvement in task efficiency. During the first training day, the amount of time spent on the suturing task and five out of eight MAPs improved significantly. After the retention period, five out of eight MAPS demonstrated a significant improvement compared to the end of the first training day.ConclusionsLaparoscopic skill of trainees as recorded by the TrEndo laparoscopic simulator grows toward an expert level during a laparoscopic training course in a large and heterogeneous study group. Construct validity of the TrEndo is established.

Objective: Purpose of this study is to determine the interobserver and intraobserver variability of 3D GIS in the assessment of intrauterine abnormalities. Study design: Forty five 3D volumes were randomly selected from a larger prospective cohort study that studied the diagnostic accuracy of 3D GIS in addition to 2D GIS. To study interobserver agreement volumes were reviewed by two independent examiners. One examiner reviewed these samples twice with an interval of 1 month in a random order. Interobserver and intraobserver agreement were tested with Cohen's kappa coefficient and shown in Bland and Altman plots. Quality of the 3D volumes was evaluated. Results: Cohen's kappa for interobserver variability for type of abnormalities (none, polyp, fibroid, other) was 0.64 and for presence of a fibroid (fibroid yes/no) 0.77. Agreement on type of fibroid was 0.59. Intraobserver agreement was almost perfect for type of abnormality (Cohen's kappa of 1.0) and good for fibroid diameter. Quality of the 3D volumes was poor in 11 out of 45 cases. Reproducibility increased when poor quality images were excluded. Conclusion: Substantial interobserver and intraobserver agreement for 3D GIS in the diagnoses of intrauterine abnormalities was found. 3D GIS interobserver and intraobserver agreement are good for fibroid diameter and moderate for volume and protrusion. © 2014 Elsevier Ireland Ltd. All rights reserved.

Objectives. To survey practice variation in the management of first trimester miscarriage in The Netherlands.Methods. We sent an online questionnaire to gynecologists in eight academic, 37 nonacademic teaching, and 47 nonteaching hospitals. Main outcome measures were availability of a local protocol; estimated number of patients treated with curettage, misoprostol, or expectant management; misoprostol regimen; and estimated number of curettages performed after initial misoprostol treatment. Outcomes were compared to the results of a previous nationwide survey.Results. The response rate was 100%. A miscarriage protocol was present in all academic hospitals, 68% of nonacademic teaching hospitals, and 38% of nonteaching hospitals (P=0.008). Misoprostol was first-choice treatment for 41% of patients in academic hospitals versus 34% and 27% in teaching-and nonteaching hospitals (P=0.045). There were 23 different misoprostol regimens. Curettage was first-choice treatment in 29% of patients in academic hospitals versus 46% and 50% in nonacademic teaching or nonteaching hospitals (P=0.007). In 30% of patients, initial misoprostol treatment was followed by curettage.Conclusions. Although the percentage of gynaecologists who are aware of the availability of misoprostol for miscarriage treatment has doubled to almost 100% since 2005, practice variation is still large. This practice variation underlines the need for a national guideline.

Background. The equality of subjective- and objective-assessment methods in laparoscopic surgery are unknown. The aim of this study was to compare a subjective assessment method to an objective assessment method to evaluate laparoscopic skill. Methods. A prospective observational cohort study was conducted. Seventy-two residents completed a basic laparoscopic suturing task on a box trainer at two consecutive assessment points. Laparoscopic skill was rated subjectively using the Objective Structured Assessment of Technical Skills (OSATS) list and objectively using the TrEndo, an augmented-reality simulator. Results. TrEndo scores between the two assessment points correlated. OSATS scores did not correlate between the two assessment points. There was a correlation between TrEndo and OSATS scores at the first assessment point, but not at the second assessment point. Overall, OSATS scores correlated with TrEndo scores. There was a greater spread within OSATS scores compared to TrEndo scores. Conclusion. OSATS scores correlated with TrEndo scores. The TrEndo may be more responsive at rating individual’s laparoscopic skill, as demonstrated by a smaller overall spread in TrEndo scores. The additional value of objective assessment methods over conventional assessment methods as provided by laparoscopic simulators should be investigated.

Background: There is an increasing demand for structured objective ex vivo training and assessment of laparoscopic psychomotor skills prior to implementation of these skills in practice. The aim of this study was to establish the internal validity of the TrEndo, a motion-tracking device, for implementation on a laparoscopic box trainer.Methods: Face validity and content validity were addressed through a structured questionnaire. To assess construct validity, participants were divided into an expert group and a novice group and performed two basic laparoscopic tasks. The TrEndo recorded five motion analysis parameters (MAPs) and time.Results: Participants demonstrated a high regard for face and content validity. All recorded MAPs differed significantly between experts and novices after performing a square knot. Overall, the TrEndo correctly assigned group membership in 84.7 and 95.7% of cases based on two laparoscopic tasks.Conclusion: Face, content, and construct validities of the TrEndo were established. The TrEndo holds real potential as a (home) training device.

Background: Knot tying and suturing skills in minimally invasive surgery (MIS) differ markedly from those in open surgery. Appropriate MIS training is mandatory before implementation into practice. The Advanced Suturing Course (ASC) is a structured simulator based training course that includes a 6-week autonomous training period at home on a traditional laparoscopic box trainer. Previous research did not demonstrate a significant progress in laparoscopic skills after this training period. This study aims to identify factors determining autonomous training on a laparoscopic box trainer at home.Methods: Residents (n = 97) attending 1 of 7 ASC courses between January 2009 and June 2011 were consecutively included. After 6 weeks of autonomous, training a questionnaire was completed. A random subgroup of 30 residents was requested to keep a time log. All residents received an online survey after attending the ASC. We performed outcome comparison to examine the accuracy of individual responses.Results: Out of 97 residents, the main motives for noncompliant autonomous training included a lack of (training) time after working hours (n = 80, 83.3%), preferred practice time during working hours (n = 76, 31.6%), or another surgical interest than MIS (n = 79, 15.2%). Previously set training goals would encourage autonomous training according to 27.8% (n = 18) of residents. Thirty participants submitted a time log and reported an average 76.5-minute weekly training time. All residents confirmed that autonomous home practice on a laparoscopic box trainer is valuable.Conclusions: Autonomous practice should be structured and inclusive of adequate and sufficient feedback points. A minimally required practice time should be set. An obligatory assessment, including corresponding consequence should be conducted. Compliance herewith may result in increased voluntary (autonomous) simulator based (laparoscopic) training by residents.