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Bandr Hafedh, Sarah Mohammed Idris, Farah Nadreen, Abdulrhman M Banasser, Radiah Iskandarani, Saeed Baradwan Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi ArabiaCorrespondence: Saeed Baradwan, Email dr.saeed_bardwan@yahoo.comBackground: Laparoscopic sacrohysteropexy is an emerging uterine-preserving strategy for management of uterovaginal prolapse (UVP). The literature on laparoscopic sacrohysteropexy for management of UVP is very scarce from Saudi Arabia. This research examined the feasibility, clinical utility, and safety of laparoscopic sacrohysteropexy in a Saudi setting.Methods: A retrospective study was conducted, including all patients who met the inclusion criteria. The laparoscopic sacrohysteropexy technique was adapted with modifications from the “Oxford hysteropexy”. The primary endpoint was overall success, defined as anatomical success in all vaginal compartments (UVP grade 0 or 1 postoperatively). The secondary endpoint was the mean change in point C. Descriptive data were summarized with numbers and percentages, while numerical data used means ± standard deviations. Fisher’s exact and Student’s t tests were used for univariate analyses. Significant surgical outcome predictors were identified via logistic regression, with p < 0.05 considered statistically significant.Results: Overall, 21 patients met the inclusion criteria. The most frequent indication for laparoscopic sacrohysteropexy was UVP without anterior or posterior wall prolapse (n = 15, 71.4%), whereas the most frequent grade of UVP was grade III (n = 13, 61.9%). One patient (4.8%) required switch to laparotomy due to severe adhesions. No perioperative complications were recorded. The mean change in point C and hospital stay were 5.8 ± 2.1 (range: 0– 8) and 1.4 ± 0.6 days (range: 1– 3), respectively. Surgical success was achieved in 18 patients (85.7%). Only three patients experienced recurrences (one, two, and six months postoperatively). The mean change in point C was significantly higher in successful cases contrasted with the failed cases (6.5 versus 1.3).Conclusion: Laparoscopic sacrohysteropexy for management of uterovaginal prolapse revealed technical feasibility, safety, and beneficial utility of the procedure. Further large-sized and multicentric investigations are important to gather additional pertinent information on laparoscopic sacrohysteropexy.Keywords: pelvic organ prolapse, uterovaginal prolapse, sacrohysteropexy, surgical failure, success rate

Saeed Baradwan, Abdullah Alyousef, Abdulrhman Turkistani Department of Obstetrics and Gynecology, King Fahad Medical City, Riyadh, Saudi Arabia Background: Iron deficiency anemia (IDA) during pregnancy is a common and preventable disorder. It remains a contributing factor to maternal morbidity and mortality and is associated with high perinatal mortality rates.Objective: To determine the prevalence of IDA and its associated clinical features among pregnant women.Methods: This analytical prospective cohort study included 1,579 pregnant women who attended an antenatal clinic, Women’s Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia, between January 2018 and April 2018. The type of anemia and its associated maternal and fetal outcomes were determined.Results: About 702 women were confirmed to have IDA, with a prevalence of 44.5 %. Most women (79.8%) were younger than 35 years. A low hemoglobin concentration was reported in 45 % of participants. The major type of anemia was microcytic hypochromic anemia (98.7%). More than half of the participants (57.3%) reported use of iron supplementation during pregnancy. IDA anemia was highest in pregnant women with gravidity >8 in 40 (56.3%) compared to normal pregnant women 31 (43.7%), and lowest in those with gravidity ≤2 in 281 (41.4%) compared to normal pregnant women 397 (58.6%). The difference was statistically significant, P=0.024. Similarly, this type of anemia was highest in those with parity of >3 (53.3%) and lowest in nulliparous women (39.3%) compared to normal pregnant women (46.7%) and (60.7%), respectively. This was statistically significant P=0.002. IDA had significantly (P=0.012) lower spontaneous vaginal delivery rates compared with normal pregnant women (44.5% vs 55.5%, respectively). IDA had significantly (P=0.017) lower antenatal fetal distress rates compared with normal pregnant women (68.5% vs 31.5%, respectively).Conclusion: Anemia in general and microcytic hypochromic anemia in particular were significantly associated with higher gravidity and parity. The significant outcome associated with IDA during pregnancy was a lower rate of spontaneous vaginal delivery and antenatal fetal distress. Compliance with iron supplementation in order to prevent maternal and fetal adverse outcomes was observed. Keywords: microcytic hypochromic anemia, pregnancy, iron deficiency anemia

Saeed Baradwan,1 Dina Shafi,1 Amira Baradwan,2 Muhammad Salman Bashir,3 Dania Al-Jaroudi1,4 1Department of Obstetrics and Gynecology, Women’s Specialized Hospital, King Fahad Medical City, Riyadh, 2Faculty of Medicine, King Abdulaziz University, Jeddah, 3Research Center, King Fahad Medical City, Riyadh, 4Department of Obstetrics and Gynecology, Reproductive Infertility and Medicine Department, King Fahad Medical City, Riyadh, Saudi Arabia Background: Hysteroscopic adhesiolysis anatomically restores the uterine cavity in cases of Asherman’s syndrome (AS); however, the extent of endometrial fibrosis could determine the pregnancy outcome.Objectives: To determine whether endometrial thickness could influence pregnancy outcome of hysteroscopic adhesiolysis in women with a history of AS.Subjects and methods: This was a retrospective cohort study that included 41 women who attended Women’s Specialized Hospital, King Fahad Medical City from December 2008 to December 2015, presented with a history of infertility or recurrent pregnancy loss, and were diagnosed with intrauterine adhesions and treated by hysteroscopic adhesiolysis. To analyze the causative factors of AS, history of curettage, miscarriage, postpartum hemorrhage, hysteroscopy, endometritis, and any uterine surgery were recorded. Patients were followed up for 2 years to account for pregnancy. Patients were divided into two groups based on measurement of endometrial thickness in the midsagittal plane at mid-cycle of a menstrual period. Group A consisted of 26 patients with endometrial thickness ≤5 mm, and group B included 15 patients with endometrial thickness >5 mm. The main outcome measures included endometrial thickness and pregnancy outcome.Results: Group A had significantly (P5 mm in thickness among patients with AS and miscarriage rates may be reduced in this group. Keywords: intrauterine adhesion, operative hysteroscopy, Asherman’s syndrome, endometrial thickness

Background and Objectives : Polycystic ovary syndrome (PCOS) is a common endocrine disorder associated with various cardiometabolic risk factors, including insulin resistance, dyslipidemia, hypertension, and obesity, which contribute to an increased risk of cardiovascular diseases. This inaugural systematic review and meta-analysis of randomized controlled trials (RCTs) evaluated the impact of magnesium supplementation on various cardiometabolic risk factors and hormonal parameters in patients with polycystic ovary syndrome (PCOS). Materials and Methods : We systematically searched the MEDLINE, Web of Science, Scopus, and Cochrane databases until 30 March 2024 for studies comparing magnesium supplementation to control in improving cardiometabolic and hormonal factors in PCOS patients. Endpoints were summarized as mean differences (MD) and 95% confidence intervals (CIs) in a random-effects model. Results : The primary search yielded 176 studies. After screening, six studies met our inclusion criteria. Our meta-analysis showed no significant effects of magnesium supplementation on cardiometabolic risk factors and hormonal parameters in patients with PCOS. Conclusions : Magnesium supplementation does not appear to influence the cardiometabolic and hormonal factors in PCOS patients. Further rigorous RCTs are needed to strengthen the evidence and support comprehensive analysis in this area. PROSPERO database (CRD42024526110).

Background: The primary perioperative concern during laparoscopic myomectomy is the risk of significant intraoperative blood loss, which can lead to hypovolemia, necessitate blood transfusion, and result in postoperative anemia. To address this issue, we conducted a systematic review and meta-analysis to assess the impact of temporarily clamping the uterine and utero-ovarian arteries on operative blood loss during laparoscopic myomectomy., Methods: We conducted a comprehensive search across various databases to identify eligible clinical trials from inception to May 2024, focusing on randomized controlled trials (RCTs). In the intervention group, temporary bilateral clamping of the uterine and utero-ovarian arteries was performed during laparoscopic myomectomy, while the control group underwent laparoscopic myomectomy without arterial clamping. A meta-analysis was carried out on the gathered data using Revman software. The primary outcomes examined were blood loss and change in hemoglobin, with secondary outcomes including operation time and length of hospital stay., Results: Three RCTs, involving a total of 275 patients, met our inclusion criteria. The intervention group showed significantly lower operative blood loss and a smaller reduction in hemoglobin compared to the control group. There was no notable difference in operation time between the two groups. Moreover, patients in the experimental group experienced a significantly shorter hospitalization duration than those in the control group., Conclusions: The temporary bilateral occlusion of the uterine and utero-ovarian arteries is an effective method for reducing surgical blood loss, hemoglobin decline, and hospital stay duration during laparoscopic myomectomy. However, additional studies are needed to validate these findings., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Objective: The aim of our study was to assess the impact of sequential embryo transfer on pregnancy outcomes among patients with recurrent implantation failure (RIF)., Methods: We conducted a comprehensive search across various databases for eligible clinical trials from inception to January 2024. Randomized controlled trials (RCTs) were included if they compared sequential embryo transfer, comprising both cleavage-stage and blastocyst-stage embryos, with other transfer protocols in infertile women with repeated implantation failure. Meta-analysis was performed using Revman software. Our primary focus was on the ongoing pregnancy rate. Our secondary measures included rates of chemical pregnancies, clinical pregnancies, miscarriages, and multiple pregnancies., Results: Seven RCTs, encompassing 909 patients, met the inclusion criteria. Sequential embryo transfer demonstrated a significant increase in the ongoing pregnancy rate compared to the control group (OR = 2.28, 95% CI [1.46, 3.56], p = 0.003). Moreover, the sequential embryo transfer group exhibited notable improvements in chemical and clinical pregnancy rates. There were no statistically significant differences between the groups regarding multiple pregnancy and miscarriage rates (p > 0.05)., Conclusions: Sequential embryo transfer shows promise in enhancing pregnancy outcomes among RIF patients. However, additional trials are warranted to validate our findings., Competing Interests: Declarations. Conflict of interest: The authors have no conflicts of interest., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Anxiety prior to caesarean section can lead to a negative birth experience, which may affect different aspects of woman's life in the long term. Improving preoperative information may result in lower anxiety leading to a more positive birth experience. Thus, we aimed to evaluate the impact of informational video before planned caesarean delivery on maternal anxiety and satisfaction., Methods: Four different databases were searched from inception till March 2023. We selected randomised controlled trials (RCTs) that compared educational or informative videos about the aspects of the expected caesarean delivery process versus no preoperative information in the control group. No language restrictions were imposed. We used Revman software during performing our meta-analysis. Our main outcomes were preoperative and postoperative anxiety as well as maternal satisfaction post-procedure., Results: Six RCTs were retrieved with a total number of 702 patients. Informative video significantly reduced the anxiety level before caesarean delivery in comparison with the control group (MD = -4.21, 95% CI [-5.46, -2.95], p <0001). Moreover, the postoperative anxiety level was significantly improved in the informational video group (MD = -4.71, 95% CI [-7.06, -2.36],    p <0001). In addition, there was a significant improvement in maternal satisfaction score after caesarean delivery among the informational video group ( p  = 0.001)., Conclusions: Informational video prior to caesarean delivery decreases preoperative and postoperative anxiety levels with improvement in maternal post-procedure satisfaction. However, the existing evidence is limited by several shortcomings, chiefly small sample size. More trials with larger sample size are required to confirm our findings.

Introduction: This study assessed the knowledge, awareness, and acceptability of antenatal perineal massage (APM) among pregnant women in Saudi Arabia., Methods: This cross-sectional study included 240 pregnant women who met the predefined inclusion criteria and attended the Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia, from 1 October to 31 December 2023. Participants answered seven knowledge questions, classified as having good knowledge if they answered ≥4 correctly and poor knowledge if <4 were correct., Results: Most women (46.25%) reported it was their first encounter with APM. Common sources of information included the internet (39.58%), physicians/midwives (7.92%), and friends/family (3.75%). Nearly half (47.5%) had heard of APM, but only 8.75% had practiced it, and 3.75% attended related classes. Only 17.5% knew that APM could be performed by the woman or her partner, while 25.83% knew it should start at 34 weeks, and 17.92% recognized the recommended duration of 5 to 10 minutes daily. Additionally, 22.5%, 15.83%, and 35.42% acknowledged APM's benefits for labor duration, anal sphincter dysfunction, and perineal injuries, respectively. The average knowledge score was 1.39±1.84, with 84.17% classified as having poor knowledge. No significant differences were found between knowledge levels (p>0.05). Low acceptability was noted, with only 58% of patients and 37% of their partners willing to engage in APM. No significant differences in acceptability were found between poor and good knowledge groups (p>0.05)., Conclusions: The study revealed low awareness, poor knowledge, and weak acceptability of APM among pregnant patients. Targeted education for patients and healthcare providers could enhance knowledge and improve maternal-fetal health outcomes., Competing Interests: The authors have completed and submitted the ICMJE Form for disclosure of Potential Conflicts of Interest and none was reported., (© 2024 Baradwan S. et al.)

Introduction: Extrauterine recurrent metastasis of Low-grade endometrial stromal sarcoma (LG-ESS) to major blood vessels is largely rare with few reported cases., Case: Herein, we present a case of a 51-year-old female with recurrent LG-ESS that has metastasized after 12 years to the inferior vena cava (IVC) and extended into the right atrium and common iliac veins. Computed tomography showed an intracardiac larger thrombus within the right atrium extending into the inferior vena cava and common iliac veins. The patient underwent cytoreduction of the intravenous tumor. Final histopathology confirmed metastatic LG-ESS. Follow-up CT scan after six months showed no residual or recurrence., Conclusion: Treatment for extrauterine metastasis from LG-ESS prioritizes reducing tumor burden through surgical resection and may require collaboration across disciplines. Follow-up hormonal therapy with progestins or aromatase inhibitors significantly impacts patient prognosis., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Author(s).)

Objective: Several graft options can be used to construct a neovagina. This study aimed to evaluate the efficacy of creating a neovagina using a fresh human amnion in women with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome., Methods: Ten patients were analyzed retrospectively. Anatomical success was defined by a postoperative vaginal length ≥5 cm, and a width sufficient to comfortably accommodate the insertion of two fingers. Functional success was achieved when a score of >26.5 was attained on the Arabic validated version of the functional sexual function index (FSFI)., Results: Overall, the mean vaginal length before surgery was 2.15±0.85 cm (range, 1.5-4.5). The mean vaginal length after surgery was 5.5±0.53 cm (range, 5-6), and all patients (n=10) achieved anatomical success. The FSFI score after surgery was 29.2±2.4, and eight patients achieved functional success. The mean operative time and estimated blood loss were 83.5±50.31 minutes (range, 42-210) and 122.0±75.69 mL (range, 20-250), respectively. None of the patients required intraoperative blood transfusion or experienced injury to vital organs. Four patients developed postoperative leukocytosis within 48 hours, and one patient experienced chronic pelvic pain that lasted more than 6 months postoperatively. No major postoperative complications, such as pelvic abscesses, open wounds, chronic vaginal discharge, or reoperation, were reported., Conclusion: In conclusion, surgical dissection of the vesicorectal space and utilization of fresh human amnion to create a neovagina over a vaginal mold are technically feasible and safe, and are linked to favorable anatomical and functional outcomes in MRKH patients with vaginal agenesis.

Objective : This study offered an updated meta-analysis of randomized controlled trials (RCTs) that assessed preoperative misoprostol compared to control (matched placebos or no treatment) during abdominal myomectomies. Methods : Six databases underwent screening until 7 April 2024. The risk of bias was assessed using the Cochrane Collaboration tool. The results were presented as mean differences (MDs) or risk ratios (RRs) along with 95% confidence intervals (CIs) using the random-effects model. Results : Sixteen RCTs were analyzed, involving 975 women. The overall quality of the studies was rated as "low" or had "some concerns" of bias in seven and eight RCTs, respectively; one RCT had an overall "high" risk of bias. For primary endpoints, the misoprostol intervention had significantly lower mean intraoperative blood loss (n = 15, MD = -180.2 mL, 95% CI [-224.04, -136.35], p < 0.001), mean hemoglobin drop (n = 13, MD = -0.58 g/dl, 95% CI [-0.82, -0.35], p < 0.001), and rate of perioperative blood transfusion (n = 13, RR = 0.43, 95% CI [0.29, 0.63], p < 0.001) compared to the control intervention. For secondary endpoints, the misoprostol intervention had significantly lower mean hematocrit drop (MD = 2.15, 95% CI -3.34, -0.96], p < 0.001), mean operative time (MD = -12.95 min, 95% CI [-19.89, -6.01], p < 0.001), and mean hospital stay (MD = -0.14 days, 95% CI [-0.25, -0.02], p = 0.02) compared to the control intervention. Nonetheless, no significant change was indicated between both interventions regarding the rate of postoperative fever. Conclusions : During abdominal myomectomy, the administration of preoperative misoprostol was generally safe and yielded statistically significant reductions in intraoperative blood loss, hemoglobin drop, and perioperative blood transfusion.

Vulvar leiomyomas are rare benign tumors originating from smooth muscle cells of the vulvar tissue. This report concerns a 31-year-old woman who presented with a painless vulvar mass measuring 5 × 4 cm. The mass was clinically diagnosed as a Bartholin cyst due to its non-tender and soft nature, and as a result the patient underwent wide local excision of the vulvar mass. Histopathology confirmed it to be benign vulvar leiomyoma. This case emphasizes the importance of thorough clinical evaluation and accurate histopathological examination in identifying vulvar masses. This report underscores the diagnostic difficulties associated with rare vulvar lesions and stresses the necessity of a comprehensive approach to their evaluation and treatment., (© 2024 The Authors.)

Introduction and Hypothesis: There is a rising trend among women towards nonpharmacological approaches owing to their minimally invasive nature and limited adverse effects. Virtual reality (VR) has recently gained popularity as a new technology for reducing pain and anxiety in medical settings. Our research sought to investigate the impact of VR on pain and anxiety levels while undergoing episiotomy repair., Methods: A comprehensive search was carried out across PubMed, Scopus, Cochrane Library, and ISI Web of Science to find relevant randomized clinical trials (RCTs) up to January 2024. These trials investigated the use of VR as a treatment during episiotomy repair compared with a control group that did not receive VR intervention. Meta-analysis was performed using Review Manager software to analyze the data collected. Our primary outcomes were pain scores reported during and after episiotomy repair measured by a visual analog scale. Secondary outcomes analyzed included anxiety scores during and after the procedure, as well as the duration of episiotomy repair., Results: Seven RCTs, involving 578 patients, met the inclusion criteria. VR resulted in a significant reduction in pain scores both during and after episiotomy repair (p < 0.001). Additionally, anxiety levels during and after the procedure were significantly reduced in the VR group compared with the control group. Moreover, the duration of episiotomy repair was significantly shorter in the VR group., Conclusion: Using VR has proven to be an effective technique in reducing pain and anxiety during and after episiotomy repair, as well as potentially speeding up the procedure., (© 2024. The International Urogynecological Association.)

Aim: To conduct the first-ever systematic review and meta-analysis evaluating calcium infusion versus cabergoline in preventing ovarian hyperstimulation syndrome (OHSS) among high-risk women undergoing assisted reproductive technology., Methods: Six databases were screened from inception until April 1, 2024. The included randomized and non-randomized controlled studies were assessed for quality. The endpoints included the severity of OHSS and selected pregnancy-related outcomes. Endpoints were summarized as risk ratios (RRs) and 95% confidence intervals (CIs) in a random-effects model., Results: Six studies were analyzed, including 1687 patients (828 in the calcium group and 859 in the cabergoline group). The quality of the studies varied and reflected low risk and high risk of bias in two and four studies, respectively, according to the revised Cochrane risk of bias tool. No significant differences were noted between both groups regarding the rates of overall (n = 5, RR = 0.65, 95 % CI [0.39, 1.07], p = 0.09), mild (n = 4, RR = 1.05, 95 % CI [0.59, 1.89], p = 0.86), moderate (n = 5, RR = 0.41, 95 % CI [0.15, 1.08], p = 0.07), and severe (n = 6, RR = 0.36, 95 % CI [0.11, 1.22], p = 0.1) cases of OHSS. Leave-one-out sensitivity analysis of an outlier study revealed that calcium significantly reduced the occurrence of severe OHSS compared with cabergoline (n = 5, RR = 0.16, 95 % CI [0.09, 0.43], p < 0.001, Higgins I 2  = 0 %). No significant differences were observed between both groups regarding the rates of clinical pregnancy (n = 4, RR = 0.97, 95 % CI [0.88, 1.07], p = 0.57), ongoing pregnancy, live birth, and spontaneous abortion (Higgins I 2  < 50 % for all)., Conclusion: Both agents yielded similar pregnancy-related outcomes. However, calcium infusion could potentially be more effective than cabergoline in reducing the rate of severe OHSS. Additional high-quality and well-controlled trials are essential to draw firm conclusions., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Recent studies indicate that vitamin D impacts male reproductive function, with deficiency linked to infertility. This review evaluates the effect of vitamin D supplementation on male fertility, focusing on total testosterone, free testosterone, the free androgen index (FAI), follicle-stimulating hormone (FSH), luteinizing hormone (LH), sex-hormone-binding globulin (SHBG), and estradiol., Methods: We systematically searched Medline, Web of Science, Cochrane Library, and Scopus from their inception until July 2024 for randomized controlled trials (RCTs) involving adult males. The primary focus of these studies was on reproductive hormone parameters, analyzed using a random-effects meta-analysis and weighted mean difference (WMD). Evidence quality was assessed using ROB2 and GRADE. Meta-regression and dose-response analyses were performed., Results: Seventeen studies met the criteria for quantitative analysis. Vitamin D supplementation significantly increased total testosterone levels (WMD 0.38, 95% CI 0.06-0.70, n = 15, I 2 = 67.03). However, it had no significant effect on other hormone parameters: free testosterone (WMD 0.00, 95% CI -0.02-0.03, n = 9, I 2 = 48.12), FSH (WMD -0.02, 95% CI -0.57-0.53, n = 7, I 2 = 48.72), LH (WMD -0.09, 95% CI -0.30-0.12, n = 8, I 2 = 0.00), SHBG (WMD 0.73, 95% CI -1.14-2.61, n = 10, I 2 = 69.05), FAI (WMD -0.92, 95% CI -2.12-0.27, n = 6, I 2 = 0.00), and estradiol (WMD -0.02, 95% CI -2.95-2.92, n = 5, I 2 = 20.63)., Conclusion: This meta-analysis shows that vitamin D supplementation may increase total testosterone levels in men. However, further well-designed RCTs are needed to determine vitamin D's effects on other reproductive hormone parameters.

Objective: To compare letrozole in combination with gonadotropins versus letrozole monotherapy in ovulation induction and clinical pregnancy among infertile women with polycystic ovarian syndrome (PCOS)., Methods: Several databases were searched for available clinical trials from inception until March 2023. We selected randomized controlled trials (RCTs) that compared sequential letrozole/gonadotropin versus letrozole alone among infertile women who met the Rotterdam criteria for PCOS. RevMan software was used to perform our meta-analysis. Our primary outcomes were ovulation and clinical pregnancy rates. Our secondary outcomes were endometrial thickness, number of mature follicles (diameter ≥ 18 mm), and incidence of miscarriage and ovarian hyperstimulation syndrome (OHSS)., Results: Six RCTs were retrieved with a total number of 723 patients. The ovulation and clinical pregnancy rates were significantly higher among the letrozole/gonadotropin group versus the letrozole monotherapy group (p < 0.001). In addition, there were significant improvements in endometrial thickness and number of mature follicles in the letrozole/gonadotropin group. There were no significant differences between the two groups regarding incidence of miscarriage and ovarian hyperstimulation syndrome., Conclusion: Letrozole in combination with gonadotropin is superior to letrozole alone in improving ovulation induction and clinical pregnancy among PCOS patients. More trials are required to confirm our findings., (© 2024. The Author(s), under exclusive licence to Hellenic Endocrine Society.)

Introduction: To evaluate the effect of injecting vasopressin during laparoscopic excision of ovarian endometriomas on ovarian reserve., Evidence Acquisition: Four different databases (PubMed, Cochrane Library, Scopus, and ISI Web of Science) were searched to identify relevant studies in March 2023. We selected randomized controlled trials (RCTs) that compared vasopressin injection in the intervention group versus no injection of vasopressin in the control group among women undergoing laparoscopic cystectomy of ovarian endometriomas. The main outcomes were the amount of bleeding, number of coagulation events, and levels of serum anti-Müllerian hormone (AMH) and follicle-stimulating hormone (FSH). The available data were extracted and analyzed in a meta-analysis model using RevMan software., Evidence Synthesis: Seven RCTs, involving a total number of 478 patients, were included in our study. The vasopressin group had significantly reduced blood loss amount and number of coagulation events compared to the control group (P=0.004 and P=0.005). There was a significant improvement in the AMH levels within 6 months after surgery in the vasopressin group (MD=0.52, 95% CI: 0.11, 0.93, P=0.01). In addition, the FSH levels within 6 months after laparoscopic cystectomy were significantly reduced with vasopressin injection., Conclusions: Vasopressin injection during laparoscopic cystectomy of ovarian endometriomas is effective in reducing blood loss amount and frequency of coagulation, as well as protecting the ovarian reserve. More trials are encouraged to confirm our findings.

Objective: This study aimed to systematically examine the relationship between polycystic ovary syndrome and ovarian, endometrial, and cervical cancers using the National Inpatient Sample (NIS) database., Methods: We utilized the International Classification of Diseases (ICD-10) system to identify relevant codes from the NIS database (2016-2019). Univariate and multivariable regression analyses (adjusted age, race, hospital region, hospital teaching status, income Zip score, smoking, alcohol use, and hormonal replacement therapy) were conducted to evaluate association between PCOS and gynecologic cancers. Results were summarized as odds ratio (OR) with 95% confidence intervals (CI)., Results: Overall, 15,024,965 patients were analyzed, of whom 56,183 and 14,968,782 patients were diagnosed with and without PCOS, respectively. Among the patients diagnosed with gynecologic cancers (n = 91,599), there were 286 with PCOS and 91,313 without PCOS. Univariate analysis revealed that PCOS was significantly associated with higher risk of endometrial cancer (OR = 1.39, 95 % CI [1.18-1.63], p < 0.0001), but lower risk of ovarian cancer (OR = 0.55, 95 % CI [0.45-0.67], p < 0.0001) and cervical cancer (OR = 0.68, 95 % CI [0.51-0.91], p = 0.009). In contrast, after Bonferroni correction, multivariable analysis depicted that PCOS remained significantly associated with higher risk of endometrial cancer (OR = 3.90, 95 % CI [4.32-4.59], p < 0.0001). There was no significant correlation between PCOS and risk of ovarian cancer (OR = 1.09, 95 % CI [0.89-1.34], p = 0.409) and cervical cancer (OR = 0.83, 95 % CI [0.62-1.11], p = 0.218)., Conclusion: This first-ever NIS analysis showed that patients with PCOS exhibited unique gynecologic cancer risk profiles, with higher risk for endometrial cancer, and no significant risk for ovarian or cervical cancers., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Objective: Saline vaginal douching prior to intravaginal prostaglandin application might increase the vaginal pH, leading to improvement of prostaglandin bioavailability, by which the outcomes of labor induction can be greatly improved. Thus, we aimed to evaluate the effect of vaginal washing with normal saline before insertion of vaginal prostaglandin for labor induction., Study Design: A systematic search was done in PubMed, Cochrane Library, Scopus, and ISI Web of Science from inception to March 2022. We selected randomized controlled trials (RCTs) that compared vaginal washing using normal saline versus no vaginal washing in the control group before intravaginal prostaglandin insertion during labor induction. We used RevMan software for our meta-analysis. Our main outcomes were the duration of intravaginal prostaglandin application, duration from intravaginal prostaglandin insertion to active phase of labor, duration from intravaginal prostaglandin insertion till total cervical dilatation, labor induction failure rate, incidence of cesarean section (CS), and rates of neonatal intensive care unit (NICU) admission and fetal infection postdelivery., Results: Five RCTs were retrieved with a total number of 842 patients. Duration of prostaglandin application, duration from prostaglandin insertion to active phase of labor, and time interval from prostaglandin insertion to total cervical dilatation were significantly shorter among vaginal washing group ( p  < 0.05). Vaginal douching prior to prostaglandin insertion significantly decreased the incidence of failed labor induction ( p  < 0.001). After the removal of reported heterogeneity, vaginal washing was linked to a significant decline in CS incidence ( p  = 0.04). In addition, the rates of NICU admission and fetal infection were significantly lower in the vaginal washing group ( p  < 0.001)., Conclusion: Vaginal washing with normal saline before intravaginal prostaglandin insertion is a useful and easily applicable method for labor induction with good outcomes., Key Points: · Induction of labor is frequently used in the obstetrics field.. · We assessed vaginal washing impact before prostaglandin insertion for labor induction.. · Vaginal washing is an easily applicable method for labor induction with good outcomes.., Competing Interests: None declared., (Thieme. All rights reserved.)

Fetal vein of Galen malformation (VOGM) represents a rare congenital anomaly affecting the fetal cerebral vasculature. A 27-year-old Middle Eastern woman was referred due to intrauterine growth restriction (IUGR) and fetal cardiac anomalies identified at 35 weeks of gestation. The diagnosis of fetal VOGM with dilated neck vessels was established through a combination of color Doppler ultrasonography and magnetic resonance imaging. A multidisciplinary approach involving maternal-fetal medicine, neonatology, pediatric cardiology, and interventional radiology was implemented. Given the grave prognosis for the baby, the patient received comprehensive counseling. Subsequent monitoring revealed a non-reassuring fetal heart trace, prompting the decision to perform a cesarean section. The newborn, a girl, was admitted to the neonatal intensive care unit for further management but she died shortly thereafter, with heart failure and intracranial hemorrhage identified as the probable causes of death. In summary, the diagnosis and management of VOGMs demand specialized expertise and a collaborative, multidisciplinary approach to optimize patient care and outcomes., (© 2024 The Author(s). Published by Elsevier B.V.)

Aim: To conduct a systematic review and meta-analysis of all randomized controlled trials (RCTs) that evaluated the efficacy of low-dose aspirin (LDA, ≤ 160 mg/day) on preventing preterm birth (PB)., Methods: Five databases were screened from inception until June 25, 2023. The RCTs were assessed for quality according to Cochrane's risk of bias tool. The endpoints were summarized as risk ratio (RR) with 95% confidence interval (CI)., Results: Overall, 40 RCTs were analyzed. LDA significantly decreased the risk of PB < 37 weeks (RR: 0.91, 95% CI 0.87, 0.96, p < 0.001, moderate certainty of evidence) with low between-study heterogeneity (I 2  = 23.2%, p = 0.11), and PB < 34 weeks (RR: 0.78, 95% CI 0.61, 0.99, p = 0.04, low certainty of evidence) with high between-study heterogeneity (I 2  = 58.3%, p = 0.01). There were no significant differences between both groups regarding the risk of spontaneous (RR: 0.94, 95% CI 0.83, 1.07, p = 0.37) and medically indicated (RR: 1.28, 95% CI 0.87, 1.88, p = 0.21) BP < 37 weeks. Sensitivity analysis revealed robustness for all outcomes, except for the risk of PB < 34 weeks. For PB < 37 weeks and PB < 34 weeks, publication bias was detected based on visual inspection of funnel plots for asymmetry and statistical significance for Egger's test (p = 0.009 and p = 0.0012, respectively)., Conclusion: LDA can significantly reduce the risk of PB < 37 and < 34 weeks. Nevertheless, further high-quality RCTs conducted in diverse populations, while accounting for potential confounding factors, are imperative to elucidate the optimal aspirin dosage, timing of initiation, and treatment duration for preventing preterm birth and to arrive at definitive conclusions., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: To compare Foley catheter insertion by digital blind method to its placement with a sterile speculum in women with unripe cervix for induction of labor., Methods: A systematic search was conducted in Cochrane Library, PubMed, Web of Science, and Scopus databases for randomized clinical trials (RCTs) from inception to July 2023. Included studies compared digital to speculum placement of the Foley catheter for labor induction. Data from the included studies were extracted and pooled using RevMan software for meta-analysis. The primary outcome was pain score during the procedure measured by the Visual Analog Scale (VAS). Secondary outcomes included Foley catheter insertion duration, cesarean delivery rate, induction to delivery interval, Bishop score, need for other cervical ripening methods, maternal satisfaction, and maternal fever., Results: Four RCTs involving a total of 600 patients met the inclusion criteria. Pain during the procedure and Foley catheter insertion duration were significantly reduced in the digital insertion group compared to the speculum-guided group (p < 0.05). The Bishop score showed a significant improvement in the digital Foley catheter placement group. However, there were no statistically significant differences in the cesarean delivery rate or the requirement for additional cervical ripening methods between the two groups. Maternal satisfaction with the delivery process was significantly improved in the digital insertion group (p < 0.001). Induction to delivery interval and maternal fever were comparable between both groups., Conclusions: Digital placement of Foley catheter can be considered as an alternative to the sterile speculum method for pre-induction cervical ripening. More trials are required to confirm our findings., Competing Interests: Declaration of competing interest The authors declare that they have no conflict of interest., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Objective: This study aimed to conduct a systematic review and meta-analysis of all randomized and nonrandomized controlled trials (RCTs and NCTs, respectively) that explored the maternal-neonatal outcomes of cervical osmotic dilators versus dinoprostone in promoting cervical ripening during labor induction., Study Design: Six major databases were screened until August 27, 2022. The quality of included studies was evaluated. The data were summarized as mean difference or risk ratio (RR) with 95% confidence interval (CI) in a random-effects model., Results: Overall, 14 studies with 15 arms were analyzed ( n  = 2,380 patients). Ten and four studies were RCTs and NCTs, respectively. The overall quality for RCTs varied (low risk n  = 2, unclear risk n  = 7, and high risk n  = 1), whereas all NCTs had good quality ( n  = 4). For the primary endpoints, there was no significant difference between both groups regarding the rate of normal vaginal delivery (RR = 1.04, 95% CI: 0.95-1.14, p  = 0.41) and rate of cesarean delivery (RR = 1.04, 95% CI: 0.93-1.17, p  = 0.51). Additionally, there was no significant difference between both groups regarding the mean change in Bishop score and mean time from intervention to delivery. The rate of uterine hyperstimulation was significantly lower in the cervical osmotic dilator group. For the neonatal outcomes, during cervical ripening, the rate of fetal distress was significantly lower in the cervical osmotic dilator group. There was no significant difference between both groups regarding the mean Apgar scores, rate of meconium-stained amniotic fluid, rate of umbilical cord metabolic acidosis, rate of neonatal infection, and rate of neonatal intensive care unit admission., Conclusion: During labor induction, cervical ripening with cervical osmotic dilators and dinoprostone had comparable maternal-neonatal outcomes. Cervical osmotic dilators had low risk of uterine hyperstimulation compared with dinoprostone. Overall, cervical osmotic dilators might be more preferred over dinoprostone in view of their analogous cervical ripening effects, comparable maternal-neonatal outcomes, and lack of drug-related adverse events., Key Points: · This is the first analysis of cervical osmotic dilators versus PGE2 for cervical ripening during labor.. · There was no difference between both arms regarding the rates of normal vaginal/cesarean deliveries.. · There was no difference between both arms regarding the rates of neonatal adverse events.. · Cervical osmotic dilators had significant lower risk of uterine hyperstimulation compared with PGE2.. · Cervical osmotic dilators may be superior to PGE2 in view of their similar efficacy and better safety.., Competing Interests: None declared., (Thieme. All rights reserved.)

Clomiphene citrate (CC) and letrozole are the predominant medical interventions for the management of infertility in patients with polycystic ovary syndrome (PCOS). To comprehensively summarize the evidence, a systematic review and meta-analysis of randomized clinical trials (RCTs) was carried out to assess the effect of letrozole and CC on pregnancy outcomes in PCOS patients. We searched PubMed/MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials from inception to January 2023. We included RCTs conducted on PCOS women comparing letrozole to CC and assessing endometrial thickness, the number and size of follicles, and ovulation and pregnancy rates. The endpoints were summarized as risk ratio (RR) or standardized mean difference (SMD) with 95% confidence interval (CI) using the random-effects model. Heterogeneity was examined using the I 2 statistic. Fifty trials met our inclusion criteria. The mean endometrial thickness was significantly higher in the letrozole group compared to CC group (SMD: 0.89; 95% CI: 0.49, 1.28; I 2 =97.72%); however, the number of follicles was higher in the CC group (SMD: -0.56; 95% CI: -0.96, -0.17; I 2 =96.34%). Furthermore, letrozole intake induced higher ovulation rate (RR: 1.20; 95% CI: 1.13, 1.26; I 2 =54.49%) and pregnancy rate (RR: 1.44; 95% CI: 1.28, 1.62; I 2 =65.58%) compared to CC. Compared to CC, letrozole has a positive effect on endometrial thickness, monofollicular development, and ovulation and pregnancy rates suggesting that letrozole may be a strong alternative to CC as a first-line medical intervention for chronic anovulation in PCOS women. Larger studies are warranted to further clarify these findings., (© 2023. The Author(s), under exclusive licence to Society for Reproductive Investigation.)

Objective: Our study aimed to evaluate the effectiveness of virtual reality (VR) intervention for pain and anxiety relief during outpatient hysteroscopy., Methods: Various databases were searched for available clinical trials from inception until June 2023. We selected randomized controlled trials (RCTs) that compared virtual reality intervention versus standard care among women undergoing outpatient hysteroscopy. We used Revman software to perform our meta-analysis. The primary outcome was the pain score during the procedure. The secondary outcomes were anxiety during the procedure and pain post-procedure. The Visual Analog Scale (VAS) was used to assess pain and anxiety., Results: Six RCTs were retrieved, involving a total of 457 patients. Virtual reality was associated with a significant reduction in pain score during the procedure in comparison with the control group (MD = - 1.43, 95% CI [- 1.69, - 1.16], p < 0.001). In addition, there was a significant decrease in anxiety during the procedure among the virtual reality group compared to the control group (p = 0.01). The pain score post-procedure significantly decreased within the virtual reality group (MD = - 1.52, 95% CI [- 1.78, - 1.26], p < 0.001)., Conclusions: Virtual reality technology is a simple, feasible, and effective intervention for reducing pain and anxiety during outpatient hysteroscopy. More trials are required to confirm our findings., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: We investigated the potential association between Marfan Syndrome (MFS) and adverse obstetric outcomes using the National Inpatient Sample (NIS) database., Methods: We utilized the International Classification of Diseases (ICD-10) system to identify relevant codes and extracted data from the NIS database covering the period 2016-2019. Descriptive statistics and χ 2 tests were employed to summarize and compare baseline characteristics. Univariate and multivariate regression analyses (adjusted for age, race, hospital region, smoking status, and alcohol misuse) were conducted to evaluate association between MFS and adverse obstetric outcomes. The regression analyses were summarized as Odds Ratios (OR) with 95% confidence intervals (CI)., Results: Among the 2,854,149 pregnant individuals, 179 had MFS. Baseline characteristics revealed significant associations between MFS and age, race, and hospital location. Univariate analysis showed MFS individuals had significantly increased risks of amniotic fluid/membrane abnormalities (AFAs, OR=1.64, 95% CI: 1.01-2.68, P=0.045) and postpartum hemorrhage (PPH, OR=3.73, 95% CI: 2.41-5.78, P<0.001). Several obstetric outcomes showed some trends towards increased (multiple gestation, placenta previa, and preterm labor) and decreased (premature rupture of membrane, gestational diabetes, and preeclampsia) obstetric risks with MFS; however, they were not statistically significant. Multivariate analysis showed MFS was significantly associated with increased risks of AFAs (adjusted OR=1.68, 95% CI: 1.03-2.74, P=0.037) and PPH (adjusted OR=3.62, 95% CI: 2.31-5.68, P<0.001)., Conclusions: MFS is associated with increased risks of adverse obstetric outcomes, specifically AFAs and PPH. These results highlight the importance of monitoring these specific pregnancy outcomes in MFS individuals to ensure optimal maternal-fetal health.

This study aimed to review randomized controlled trials (RCTs) investigating the effects of dietary antioxidant supplements on the severity of endometriosis-related pain symptoms. The PubMed/Medline, Scopus, and Web of Science databases were searched until April 2022. Additionally, we manually searched the reference lists. Endpoints were summarized as standardized mean difference (SMD) with 95% confidence intervals (CIs) in a random-effects model. The I2 statistic was used to assess heterogeneity. Ten RCTs were included in this meta-analysis. Overall, 10 studies were related to dysmenorrhea, four to dyspareunia, and four to pelvic pain. Antioxidants significantly reduced dysmenorrhea (SMD, -0.48; 95% CI, -0.82 to -0.13; I2=75.14%). In a subgroup analysis, a significant reduction of dysmenorrhea was observed only in a subset of trials that administered vitamin D (SMD, -0.59; 95% CI, -1.13 to -0.06; I2=69.59%) and melatonin (SMD, -1.40; 95% CI, -2.47 to -0.32; I2=79.15%). Meta-analysis results also suggested that antioxidant supplementation significantly improved pelvic pain (SMD, -1.51; 95% CI, -2.74 to -0.29; I2=93.96%), although they seem not to have a significant beneficial impact on the severity of dyspareunia. Dietary antioxidant supplementation seems to beneficially impact the severity of endometriosis-related dysmenorrhea (with an emphasis on vitamin D and melatonin) and pelvic pain. However, due to the relatively small sample size and high heterogeneity, the findings should be interpreted cautiously, and the importance of further well-designed clinical studies cannot be overstated.

Background: An inverse relationship between vitamin D supplementation and C-reactive protein (CRP) and hypertension has been reported, mostly through observational data. This inverse relationship, however, has not been confirmed in randomized controlled trials (RCTs). A meta-analysis of RCTs is needed to provide more robust evidence., Objective: This systematic review of RCTs was conducted to assess the effect of vitamin D supplementation on CRP, systolic blood pressure (SBP), and diastolic blood pressure (DBP) in postmenopausal women., Methods: Four databases (PubMed, Web of Science, Embase, and Scopus) were systemically searched to identify relevant RCTs published in international scientific journals up to January 2023. Changes from baseline and SDs of CRP, SBP, and DBP were compared between postmenopausal women who received vitamin D supplementation and those who did not (controls). These parameters were applied to compute the overall effect sizes using the random-effects model. Data were summarized as mean difference (MD) with 95% CI. Heterogeneity among arms was scrutinized using the Cochrane's Q test and I 2 statistic. Publication bias was judged by means of funnel plots and Egger's test., Results: Seven studies with 6 arms on CRP, 6 arms on SBP, and 6 arms on DBP were included in the meta-analysis. Combined effect sizes suggested a significant effect of vitamin D supplementation on CRP (MD = -0.65 mg/L; 95% CI -0.93 to -0.37 mg/L; P < .001). In addition, CRP concentrations were significantly reduced after vitamin D supplementation in studies with a duration of more than 3 months (MD = -0.91 mg/L; 95% CI -1.37 to -0.45 mg/L; P < .001) and studies involving doses of ≤1,000 IU/d (MD = -2.10 mg/L; 95% CI -2.51 to -1.68 mg/L; P < .001). Vitamin D supplementation did not reduce SBP significantly (MD = -1.06 mm Hg; 95% CI -2.43 to 0.30 mm Hg; P = .127) and DBP (MD = 0.003 mm Hg; 95% CI -0.86 to 0.86 mm Hg; P = .994) levels compared with control groups., Conclusions: This meta-analysis concluded that vitamin D supplementation is associated with reduced CRP concentrations among postmenopausal women., (Copyright © 2024 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

The aim of this study was to report our single-center experience of the da Vinci robotic surgery system in the management of endometrial cancer (EC) patients during 2019-2023. We descriptively summarized the preoperative, intraoperative, and postoperative outcomes. Moreover, we conducted subgroup analyses based on obesity (BMI ≥ 30 kg/m 2 ) and the intraoperative use of indocyanine green dye (ICG). Overall, 100 patients were analyzed. Eighty-five patients (85%) were obese. The mean operative time and estimated blood loss (EBL) were 240.84 ± 70.08 min (range: 110-720) and 104.2 ± 80.3 ml (range: 20-500), respectively. The mean number of retrieved pelvic LNs was 3.01 ± 3.06 (range: 0-15). The use of ICG was employed in 58 (58%). Only a single patient (1%) underwent conversion to laparotomy. Besides, only three (3%) patients experienced vaginal laceration intraoperatively, respectively. The mean hospital stay was 1.34 ± 0.69 days (range: 1-5). No patient experienced postoperative complications. Most tumors had endometrioid histology (82%), grade-1 tumor (49%), and stage-1A disease (67%). At 3-year follow-up, only two patients (2%) developed recurrence. Patients who received the ICG had significantly lower operative time (225.86 vs. 261.52 min, p = 0.011), estimated blood loss (90 vs. 123.81 ml, p = 0.037), and hospital stay (1.12 vs. 1.64 days, p < 0.001) compared with patients who did not receive it. However, there was no significant difference between both groups regarding the number of retrieved pelvic LNs. Obesity had no significant impact on the rates of intraoperative complications, postoperative complications, and 3-year recurrence incidence. In conclusion, robotic surgery was technically feasible and safe. The use of ICG was statistically linked to favorable outcomes, in terms of decreased operative time, EBL, and hospital stay. Obesity did not impact the perioperative surgical outcomes., (© 2024. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

A systematic review and meta-analysis were conducted to investigate the effectiveness of the Pilates exercise program during pregnancy on different delivery outcomes. Various databases were searched from inception until November 2022. The included studies compared Pilates exercise to routine antenatal care in pregnant women. The primary outcomes assessed were vaginal and cesarean delivery rates, as well as labor duration. Secondary outcomes included episiotomy incidence, Apgar scores, and epidural analgesia. Seven studies met the inclusion criteria, involving a total of 1,003 patients. Results indicated a significant increase in the vaginal delivery rate among the Pilates exercise group compared to the control group ( p  < .001). Moreover, the Pilates exercise group exhibited significantly reduced rates of cesarean delivery and shorter labor duration. Pilates exercise was associated with a significant decline in the incidence of episiotomy and the number of women requiring epidural analgesia during delivery ( p  < .001 & p  = .008). In addition, Apgar scores at one and five minutes were significantly higher in the Pilates exercise group compared to the control group ( p  < .001). In conclusion, Pilates exercise during pregnancy has a positive effect on maternal outcomes and Apgar scores. However, more trials are needed to confirm these findings.

Objective: We investigated the potential relationship between endometriosis and risk of ovarian, endometrial, cervical, and breast cancers using the National Inpatient Sample (NIS) database., Methods: We utilized the International Classification of Diseases (ICD-10) system to identify relevant codes from the NIS database (2016-2019). Univariate and multivariate regression analyses (adjusted for age, race, hospital region, hospital teaching status, income Zip score, smoking, alcohol use, and hormonal replacement therapy) were conducted to evaluate the association between endometriosis and gynecologic cancers and summarized as odds ratios (ORs) with 95% confidence intervals (CIs)., Results: In the examined dataset, there were 1164 and 225,323 gynecologic cancer patients with and without endometriosis, respectively. Univariate analysis showed endometriosis was significantly associated with a higher risk of ovarian (OR = 3.42, 95% CI: 3.05-3.84, p < 0.001) and endometrial (OR = 3.35, 95% CI: 2.97-3.79, p < 0.001) cancers. There was no significant association between endometriosis and cervical cancer (OR = 1.05, 95% CI: 0.85-1.28, p = 0.663). Interestingly, endometriosis was significantly associated with a low risk of breast cancer (OR = 0.12, 95% CI: 0.10-0.17, p < 0.001). Multivariate analysis after Bonferroni correction ( p < 0.006) showed that endometriosis was significantly associated with a high risk of ovarian (adjusted OR = 3.34, 95% CI: 2.97-3.75, p < 0.001) and endometrial (adjusted OR = 3.61, 95% CI: 3.12-4.08, p < 0.001) cancers. Conversely, there was no significant association between endometriosis and cervical cancer (OR = 0.80, 95% CI: 0.65-0.99, p = 0.036)., Conclusions: Patients with endometriosis exhibited unique gynecologic cancer risk profiles, with higher risks for ovarian and endometrial cancers, and no significant risk for cervical cancer. The observed connection between endometriosis and a reduced risk of breast cancer remains a perplexing phenomenon, which cannot be put into context to date.

This systematic review and meta-analysis aimed to examine the effect of the antioxidant alpha-lipoic acid (ALA) on various cardiometabolic risk factors and hormonal parameters in patients with polycystic ovary syndrome (PCOS). We searched PubMed, EMBASE, SCOPUS, Cochrane Library, and Web of Science databases without language restrictions until May 2023 to find randomized controlled trials (RCTs) that assessed the impact of ALA supplementation on anthropometric, glycemic, lipid, oxidative stress, and hormonal parameters in women with PCOS. Outcomes were summarized using the standardized mean difference (SMD) and 95% confidence interval (CI) in a random-effects model. An I2 statistic of >60% established significant between-study heterogeneity. The overall certainty of the evidence for each outcome was determined using the grading of recommendations, assessment, development, and evaluations system. Seven RCTs met the inclusion criteria. The ALA group had significant reductions in fasting blood sugar (fasting blood sugar (FBS), n=7 RCTs, SMD, -0.60; 95% CI, -1.10 to -0.10; I2=63.54%, moderate certainty of evidence) and homeostatic model assessment for insulin resistance (homeostatic model assessment of insulin resistance (HOMA-IR), n=4 RCTs, SMD, -2.03; 95% CI, -3.85 to -0.20; I2=96.32%, low certainty of evidence) compared with the control group. However, significant differences were observed between the groups in body mass index, insulin, estrogen, follicle-stimulating hormone, luteinizing hormone, testosterone, low-density lipoprotein, highdensity lipoprotein, triglyceride, total cholesterol, malondialdehyde, or total antioxidant capacity profiles. ALA supplementation improves FBS and HOMA-IR levels in women with PCOS. ALA consumption is an effective complementary therapy for the management of women with PCOS.

Impaired vitamin D status is highly prevalent among women with UFs. The objective of this first-ever systematic review and meta-analysis was to summarize the effect of vitamin D supplementation on the size of uterine fibroids (UFs). We performed a comprehensive literature search for published randomized controlled trials (RCTs) in Medline, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials from inception to September 2022. Five trials including 511 participants (256 cases and 255 controls) were included. Pooling results from five trials, which compared size of UFs between experimental and placebo groups, revealed that vitamin D supplementation could significantly decrease the size of UFs (standardized mean difference [SMD]: -0.48, 95% confidence interval [CI]: -0.66, -0.31) and cause improvement in serum level of vitamin D compared to placebo group (SMD: 3.1, 95% CI: 0.66, 5.55). A significant effect was observed in the subset of trials administering vitamin D supplementation for >8 wk (SMD: -0.62, 95% CI: -0.88, -0.37). In conclusion, vitamin D supplementation significantly increases serum levels of vitamin D and reduces the size of UFs. However, larger, well-designed RCTs are still needed to determine the effect of vitamin D on other parameters of UFs.

Membrane sweeping is considered a simple and effective method for initiating spontaneous onset of labor. Despite the widely accepted membrane sweeping use to prevent post-term birth, the optimal frequency has not been estimated. We aimed to assess the effectiveness and safety of twice-weekly versus once-weekly membrane sweeping in post-term pregnancy prevention. Four different databases were searched for available clinical trials from inception to October 2022. We selected randomized controlled trials (RCTs) that compared twice-weekly membrane sweeping in intervention group versus once-weekly membrane sweeping in control group among pregnant women with singleton pregnancy at ≥ 39 gestational weeks. Our primary outcomes were the rate of spontaneous onset of labor and the requirement for formal methods of labor induction. Our secondary outcomes were sweeping to delivery interval in days, gestational age at delivery in weeks, Bishop score at admission, chorioamnionitis, and premature rupture of membranes. Three RCTs (596 patients) were included. Twice-weekly membrane sweeping was associated with significant increase in the rate of spontaneous onset of labor and significant decline in labor induction rate in comparison with once-weekly group. Duration from sweeping to delivery was significantly shorter among the twice-weekly group (p<0.001). Furthermore, gestational age at delivery was significantly earlier in the twice-weekly group. A significantly higher Bishop score at admission was observed in the twice-weekly group (p=0.02). There were no significant differences across both groups in chorioamnionitis and premature rupture of membranes. In conclusion, twice-weekly membrane sweeping is more effective in preventing post-maturity pregnancy than once-weekly sweeping without added adverse events., (© 2023. The Author(s), under exclusive licence to Society for Reproductive Investigation.)

Objective: This study aimed to investigate the relationship between endometriosis and adverse obstetric outcomes using data from the National Inpatient Sample (NIS) database., Methods: The ICD-10 coding system was used to identify codes for endometriosis and obstetric outcomes, and data from the NIS (2016-2019) were analyzed. Descriptive statistics were used to summarize variables, while the chi-square test was used to detect significant differences for categorical variables. Univariate and multivariate regression analyses were conducted to assess the association between endometriosis and obstetric outcomes. On multivariate analysis, adjustment was done for age, race, hospital region, smoking status, and alcohol misuse. Forest plots were used to visualize odds ratios and their 95% confidence intervals., Results: Overall, 2,854,149 women were included in this analysis, of whom 4,006 women had endometriosis. The post-hoc Bonferroni correction was applied to account for multiple comparisons, and our analyses revealed several statistically significant associations (p < 0.004). Specifically, on univariate analysis, significant associations with endometriosis were identified for ruptured uterus, placenta previa, placental abruption, postpartum hemorrhage, preeclampsia, amniotic fluid abnormality, gestational diabetes, preterm labor, and multiple gestation. On multivariate analysis, significant associations with endometriosis were observed for placenta previa, placental abruption, postpartum hemorrhage, preeclampsia, amniotic fluid abnormality, preterm labor, premature rupture of membranes, and multiple gestation., Conclusion: The present findings provide important insights into the potential relationship between endometriosis and various adverse obstetric outcomes and may help inform clinical practice and future research. Further studies that use more detailed clinical data and longitudinal designs are needed to solidify the presented conclusions., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Assisted reproductive technologies (ART) have become a vital option for women facing fertility challenges. One of the potential interventions being explored is the use of sildenafil citrate (SC) to improve clinical outcomes in ART procedures. The aim of this study was to assess the impact of SC on clinical outcomes in women undergoing ART. A comprehensive literature search was conducted using multiple databases, including PubMed, Scopus, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials. The search covered studies from inception until April 15, 2023, and identified relevant randomized controlled trials (RCTs) for inclusion in the analysis. The endpoints were summarized as risk ratio (RR) or standardized mean difference (SMD) with 95% confidence interval (CI). After meticulous analysis, twenty-eight RCTs comprising 3,426 women were included in the study. The results revealed significant findings regarding the impact of SC on clinical pregnancy (CP) rates. Women receiving SC demonstrated a significantly higher probability of CP compared to the control group (n=21 RCTs, RR=1.43; 95% CI: 1.29, 1.59). Additionally, when SC was combined with other medications like clomiphene citrate (CC) or estradiol valerate, it further improved the likelihood of CP compared to these medications alone (RR=1.35, 95% CI: 1.19, 1.53; RR=1.55, 95% CI: 1.08, 2.22, respectively). Furthermore, the study observed that the mean endometrial thickness (ET) was significantly higher in women who received SC compared to the control group, which involved other active interventions or placebo (SMD=0.77, 95% CI: 0.20, 1.34). Particularly, the administration of SC resulted in a notably higher ET level compared to the placebo (SMD: 1.33, 95% CI: 0.15, 2.51). The findings suggest that luteal supplementation of SC can be considered a beneficial approach to enhance ET and improve the CP rate in women undergoing ART.

We systematically investigated the efficacy and safety of EMLA (5% lidocaine-prilocaine cream) versus placebo for pain relief among infertile patients undergoing hysterosalpingography (HSG). We screened four databases from inception until 25 November 2020. We included only randomised placebo-controlled trials (RCTs) and assessed their risk of bias. The main efficacy outcomes included safety and pain scores during the different stages of HSG. The pooled outcomes were summarised as mean difference (MD) with 95% confidence interval (CI). Three RCTs were included, comprising 258 patients (131 and 127 patients received EMLA and placebo, respectively). All RCTs revealed an overall low risk of bias. EMLA significantly reduced pain perception during cervical instrumentation of tenaculum and cannula ( MD = -1.53, 95% CI [-2.59, -0.47], p  = 0.005) and at 24 h after completion of HSG ( MD = -1.30, 95% CI [-2.57, -0.03], p  = 0.04). Despite EMLA decreased pain perception during the other procedural stages of HSG, the differences were not statistically significant compared with placebo. EMLA was safe and free of local and systemic adverse reactions. This meta-analysis advocates that topical application of 5% EMLA cream is safe and correlates with decreased pain perception during HSG, particularly during the cervical instrumentation step and at 24 h after HSG completion.

Objective: To investigate the efficacy of vaginal probiotics administration in combination with prophylactic antibiotics versus antibiotic prophylaxis only on perinatal outcomes in women with preterm premature rupture of membrane (PPROM)., Methods: Four different databases were searched from inception till March 2023. We selected randomized controlled trials (RCTs) that compared vaginal probiotics along with antibiotics versus antibiotics only among pregnant women who were presented with PPROM between 24 and 34 weeks of gestation. We performed the meta-analysis using Revman software. Our primary outcomes were gestational age at birth and latency period duration. Our secondary outcomes were the rate of admission in the neonatal intensive care unit (NICU), infant birth weight, length of stay in the NICU, and neonatal complications., Results: Four RCTs, involving a total of 339 patients, were included in the meta-analysis. The gestational age at the time of delivery and latency period duration were significantly higher among probiotics + antibiotics group (p = 0.01 & p < 0.001). There was a significant reduction in the rate of NICU admission and length of NICU stay among the probiotics + antibiotics group compared to the antibiotics only group. A significant improvement in the infant birth weight after delivery was demonstrated among the probiotics + antibiotics group (p = 0.002). Although there was a decrease in the incidence of neonatal sepsis and respiratory distress syndrome within probiotics + antibiotics group versus antibiotics only group, these differences were not statistically significant (p > 0.05)., Conclusions: The combination of vaginal probiotics and antibiotic prophylaxis has been shown to effectively improve perinatal outcomes in women with PPROM. Further trials are needed to validate our findings., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Aim: To conduct the first-ever systematic review and meta-analysis of randomized controlled trials (RCTs) on the antihemorrhagic utility and safety of tranexamic acid (TXA) versus misoprostol for management (prevention and/or treatment) of postpartum hemorrhage (PPH)., Methods: Six databases were screened from inception until May 2023 and updated in September 2023. The RCTs were assessed for quality according to the Cochrane's risk of bias tool. The endpoints were summarized as mean difference (MD) or risk ratio (RR) with 95% confidence interval (CI) in a random-effects model., Results: Ten RCTs with 2121 patients (TXA = 1061 and misoprostol = 1060) were analyzed. There was no significant difference between TXA and misoprostol groups regarding the mean intraoperative blood loss (n = 9 RCTs, MD = 17.32 ml, 95% CI [-40.43, 75.07], p = 0.56), mean change in hemoglobin (n = 6 RCTs, MD = 0.11 mg/dl, 95% CI [-0.1, 0.31], p = 0.30), mean hospital stay (n = 2 RCTs, MD = -0.3 day, 95% CI [-0.61, 0.01], p = 0.06), blood transfusion rate (n = 4 RCTs, RR = 0.49, 95% CI [0.16, 1.47], p = 0.2), and rate of additional uterotonic agents (n = 4 RCTs, RR = 1.05, 95% CI [0.72, 1.53], p = 0.81). Leave-one-out sensitivity analysis showed robustness of the results, and there was no evidence of publication bias. Regarding safety endpoints, there was no significant difference between both groups regarding the rates of minor side effects, such as diarrhea, fever, nausea, and vomiting. No patient developed thromboembolic events in the TXA group., Conclusion: There was no significant antihemorrhagic efficacy between adjunct TXA and misoprostol for the management of PPH. The safety profile was comparable between both agents., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Carbon dioxide (CO 2 ) laser therapy is an emerging treatment for women with stress urinary incontinence (SUI)., Objectives: To examine the efficacy of CO 2 laser therapy for management of SUI-related symptoms in women., Design: A systematic review and meta-analysis of randomized controlled trials and cohort studies., Data Sources and Methods: Four databases were screened until January 2023. All efficacy continuous endpoints were assessed via subtraction of the posttreatment from pretreatment values. The data were summarized as mean difference (MD) with 95% confidence interval (CI) using the random-effects model., Results: A total of 15 studies with 700 patients were analyzed. CO 2 laser therapy significantly decreased the 1-h pad weights at 3 months [ n  = 5 studies, MD = -3.656 g, 95% CI (-5.198, -2.113), p  < 0.001], 6 months [ n  = 6 studies, MD = -6.583 g, 95% CI (-11.158, -2.008), p  = 0.005], and 12 months [ n  = 6 studies, MD = -3.726 g, 95% CI (-6.347, -1.106), p  = 0.005]. Moreover, CO 2 laser therapy significantly decreased the International Consultation of Incontinence Questionnaire-Urinary Incontinence Short Form Scores at 3 months [ n  = 10 studies, MD = -4.805, 95% CI (-5.985, -3.626), p  < 0.001] and 12-months [ n  = 6 studies, MD = -3.726, 95% CI (-6.347, -1.106), p  = 0.005]. Additionally, CO 2 laser therapy significantly decreased the Pelvic Floor Impact Questionnaire scores at 6 months [ n  = 2 studies, MD = -11.268, 95% CI (-18.671, -3.865), p  = 0.002] and 12 months [ n  = 2 studies, MD = -10.624, 95% CI (-18.145, -3.103), p  = 0.006]. Besides, CO 2 laser therapy significantly decreased the Urogenital Distress Inventory-6 scores at 3 months [ n  = 2 studies, MD = -21.997, 95% CI (-32.294, -11.699), p  < 0.001], but not at 6 months [ n  = 3 studies, MD = -3.034, 95% CI (-7.357, 1.259), p  = 0.169]. Lastly, CO 2 laser therapy significantly increased the Vaginal Health Index Score at 6 months [ n  = 2 studies, MD = 2.826, 95% CI (0.013, 5.638), p  = 0.047] and 12 months [MD = 1.553, 95% CI (0.173, 2.934), p  = 0.027]., Conclusion: CO 2 laser therapy improved the SUI-related symptoms in women. To obtain solid conclusions, future studies should be well-designed with standardized settings, consistent therapeutic protocols, and long-term follow-up periods., Competing Interests: The authors declare that there is no conflict of interest., (© The Author(s), 2023.)

Background: Pregnancy and postpartum period are associated with stress and pain. Chronic medical conditions can aggravate depressive and psychotic mental illnesses in the peripartum period., Aim: The study aimed to investigate the association between different chronic medical conditions and mental illnesses during pregnancy and the postpartum period using the National Inpatient Sample (NIS)., Methods: Pregnant women or women in the postpartum period were retrieved from the NIS 2016-2019 database using the International Classification of Diseases (ICD)-10 and set as our targeted population. Postpartum depression, puerperal psychosis, and mental illnesses related to pregnancy were also retrieved as our outcomes of interest. STATA 15 was used to analyze the data and investigate the relationship between chronic medical conditions and pregnancy-related mental illnesses., Results: 2,854,149 admissions were retrieved from the database with a mean age of 29 ± 6 years old. Univariate and multivariate analyses showed a significant association between chronic medical conditions and postpartum depression, puerperal psychosis, and other mental illnesses. On univariate analysis, heart failure (odds ratio [OR] = 13.9; 95% confidence interval [CI] = 3.5-55.88; P < 0.001), alcohol misuse (OR = 5.3; 95% CI = 1.7-16.4; P = 0.004), and migraine (OR = 3.9; 95% CI = 2.8-5.3; P < 0.001) showed high association with postpartum depression. Epilepsy (OR = 54.37; 95% CI = 7.4-399.34; P < 0.001), systemic lupus erythematosus (OR = 24.66; 95% CI = 3.36-181.1; P = 0.002), and heart diseases (OR = 15.26; 95% CI = 3.6-64.5; P < 0.001) showed the highest association with puerperium psychosis. Alcohol misuse (OR = 8.21; 95% CI = 7.4-9.12; P < 0.001), osteoarthritis (OR = 6.02; 95% CI = 5.41-6.70; P < 0.001), and migraine (OR = 5.71; 95% CI = 5.56-5.86; P < 0.001) showed the highest association with other mental illnesses during pregnancy and the postpartum period., Conclusion: Heart diseases, alcohol misuse, migraine, systemic lupus erythematosus, and epilepsy were the most important chronic medical conditions associated with mental diseases during pregnancy and the postpartum period. This investigation recommends integrating management of chronic diseases and mental health care together. Specifically, screening for mental illnesses should be a routine part of care for patients with chronic medical conditions, especially during pregnancy and early postpartum. By identifying and addressing mental health issues early on, healthcare providers can improve the overall health and well-being of these patients, ultimately leading to better maternal and fetal outcomes., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Aim: The effects of vitamin D administration on bone turnover markers (BTMs) in adults are controversial. Thus, we carried out a meta-analysis of available randomised controlled trials (RCTs) to examine the impact of vitamin D supplementation on BTMs., Methods: To identify relevant RCTs, we searched the PubMed/MEDLINE, Web of Science, Scopus, Cochrane Library and Embase databases for manuscripts published up to July 2022. The present study was conducted in agreement with the PRISMA guidelines. Weighed mean difference (WMD) and 95% confidence intervals (CI) were used to calculate the magnitude of the effect of the intervention., Results: A total of 42 RCTs were included in the meta-analysis. The age of the participants enrolled in the RCTs ranged from 19.4 to 84 years. The pooled results depicted a decrease in deoxypyridinoline (DPD) concentrations (WMD: -1.58 nmol/mmol, 95% CI: -2.55, -.61, p = .001) following vitamin D supplementation. In addition, subgroup analyses demonstrated that vitamin D administration notably reduced procollagen type I N-terminal propeptide (PINP) levels in individuals aged >50 years and led to a pronounced decrease in alkaline phosphatase (ALP) values when the intervention lasted >12 weeks. No significant effect was observed on other BTMs, for example, collagen type 1 cross-linked C-telopeptide (CTX) and osteocalcin (OC) levels., Conclusion: Vitamin D administration decreases DPD, PINP and ALP levels, indicating a reduced bone turnover following the intervention. Other BTMs, for example, CTX or OC values, were not affected by vitamin D prescription. Vitamin D supplementation may exert a positive effect on some important BTMs., (© 2023 Stichting European Society for Clinical Investigation Journal Foundation. Published by John Wiley & Sons Ltd.)

Background and Objectives : Cardiovascular disease (CVD) is a major contributor to the high mortality rate among individuals with ovarian cancer. Nevertheless, there is limited understanding regarding the specific patient attributes that might impact the risk of CVD in this group. Materials and Methods : A retrospective cohort study was performed using the SEER database to analyze primary ovarian cancer cases from 2000 to 2019. Multivariable logistic regression analysis was employed to identify patient characteristics linked to cardiovascular mortality. Results : The cohort included 41,930 cases of patients who were alive, 54,829 cases of cancer-related deaths, 3003 cases of cardiovascular-related deaths, and 10,238 cases with other causes of death. Poorly differentiated cancer cells and distant metastasis were associated with a higher risk of cardiovascular mortality. Logistic regression analysis identified age, year of diagnosis, race, laterality, and staging as significant risk factors for cardiovascular cause of death. The risk of cardiovascular cause of death was lower in patients aged 31-60 and higher in those aged over 60 years old, and the risk also increased with a later year of diagnosis. Patients who were not white were at a higher risk of cardiovascular cause of death. Additionally, bilateral ovarian cancer and distant staging disease were linked to elevated risks of cardiovascular cause of death. Conclusion : Cardiovascular mortality is a significant concern in ovarian cancer patients, and several patient characteristics are associated with an increased risk. Our study suggests that targeted interventions to improve cardiovascular health in high-risk patients, such as those with comorbidities or an advanced stage at diagnosis, may improve survival in this population.

Objective: To examine the knowledge of cervical cancer risk factors and human papilloma virus (HPV) vaccine among Saudi women of childbearing age., Methods: An anonymous, survey-based, cross-sectional study was conducted from November 2022 to March 2023., Results: Overall, 422 participants were included in the current study. Most participants were within the age group of 15-25 years old (42.9%), single (47.9%), and educated with a bachelor's degree (70%). Out of a total of 14 points, the average knowledge score for all participants was 7.3 ± 2.31 (range: 2-14). More than three-quarters of the surveyed participants correctly identified the following risk factors for cervical cancer: multiple sexual partners (78.2%), having weakened immunity (82.7%), infection with HPV (82.9%), and positive family history of cervical cancer (88.9%). Concerning HPV vaccine, 153 (36.3%) participants heard about HPV vaccine and only 20 (4.4%) of them were vaccinated. Only 128 (30.3%) participants stated correctly that 9-13 years old is the best age to start HPV vaccine, whereas 51 (12.1%) participants correctly stated the number of HPV vaccine doses to be three over six months. Overall, 167 (39.6%) participants declined to receive the HPV vaccine. The three most frequently reported reasons included not hearing about HPV vaccine (35.3%), fear from HPV-related side effects (30.5%), and apprehension from HPV vaccine injection (16.2%). Among several socio-demographic characteristics, occupation was statistically significantly associated with knowledge score (p < 0.001), with students in health specialties tended to have the highest knowledge score compared with others., Conclusion: Most participants displayed good knowledge about cervical cancer risk factors, but not about HPV vaccine. Very alarmingly, less than 5% of the participants received HPV vaccine and close to 40% of them declined to receive the HPV vaccine. Mechanisms to increase public awareness about HPV vaccine and its acceptance by women are recommended., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Author(s).)

Background: The adoption of telemedicine has facilitated the opportunity to offer the best health care services. Nevertheless, there is a mismatch between the presence of telemedicine programs in the Kingdom of Saudi Arabia and poor acceptance by the end-user patients., Objective: This study aimed to gain a holistic understanding of the knowledge, attitudes, and barriers of the end-user patients (ie, research participants) toward the utility of telemedicine services in the Kingdom of Saudi Arabia., Methods: A cross-sectional, survey-based study was conducted from June 1 to July 31, 2022, in the Kingdom of Saudi Arabia. The questionnaire was developed based on a literature review and was examined for validity and reliability. Knowledge questions used a yes-or-no format, whereas attitude and barrier questions used a 5-point Likert-scale format. Data were reported descriptively and analyzed using SPSS (IBM Corp) software. To evaluate the differences in mean scores and identify sociodemographic factors associated with knowledge and attitudes toward the adoption of telemedicine, the data were analyzed using univariate and multivariable regression analyses, respectively., Results: Overall, 1024 participants participated in the survey. The percentages of participants who attended a telemedicine service before, during, and after COVID-19 were 49.61% (508/1024), 61.91% (634/1024), and 50.1% (513/1024), respectively. The mean score for knowledge was 3.52 (SD 1.486; range 0-5), reflecting a high level of knowledge. The mean score for attitudes was 37.08 (SD 8.526; range 11-55), reflecting optimistic (positive) attitudes. Regarding barriers, the participants voiced some concerns regarding patient and physician resistance and attributed some cultural and technology-related limitations as potential hindrances to the full adoption of telemedicine services. The place of residence (rural vs nonrural) had a significant impact on the scores of knowledge, attitudes, and barriers, whereas gender had no significant impact. The multivariable regression analysis showed that several sociodemographic factors significantly correlated with knowledge and attitudes toward the adoption of telemedicine services., Conclusions: The participants showed good knowledge and positive attitudes toward telemedicine services. The perceived barriers were in line with the published literature. This research calls for the need to strengthen the positive attitudes and rectify the barriers, so that the utility of telemedicine services can be maximized in the community., (©Saeed Baradwan, Mohammed Al-Hanawi. Originally published in JMIR Formative Research (https://formative.jmir.org), 27.07.2023.)

Objective: To evaluate ultrasound guidance effect in pain relief during intrauterine device (IUD) insertion., Methods: Four different databases were searched from inception till June 2022. We selected randomized controlled trials (RCTs) that compared transabdominal ultrasound guidance versus traditional non-guided IUD insertion among women undergoing IUD placement for contraception. We used Revman software during performing our meta-analysis. Our primary outcome was the pain score during IUD insertion as evaluated by the Visual Analog Scale (VAS). Our secondary outcomes were the procedure insertion time, satisfaction, and incidences of complications and misplaced IUDs., Results: Seven RCTs were retrieved with a total number of 1267 patients. There was a significant reduction in the VAS pain score during IUD insertion among the ultrasound-guided group (MD = -1.91, 95% CI [-3.08, -0.73], P = .001). The procedure insertion time was significantly shorter within the ultrasound guidance group compared with the control group (MD = -1.35, 95% CI [-1.81, -0.88], P < .001). Moreover, more women were significantly satisfied with the procedure among the ultrasound-guided group (P < .001). In addition, ultrasound-guided IUD insertion was linked to significant decline in incidences of complications and misplaced IUDs., Conclusion: Ultrasound guidance can be used as a modified technique during IUD insertion as it decreases pain, procedure time, and rates of complications and misplaced IUDs with better patient satisfaction., (© 2022 American Institute of Ultrasound in Medicine.)

Objective: To evaluate reproductive outcomes after hysteroscopic adhesiolysis for patients with Asherman syndrome (AS) who presented with infertility and/or subfertility., Methods: A retrospective study was conducted in the Women's Specialized Hospital, King Fahad Medical City, from December 2010 to December 2018. The medical records were reviewed for all infertile women who had hysteroscopic adhesiolysis. The specific study's main reproductive outcomes included: [1] the overall rate of conception, [2] the overall rate of conception according to the severity degree of intrauterine adhesions (IUAs), [3] the reproductive methods for achieving conception, and [4] pregnancy outcomes. Reproductive methods for conception included spontaneous conception, ovulation induction (OI), intrauterine insemination (IUI), and in-vitro fertilization (IVF) with/without intracytoplasmic sperm injection (ICSI). Outcomes of pregnancy included ectopic pregnancy, miscarriage, and live birth events., Results: Forty-one patients (n=41) were analyzed. Their mean age was 32.2±4.6 years. The most common menstrual pattern amongst these patients was hypomenorrhea 46.4%. All patients resumed regular menstrual cycles after the adhesiolysis procedure. The overall conception rate during the 24 months follow up was 53.6%, and the overall live birth rate was 34.2%. Of the 22 patients who conceived, 12 patients (29.2%) conceived spontaneously, 2 (4.9%) with IUI, and 8 (19.5%) with IVF-ICSI. The patients with minimal IUAs had a significantly higher pregnancy rate (71.4%) when compared to those with moderate (47%) and severe (40%) IUA (two-tailed log-rank test, p=0.041)., Conclusions: The spontaneous cumulative conception rate following hysteroscopic adhesiolysis was higher in patients with minimal IUAs than those with moderate and severe IUAs.

Background: Polycystic ovary syndrome (PCOS) is a prevalent hormonal disorder distinguished by a persistent absence of ovulation. Ovarian drilling is a recognized therapeutic approach for PCOS patients who are unresponsive to medication and can be performed through invasive laparoscopic access or less-invasive transvaginal access. The aim of this systematic review and meta-analysis was to assess the efficacy of transvaginal ultrasound -guided ovarian needle drilling with conventional laparoscopic ovarian drilling (LOD) in patients with PCOS., Methods: PUBMED, Scopus, and Cochrane databases were systematically searched for eligible randomized controlled trials (RCTs) from articles published from inception to January 2023. We include RCTs of PCOS that compared transvaginal ovarian drilling and LOD and reported on ovulation and pregnancy rates as the main outcome variable. We evaluated study quality using the Cochrane Risk of bias 2 tool. A random-effects meta-analysis was performed and the certainty of the evidence was assessed according to the GRADE approach. We registered the protocol prospectively in PROSPERO (CRD42023397481)., Results: Six RCTs including 899 women with PCOS met the inclusion criteria. LOD was found to significantly reduce anti-Mullerian hormone (AMH) (SMD: -0.22; 95% CI: -0.38, -0.05; I 2  = 39.85%) and antral follicle count (AFC) (SMD: -1.22; 95% CI: -2.26, -0.19; I 2  = 97.55%) compared to transvaginal ovarian drilling. Our findings also indicated that LOD significantly increased the ovulation rate by 25% compared to transvaginal ovarian drilling (RR: 1.25; 95% CI: 1.02, 1.54; I2 = 64.58%). However, we found no significant difference between the two groups in terms of follicle stimulating hormone (SMD: 0.04; 95% CI: -0.26, 0.33; I2 = 61.53%), luteinizing hormone (SMD: -0.07; 95% CI: -0.90, 0.77; I2 = 94.92%), and pregnancy rate (RR: 1.37; 95% CI: 0.94, 1.98; I2 = 50.49%)., Conclusion: LOD significantly lowers circulating AMH and AFC and significantly increases ovulation rate in PCOS patients compared to transvaginal ovarian drilling. As transvaginal ovarian drillingremains a less-invasive, more cost-effective, and simpler alternative, further studies are warranted to compare these two techniques in large cohorts, with a particular focus on ovarian reserve and pregnancy outcomes., Competing Interests: Declaration of Competing Interest All authors declare that they have no competing interests., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)