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Can a novel closed simplified IVF culture system be used to achieve outcomes comparable to those obtained with intracytoplasmic sperm injection (ICSI) followed by conventional culturing?This analysis is part of a non-inferiority prospective study comparing ICSI and a simplified culture system (SCS) for gamete fertilization in a selected group of patients. According to protocol, sibling oocytes in intact cumulus-oocyte complexes were randomly distributed between ICSI and conventional insemination in the SCS. For women, selection criteria included being under 43 years of age and at least six eggs at retrieval. An inseminating motile sperm count ≥1 million was required. The primary outcome measure was ongoing pregnancy rate (12 weeks) per cycle; secondary outcome measures included fertilization rate, miscarriage rate and implantation rate (ongoing pregnancy rate per embryo).From January 2016 until December 2019, 653 SCS/ICSI cycles were performed yielding a total of 7915 oocytes. The fertilization rate was 61.1% and 50.4% for SCS and ICSI (P0.0001), respectively. The ongoing pregnancy rate was 32.0% for SCS and 36.7% for ICSI (P = 0.27). Implantation rate was 30.6% for SCS and 34.4% for ICSI (P = 0.35). The miscarriage rate was 7.5% and 6.5% for SCS and ICSI, respectively (P = 0.75).No difference was found in ongoing pregnancy rate, implantation rate and the miscarriage rate between SCS and ICSI in this selected patient cohort.

Background: Assisted reproductive techniques services are often not accessible to the majority of infertile couples in Low and Middle Income Countries (LMIC) due to high costs. Lowering IVF laboratory costs is a crucial step to make IVF affordable for a larger part of the world population. We developed a simplified culture system (SCS) which has proven to be effective, and the next step is to prove its safety.Methods: Preterm birth (PTB) and low birthweight (LBW) of 176 singletons born after using the SCS, 105 after fresh embryo transfer (fresh ET), and 71 after frozen embryo transfer (frozen ET) were compared with all IVF/ICSI singletons born in Belgium between 2013 and 2018. When comparing our 105 SCS babies born after fresh ET with all Belgian babies born after conventional IVF only, we also adjusted for 7 risk factors known to influence perinatal outcome, namelythe mother's age, day of transfer, pituitary inhibition protocol, rank of cycles, number of oocytes retrieved, number of embryos transferred, and gender of the baby.Findings: Before adjustment, we found a significantly higher PTB (10.2% vs. 3.8%, OR 2.852, 95% CI [1.042-7.803], p-value 0.0413) and LBW (9.8% vs. 2.9%, OR 3.692, 95% CI [1.163-11.721], p-value 0.0267) in the conventional IVF group versus SCS after fresh ET. After adjusting for seven risk parameters, these differences remained significant (PTB: OR 2.627, 95% CI [1.013-6.816], p-value 0.0471) and LBW: OR 3.267, 95% CI [1.118-9.549], p-value 0.0305). PTB and LBW between both groups was not significantly different for singletons born after frozen ET. Interpretation: Taking into account the small series, PTB and LBW rates in SCS singletons in FRET cycles are very reassuring and significantly lower compared to babies born after conventional IVF in Belgium. Being aware of its effectiveness, our results offer a good perspective for SCS to become an important tool to implement low-cost IVF in LMIC. We want to thank Gerhard Boshoff who created the figures for this paper

To develop a consensus statement of recommended terminology to use for describing different aspects of hysteroscopic procedures that can be uniformly used in clinical practice and research.Open forum discussion followed by online video meetings.International community of hysteroscopy experts PATIENTS: Not applicable.Series of online video meetings to complete a previously established agenda until a final agreement for standardized nomenclature was obtained.The adoption and implementation of a common terminology to standardize reporting of hysteroscopic procedures was proposed to cover five domains: pain management, healthcare setting, model of care, type of hysteroscopic procedure and the hysteroscopic approach to the uterine cavity. A final agreement was obtained after 3 online video meetings.Hysteroscopy is the gold standard technique for the evaluation and management of uterine disorders. A clear definition and understanding of the terminology used to describe hysteroscopic procedures is lacking. The production of this international consensus statement for terminology to describe hysteroscopic procedures, covering pain management, setting, model of care, type of procedure and hysteroscopic approach, has the potential to enable more effective communication for both clinical and research purposes with the ultimate aim of improving patient care and clinical outcomes.

Background: Manual semen assessment (MSA) is a key component in a male’s fertility assessment. Clinicians rely on it to make diagnostic and treatment decisions. When performed manually, this routine laboratory test is prone to variability due to human intervention which can lead to misdiagnosis and consequently over- or under-treatment. For standardization, continuous training, quality control (QC) programs and pricy Computer-Assisted Sperm Analysis (CASA) systems have been proposed, yet, without resolving intra- and inter-laboratory variability. In response, promising simplified sperm testing devices, able to provide cost-effective point-of-care male infertility diagnosis are prospected as a plausible solution to resolve variability and increase access to sperm testing. Materials and methods: A throughout literature research for semen testing, sperm analysis, smart-phone assisted semen analysis, ‘at-home’ semen testing, male infertility, infertility in developing countries, infertility in low- and middle-income countries (LMIC) and quantitative sperm analysis was performed. A total of 14 articles, specific to ‘at-home’ simplified sperm assessment, were included to treat the core subject. Results: Continuous training and consistent QC, are sine qua none conditions to achieve accurate and comparable MSA. Compliance does not rule-out variability, nevertheless. Emerging simplified sperm assessment devices are an actual alternative to resolve lack of standardization and accessibility to sperm analysis. YO®, SEEM®, and ExSeed® are commercially available, user-friendly smartphone-based devices which can accurately measure volume, sperm concentration (millions/ml) and total motile sperm count. More broadly, by cost-effectiveness, availability, accuracy and convenient application, these devices could effectively sort patients for first-line artificial reproduction treatments such as intrauterine insemination. Conclusions: Accuracy and cost-effectiveness make smart-phone based sperm testing devices a practical and realistic solution to overcome variability in MSA. Importantly, these tools represent an actual opportunity to standardize and affluence male subfertility diagnosis and treatment, especially in LMIC. However, before clinical application is possible, guidelines, further testing with special attention on accuracy in washed sperm, availability, cost-benefit and reliability are required.

Study Objective To evaluate the histology of the uterine septum after its complete hysteroscopic excision. Design Case series. Setting II Gynecological and Obstetric Unit of the University of Bari, Italy and Pathological Anatomy Department of the University of Bari, Italy. Patients 35 patients between 25 and 41 years old diagnosed with uterine septum by 3D ultrasound as per ESHRE/ESGE 2013/Salim 2003 criteria. Office hysteroscopy was also performed to define the anatomy of the uterine cavity and to exclude the presence of other endometrial pathology. Interventions Operative hysteroscopic septum resection was performed. The septum was initially incised with a “L shape” bipolar electrode with the 5 mm Bipolar Mini-Resectoscope (Karl Storz, Germany). Then, using the bipolar loop, two triangles of the septum were excised in parallel, obtaining uninterrupted entire septum-long strips, from the fundus to the apex of the septum. The strips were immediately removed from the uterus and reassembled “in vitro” in order to reconstruct the macroscopic 3D structure of the septum for a complete morphological and histological evaluation. Measurements and Main Results Patients presented an average BMI of 24,8 and were all nulliparous. Histologic evaluation of the uterine septa showed a different conformation of the muscle bundles along the septum. In the apex and edges of the septum, the muscle cells were arranged in nodules circumscribed by a thin area of collagen fibers. Medium size vessels were distributed in the collagen fibers around the muscle cells. Only few capillary vessels are present in the muscle nodules. This pattern is very similar to the cell arrangement of leiomyomas. In the core of the septa, near the base, the muscle bundles show a linear course, with concurrent collagen fibers and vessels. All the above-mentioned characteristics were consistently present in every patient. On high-power histological fields (200x), the muscle portion ranged from 48,3 ± 1,8% (mean 6,0) in the apex and borders, to 48,5 ± 1,3% (mean 6,0) in the core. The collagen fibers ranged from 27.1 ± 1.1% (mean 4,0) in the apex and borders, to 26.7 ± 1.3% (mean 5,0) in the core. Conclusion This study allowed us, by removing the entire septum as a whole structure, to redefine the concept of the septum as a complex structure based on islands of muscle fibers irregularly arranged in vertex, in a context of collagen tissue, similar to the structure of myomas. It appears to deeply involve the anterior and posterior uterine wall, resembling a “reverse letter H”.

Is there a difference in perinatal outcome in the same patient cohort for babies conceived following randomization of sibling oocytes allocated to a simplified IVF culture system (SCS) or intracytoplasmic sperm injection (ICSI) followed by conventional culturing?The study compared the perinatal outcomes of 367 babies born from 1 January 2013 until 31 December 2020 after using split SCS and ICSI insemination of sibling oocytes in a selected group of normo-responsive women, excluding cases of severe male infertility. Primary outcome measures were preterm birth (PTB;37 weeks' gestation), low birthweight (LBW;2.5 kg) and small for gestational age (SGA) as a primary outcome parameter while secondary outcome measures included mean birthweight, mean gestational age, extreme prematurity (32 weeks), very low birthweight (1.5 kg), perinatal mortality, multiple pregnancy and Caesarean section rate.A total of 105 and 103 singleton babies were born after fresh embryo transfer (FRET) and 71 and 50 singletons after frozen embryo transfer (FET) in the SCS and ICSI groups, respectively. For babies born after FRET, the LBW rate was 2.9% (3/105) for SCS and 7.8% (8/103) for ICSI (P = 0.10). LBW occurred in 4.2% (3/71) and 0% (0/50) of babies born after the transfer of cryopreserved-thawed SCS and ICSI embryos, respectively (P = 0.14). The rate of PTB was 3.8% and 6.8% for SCS and ICSI in FRET cycles (P = 0.33), and 8.5% and 6.0% for SCS and ICSI in FET cycles (P = 0.62). One congenital malformation was found in the SCS FET group.There was no difference in perinatal outcome for singleton and twin babies born after SCS and ICSI.

Formation of the ovarian endometrioma consists of implantation, invagination of the ovarian cortex, and adhesion formation. Progression is characterized by repeated injury and repair with degenerative changes. Already with a partially deprived ovarian reserve, resulting from the disease, surgical treatment carries a potential risk of further follicular deprivation. Surgery should therefore be performed with microsurgical precision by experienced hands. Early treatment can possibly prevent further progression. The adverse impact on ovarian reserve of the ablative approach has to be balanced against a lower recurrence rate of a cystectomy. Adapted surgical approaches like a two-step approach or a combination of excisional and ablative surgery has to be considered in case of a large endometrioma. Further studies on the possibility and advantages of sclerotherapy are warranted. Fertility preservation by cryopreservation of ovarian cortex should be part of the informed consent with the patient.

Background: The aim of this study was to evaluate the added value of transvaginal hydrolaparoscopy (THL) in the investigation of the infertile patient. Methods: A retrospective cohort study, based on records from 01/09/2006 to 30/12/2019 was undertaken in a tertiary care infertility centre. THL was performed in 2288 patients. These were patients who were referred for endoscopic exploration of the female pelvis as part of their infertility investigation. In 374 patients with clomiphene-resistant polycystic ovary syndrome (PCOS), ovarian capsule drilling was also performed. The outcome objectives of this study included the evaluation of the added diagnostic value of THL as well as the feasibility and safety of the visual inspection of the female pelvis using this technique. Results: Of the 2288 procedures failed access to the pouch of Douglas occurred in in 23 patients (1%). The complication rate was 0.74%, due to bowel perforations (n= 13) and bleeding (n= 4) requiring laparoscopy. All bowel perforations were treated conservatively, with 6 days of antibiotics, and no further complications occurred. Findings were normal in 49.8% of patients. Endometriosis was diagnosed in 366 patients (15.9%); adhesions were present in 144 patients. Conclusions: THL is a minimally invasive procedure, with a low complication and failure rate, providing an accurate visual exploration of the female pelvis in a one-day hospital setting. When indicated, minimally invasive surgery is possible in the early stages of endometriosis and for ovarian capsule drilling in patients with clomiphene-resistant PCOS.

Background Training of basic laparoscopic psychomotor skills improves the acquisition of more advanced laparoscopic tasks, such as laparoscopic intra-corporeal knot tying (LICK). This randomized controlled trial was designed to evaluate whether pre-training of basic skills, as laparoscopic camera navigation (LCN), hand-eye coordination (HEC), and bimanual coordination (BMC), and the combination of the three of them, has any beneficial effect upon the learning curve of LICK. The study was carried out in a private center in Asunción, Paraguay, by 80 medical students without any experience in surgery. Four laparoscopic tasks were performed in the ENCILAP model (LCN, HEC, BMC, and LICK). Participants were allocated to 5 groups (G1–G5). The study was structured in 5 phases. In phase 1, they underwent a base-line test (T1) for all tasks (1 repetition of each task in consecutive order). In phase 2, participants underwent different training programs (30 consecutive repetitions) for basic tasks according to the group they belong to (G1: none; G2: LCN; G3: HEC; G4: BMC; and G5: LCN, HEC, and BMC). In phase 3, they were tested again (T2) in the same manner than at T1. In phase 4, they underwent a standardized training program for LICK (30 consecutive repetitions). In phase 5, they were tested again (T3) in the same manner than at T1 and T2. At each repetition, scoring was based on the time taken for task completion system. Results The scores were plotted and non-linear regression models were used to fit the learning curves to one- and two-phase exponential decay models for each participant (individual curves) and for each group (group curves). The LICK group learning curves fitted better to the two-phase exponential decay model. From these curves, the starting points (Y0), the point after HEC training/before LICK training (Y1), the Plateau, and the rate constants (K) were calculated. All groups, except for G4, started from a similar point (Y0). At Y1, G5 scored already better than the others (G1 p = .004; G2 p = .04; G3 p K (G1 p p p p Conclusions Our data confirms that training improves laparoscopic skills and demonstrates that pre-training of all basic skills (i.e., LCN, HEC, and BMC) shortens the LICK learning curve.

Background Ultrasonography is a first-line imaging in the investigation of women’s irregular bleeding and other gynaecological pathologies, e.g. ovarian cysts and early pregnancy problems. However, teaching ultrasound, especially transvaginal scanning, remains a challenge for health professionals. New technology such as simulation may potentially facilitate and expedite the process of learning ultrasound. Simulation may prove to be realistic, very close to real patient scanning experience for the sonographer and objectively able to assist the development of basic skills such as image manipulation, hand-eye coordination and examination technique. Objective The aim of this study was to determine the face and content validity of a virtual reality simulator (ScanTrainer®, MedaPhor plc, Cardiff, Wales, UK) as reflective of real transvaginal ultrasound (TVUS) scanning. Method A questionnaire with 14 simulator-related statements was distributed to a number of participants with differing levels of sonography experience in order to determine the level of agreement between the use of the simulator in training and real practice. Results There were 36 participants: novices (n = 25) and experts (n = 11) who rated the simulator. Median scores of face validity statements between experts and non-experts using a 10-point visual analogue scale (VAS) ratings ranged between 7.5 and 9.0 (p > 0.05) indicated a high level of agreement. Experts’ median scores of content validity statements ranged from 8.4 to 9.0. Conclusions The findings confirm that the simulator has the feel and look of real-time scanning with high face validity. Similarly, its tutorial structures and learning steps confirm the content validity.

Objective To evaluate in a prospective pilot study the feasibility of cytobrushing of the fimbrial end using a transvaginal endoscopic access. Study design Prospective feasibility study. The procedure was performed in a consecutive series of 15 infertile women referred for a transvaginal laparoscopy as part of their fertility investigation. Tubal cells were collected using a 5Fr cytobrush. Cytology and immunocytochemistry was done. Results In all patients enough cell material was obtained for analysis, without traumatizing the fimbrial end. Specimens showed the presence of a sufficient amount of cells enabling standard cytologic examinations and immunocytochemistry (Ki 67, p53). Conclusion Fimbrial cytobrushing using the transvaginal approach is an easy and minimally invasive procedure. The easy accessibility of the fimbrial end and the distal ampullary part at TVL allows an accurate collection of tubal epithelial cells. In view of the recent data reporting the Fallopian tube and more specifically the fimbrial end as a possible origin of ovarian carcinoma, further research is needed to evaluate the potential of this technique as a possible screening method for patients at risk for ovarian cancer.

Objective To evaluate the long-term reproductive outcomes in patients with dysmorphic uterus treated by hysteroscopic metroplasty with miniaturized instruments. Design Retrospective multicenter cohort study. Setting Tertiary care university hospitals. Patients The study was conducted on 214 women with a dysmorphic uterus (T-shaped, infantilis, or other type of dysmorphic uterus according to the European Society of Human Reproduction and Embryology and the European Society for Gynaecological Endoscopy classification system) with history of primary unexplained infertility (group 1) or repeated (>2) early miscarriages (group 2). Dysmorphic uteri were diagnosed by office hysteroscopy and 3-dimensional transvaginal ultrasound (3D-TVS). Interventions All patients underwent in office hysteroscopic metroplasty using a continuous-flow hysteroscope with a 5 Fr operating channel introduced into the uterine cavity using the vaginoscopic approach. Longitudinal incisions were performed on the fibromuscular constriction rings in the isthmic area and in some cases on the other uterine walls with a 5 Fr bipolar electrode or scissors. At the end of the procedure, an antiadhesive gel was applied into the uterine cavity to minimize adhesion formation. Postsurgical assessment of the uterine cavity was carried out through office hysteroscopy and 3D-TVS. All patients were followed for at least 24 months. Measurements and Main Results The metroplasty was completed in all cases, resulting in a significant increase of uterine cavity volume (100%) and optimization of uterine morphology in 211 of 214 women (98.6%). After 60 months, the overall clinical pregnancy rate was 72.9% (n = 156/214), and the live birth rate was 80.1% (n = 125/156). Specifically, 74 of 156 women (47.4%) conceived spontaneously (with a median time to pregnancy of 5.5 months), of whom 32.4% had previously failed 1 or more attempts at in vitro fertilization/intracytoplasmic sperm injection. Conclusion Our long-term follow-up data demonstrate that the hysteroscopic correction of dysmorphic uteri may result in a high live birth rate in women suffering from unexplained infertility or repeated miscarriages.

The exact incidence of power morcellation complications (PMC) is unknown and probably underestimated. Medical literature mainly describes case reports and the vast majority of complications after tissue power morcellation are not reported. ESGE has run a survey among its members about complications emerging after laparoscopic electromechanical morcellation including the risk of leiomyosarcoma (LMS). The reported risk of a sarcoma after myoma or uterus morcellation is low and presented in a separate article. The Central office using the ESGE server and website, activating the ‘Survey Monkey’ programme, sent a request to 3422 ESGE members to answer, anonymously, a structured electronic questionnaire with multiple structured answer options, within 3 months. The doctors responding to the call were automatically given a serial number in an EXCEL spreadsheet, enabling statistical analysis using the SPSS v.18. The probabilities were calculated by using the raw data as reported to each individual question, dividing the number of incidence with surgeon’s lifetime experience in laparoscopic surgery. The electronic questionnaire was answered by 216 (6 %) surgeons. The majority of the respondents used the morcellator for 10 years. The overall probability of direct power morcellator injuries to internal organs is more frequent (0.12 %) than that of morcellator injuries to the abdominal and pelvic wall (0.06 %). The risk of parasitic myoma is estimated 0.08 and 0.16 % for the de novo endometriosis after myoma and adenomyoma morcellation. Furthermore, the vast majority of surgeons have never experienced bladder or ureter, aorta and vessel injuries by using the morcellator, proven by the standard deviation being close to zero. Three surgeons with morcellator experience between 1 and 5 years were involved in an injury that caused permanent damage, 1 nerve, 2 bowel and 1 port-site hernia injury due to the morcellator. According to surgeons’ answers, death has never occurred after power morcellation. Morcellator technical problems found also to be of low probability between 0.12 and 0.3 % as estimated for all endoscopic surgeries in lifetime of 188 surgeons. The average number of times per doctor where the morcellator stacked and stopped working is 2.17 with standard deviation equal to 4.4 and sum of incidents equal to 426 times for all 196 doctors. The most frequent technical problem was morcellator transient stacking and the least frequent was the morcellator stopped working and colpotomy needed to evacuate the tissue out of the abdominal cavity 0.12 % operations. The majority of surgeons 136/188 (72 %) are using reusable morcellator devices and 51 (27 %) are using disposable devices. Moreover, 97/188 (51.6 %) of surgeons are using exclusively, only reusable morcellators; 56/188 (29.8 %) are using both disposable and reusable types of morcellators. The incidence of power morcellation complications is very low reputedly. The ESGE board advises that endoscopic operations must be performed only by doctors who have had an adequate training and knowledge. It is compulsory to know the publications about dangers, contraindications and complications before performing these operations. A complete knowledge of techniques and principles of endoscopic surgery is needed to avoid and minimize complications. A training session prior to morcellator first use might decrease further PMC.

Several studies have evaluated the impact of video games (VGs) on psychomotor skills in laparoscopic surgery. Our review of literature revealed that prior VGs experience ameliorates the initial skill level of novice trainees and accelerates their learning curve by facilitating a better perception of 3D images, ambidexterity, and tone reflexes. The published studies are unfortunately limited by the small number of participants, the heterogeneity of the sample, the endpoints, and the evaluation tools of the studies. Randomized control studies with strict inclusion criteria and valid evaluation tool are required before including this concept in surgical educational programs.

Hysteroscopy enables visualisation of the uterine cavity and allows the diagnosis and surgical treatment of intrauterine pathology. To achieve this, the uterine cavity needs to be distended by a medium which could either be fluid or carbon dioxide [1]. Carbon dioxide is used for diagnostic hysteroscopy, as bleeding during operative procedures obscures visibility. For this reason, fluid media are used for operative procedures, as they allow continuous irrigation giving a clear picture and enable use of both mechanical and electrosurgical instruments. During operative hysteroscopy absorption of large volumes of distension solutions can occur leading to serious complications arising from significant fluid overload. Excessive fluid absorption is most likely with prolonged hysteroscopic procedures requiring continuous irrigation of fluid or where blood vessels within the myometrium are opened. Thus, particular care is required with resection of the endometrium (transcervical resection of the endometrium – TCRE) and hysteroscopic myomectomy – transcervical resection of fibroids – TCRF). Operative hysteroscopic procedures are usually carried out using resectoscopes which are larger diameter, continuous flow operating hysteroscopes. They incorporate a working element that moves an electrically activated wire loop. These devices were initially developed to use monopolar current, which require non-electrolyte distending media such as glycine and sorbitol. Such solutions are however hypotonic so that excessive absorption can cause a number of complications including hyponatremia, a variable degree of hypo-osmolality, and certain solution-specific problems that are described below. Isotonic electrolyte-containing solutions cannot be used with monopolar energy because this leads to activation of ions that disperse the electric current and reduce the power density. Hence the heat generated in tissues is insufficient to destroy or have a tissue effect [2]. Resectoscopes have now been developed to use bipolar electrical current with the advantage that they are compatible with electrolyte-containing distension solutions such as physiological normal saline and Ringer’s lactate. Use of these solutions reduces the risk of hyponatremia, but excessive absorption can, as with monopolar current, lead to expansion of the extracellular fluid volume with the potential to generate fluid overload, pulmonary oedema, hypertension and cardiac failure. Operative hysteroscopy can also be performed using small diameter, continuous flow hysteroscopes which incorporate a small, usually 5Fr or 7Fr, diameter working channel down which mechanical or electrosurgical instruments can be passed. Tissue removal systems refer to operative hysteroscopes that have been designed to simultaneously cut and aspirate tissue from within the uterine cavity. These systems usually incorporate their own fluid monitoring equipment but fluid overload can still occur. Smaller diameter operative hysteroscopes are less likely to cause fluid overload due to smaller diameter inflow channels and the generally less invasive nature of procedures that can be undertaken with such technology. However fluid overload may still occur and vigilance when using any operative hysteroscopic technology is mandatory.

BackgroundThe success rate of in-vitro fertilisation (IVF) remains low and many women undergo multiple treatment cycles. A previous meta-analysis suggested hysteroscopy could improve outcomes in women who have had recurrent implantation failure; however, studies were of poor quality and a definitive randomised trial was needed. In the TROPHY trial we aimed to assess whether hysteroscopy improves the livebirth rate following IVF treatment in women with recurrent failure of implantation.MethodsWe did a multicentre, randomised controlled trial in eight hospitals in the UK, Belgium, Italy, and the Czech Republic. We recruited women younger than 38 years who had normal ultrasound of the uterine cavity and history of two to four unsuccessful IVF cycles. We used an independent web-based trial management system to randomly assign (1:1) women to receive outpatient hysteroscopy (hysteroscopy group) or no hysteroscopy (control group) in the month before starting a treatment cycle of IVF (with or without intracytoplasmic sperm injection). A computer-based algorithm minimised for key prognostic variables: age, body-mass index, basal follicle-stimulating hormone concentration, and the number of previous failed IVF cycles. The order of group assignment was masked to the researchers at the time of recruitment and randomisation. Embryologists involved in the embryo transfer were masked to group allocation, but physicians doing the procedure knew of group assignment and had hysteroscopy findings accessible. Participants were not masked to their group assignment. The primary outcome was the livebirth rate (proportion of women who had a live baby beyond 24 weeks of gestation) in the intention-to-treat population. The trial was registered with the ISRCTN Registry, ISRCTN35859078.FindingsBetween Jan 1, 2010, and Dec 31, 2013, we randomly assigned 350 women to the hysteroscopy group and 352 women to the control group. 102 (29%) of women in the hysteroscopy group had a livebirth after IVF compared with 102 (29%) women in the control group (risk ratio 1·0, 95% CI 0·79–1·25; p=0·96). No hysteroscopy-related adverse events were reported.InterpretationOutpatient hysteroscopy before IVF in women with a normal ultrasound of the uterine cavity and a history of unsuccessful IVF treatment cycles does not improve the livebirth rate. Further research into the effectiveness of surgical correction of specific uterine cavity abnormalities before IVF is warranted.FundingEuropean Society of Human Reproduction and Embryology, European Society for Gynaecological Endoscopy.

Minimally invasive surgery demands specific endoscopic psychomotor skills that are usually acquired outside the operating theatre. We present the results of a systematic analysis to identify how simulation is used during training and qualification in minimal access surgery to improve gynecologist's surgical skills. We found that despite the availability of simulation tools along with methods for training and testing specific endoscopic psychomotor and technical skills, there is no clear evidence of the superiority of one tool or method over the others in skill acquisition. However, prospective studies show that well-guided training courses combined with different trainers and methods improve significantly surgeon's laparoscopic skills and suturing ability, which are unforgettable over time. However, this proficiency could deteriorate over time when it is solely learned and executed on simulation trainers. Structured curricula including theory, simulation, and live-surgery seem to be the best option for trainees. More research in this field is needed.

Myomectomy aims to preserve fertility, treat abnormal uterine bleeding, and alleviate pain. It should cause minimal damage to the endometrium, while being tolerable and durable, and reduce the incidence of myoma recurrence and complications including bleeding, hematoma, adhesions, and gravid uterus perforation. Training and experience are crucial to reduce complications. The surgical strategy depends on imaging information on the myomas. The position of the optical and secondary ports will determine the degree of ergonomic surgery performance, time and difficulty of myoma enucleation, and the suturing quality. Appropriate hysterotomy length relative to myoma size can decrease bleeding, coagulation, and suturing times. Bipolar coagulation of large vessels, while avoiding carbonization and myometrium gaps after suturing, may decrease the risk of myometrial hematoma. Quality surgery and the use of antiadhesive barriers may reduce the risk of postoperative adhesions. Slow rotation of the beveled morcellator and good control of the bag could reduce de novo myoma and endometriosis. Low intra-abdominal CO2 pressure may reduce the risk of benign and malignant cell dissemination. The benefits a patient gains from laparoscopic myomectomy are greater than the complication risks of laparoscopic morcellation. Recent publications on laparoscopic myomectomies demonstrate reduced hospitalization stays, postoperative pain, blood loss, and recovery compared to open surgery.

In laparoscopy, specimens have to be removed from the abdominal cavity. If the trocar opening or the vaginal outlet is insufficient to pass the specimen, the specimen needs to be reduced. The power morcellator is an instrument with a fast rotating cylindrical knife which aims to divide the tissue into smaller pieces or fragments. The Food and Drug Administration (FDA) issued a press release in April 2014 that discouraged the use of these power morcellators. This article has the objective to review the literature related to complications by power morcellation of uterine fibroids in laparoscopy and offer recommendations to laparoscopic surgeons in gynaecology. This project was initiated by the executive board of the European Society of Gynaecological Endoscopy. A steering committee on fibroid morcellation was installed and experienced ESGE members requested to chair an action group to address distinct clinical questions. Clinical questions were formulated with regards to the sarcoma risk in presumed uterine fibroids, diagnosis of sarcoma, complications of morcellation and future research. A literature review on the different subjects was conducted, systematic if appropriate and feasible. It was concluded that the true prevalence of uterine sarcoma in presumed fibroids is not known given the wide range of prevalences (0.45–0.014 %) from meta-analyses mainly based on retrospective trials. Age and certain imaging characteristics such as ‘lacunes’ suggesting necrosis and increased central vascularisation of the tumour are associated with a higher risk of uterine sarcoma, although the risks remain low. There is not enough evidence to estimate this risk in individual patients. Complications of morcellation are rare. Reported are direct morcellation injuries to vessels and bowel, the development of so-called parasitic fibroids requiring reintervention and the spread of sarcoma cells in the abdominal cavity, which may possibly or even likely upstaging the disease. Momentarily in-bag morcellation is investigated as it may possibly prevent morcellation complications. Because of lack of evidence, this literature review cannot give strong recommendations but offers only options which are condensed in a flow chart. Prospective data collection may clarify the issue on sarcoma risk in presumed fibroids and technology to extract tissue laparoscopically from the abdominal cavity should be perfected.

Where histology used the presence of glands and/or stroma in the myometrium as pathognomonic for adenomyosis, imaging uses the appearance of the myometrium, the presence of striations, related to the presence of endometrial tissue within the myometrium, the presence of intramyometrial cystic structures and the size and asymmetry of the uterus to identify adenomyosis. Preliminary reports show a good correlation between the features detected by imaging and the histological findings. Symptoms associated with adenomyosis are abnormal uterine bleeding, pelvic pain (dysmenorrhea, chronic pelvic pain, dyspareunia), and impaired reproduction. However a high incidence of existing comorbidity like fibroids and endometriosis makes it difficult to attribute a specific pathognomonic symptom to adenomyosis. Heterogeneity in the reported pregnancy rates after assisted reproduction is due to the use of different ovarian stimulation protocols and absence of a correct description of the adenomyotic pathology. Current efforts to classify the disease contributed a lot in elucidated the potential characteristics that a classification system should be relied on. The need for a comprehensive, user friendly, and clear categorization of adenomyosis including the pattern, location, histological variants, and the myometrial zone seems to be an urgent need. With the uterus as a possible unifying link between adenomyosis and endometriosis, exploration of the uterus should not only be restricted to the hysteroscopic exploration of the uterine cavity but in a fusion with ultrasound.

Background Increased awareness of leiomyosarcoma (LMS) risk during myomectomy or hysterectomy is essential. Objective and correct reasoning should prevail on any decision regarding the extent and type of surgery to employ. The anticipated risk of a sarcoma after myoma or uterus morcellation is low, and the frequency of leiomyosarcoma especially in women below the age of 40 is very rare. The prevalence data has a wide range and is therefore not reliable. The European Society of Gynaecological Endoscopy (ESGE) initiated a survey among its members looking into the frequency of morcellated leiomyosarcoma after endoscopic surgery. The ESGE Central office sent 3422 members a structured electronic questionnaire with multiple answer choices for each question. After 3 months, the answers were classified with a unique number in the EXCEL spread sheet. Statistical analysis was done using the SPSS v.18. Results Out of 3422 members, 294 (8.6%) gynaecologists replied to the questionnaire; however, only 240 perform myomectomies by laparoscopy and hysteroscopy and hysterectomies by laparoscopy. The reported experience in performing laparoscopic myomectomy, hysteroscopic myomectomy, laparoscopic hysterectomy (LH), and laparoscopic subtotal hysterectomy (LSH) on an average was 10.8 (1–32) years. The vast majority of 67.1% had over 5 years of practice in laparoscopic surgery. The total number of 221 leiomyosarcoma was reported among 429,777 minimally invasive surgeries (laparoscopic and hysteroscopic myomectomies and LH and LSH), performed by all doctors in their lifetime. The overall reported sarcoma risk of all types of endoscopic myoma surgeries has been estimated to be 1.5% of operations which is very rare. Categorizing by type, 57 (0.06%) LMS were operated by laparoscopic myomectomy and 54 (0.07%) by hysteroscopic myomectomy, while 38 (0.13%) leiomyosarcoma operated by laparoscopic subtotal hysterectomy and 72 (0.31%) by laparoscopic hysterectomy. The probability of a sarcoma after morcellation to be falsely diagnosed by histopathology as a benign tumour and later identified as a sarcoma in a later examination has been reported and calculated to be 0.2%. The low risk of a sarcoma is also reflected by the small number of surgeries, where only 32 doctors reported that they operated once, 29 twice, and 18 operated on 3–10 sarcomas by laparoscopy during their lifetime. Conclusion The survey demonstrated that myomectomy by hysteroscopy or laparoscopy has similar risks of sarcoma with an estimated incidence of 0.07%, much lower than that by laparoscopic hysterectomy and subtotal hysterectomy. Hence, for young patients with myoma infertility problem and low risk for LMS, myomectomy by MIS can be the first option of treatment. The fact that only 12.5% (216/1728) of uterine sarcoma cases are operated laparoscopically demonstrates the surgeons’ awareness and alertness about LMS and the potential of spreading sarcomatous cells after myoma/uterus power morcellation.

Background Training of basic laparoscopic psychomotor skills improves both acquisition and retention of more advanced laparoscopic tasks, such as laparoscopic intra-corporeal knot tying (LICK). This randomized controlled trial (RCT) was performed to evaluate the effect of different pre-training programs in hand-eye coordination (HEC) upon the learning curve of LICK. Results The study was performed in a private center in Asunción, Paraguay, by 60 residents/specialists in gynaecology with no experience in laparoscopic surgery. Participants were allocated in three groups. In phase 1, a baseline test was performed (T1, three repetitions). In phase 2, participants underwent different training programs for HEC (60 repetitions): G1 with both the dominant hand (DH) and the non-dominant hand (NDH), G2 with the DH only, G3 none. In phase 3, a post HEC/pre LICK training test was performed (T2, three repetitions). In phase 4, participants underwent a standardized training program for LICK (60 repetitions). In phase 5, a final test was performed (T3, three repetitions). The score was based on the time taken for task completion system. The scores were plotted and non-linear regression models were used to fit the learning curves to one- and two-phase exponential decay models for each participant (individual curves) and for each group (group curves). For both HEC and LICK, the group learning curves fitted better to the two-phase exponential decay model. For HEC with the DH, G1 and G2 started from a similar point, but G1 reached a lower plateau at a higher speed. In G1, the DH curve started from a lower point than the NDH curve, but both curves reached a similar plateau at comparable speeds. For LICK, all groups started from a similar point, but immediately after HEC training and before LICK training, G1 scored better than the others. All groups reached a similar plateau but with a different decay, G1 reaching this plateau faster than the others groups. Conclusions This study demonstrates that pre-training in HEC with both the DH and the NDH shortens the LICK learning curve.

Polyps of the lower reproductive tract are found in 7.8-50% of women. It has been hypothesized that cytogenetic modifications on chromosomes 6, 7 and 12 as well as epigenetic factors involving enzyme and metabolic activities may cause polyps to develop. Cervical polyps found in 2-5% of cases are of low clinical significance and can cause, although rarely, post coital bleedings. Cervical polyps grow during pregnancy and mucorrhoea. Trans vaginal ultrasound (TVU) provides an excellent diagnostic technique to diagnose the size and the anatomic location of endometrial polyps (EPs). In asymptomatic young woman with small EPs

This study evaluated and compared survival, re-expansion, and percentage of live cells of individual Days 5 and 6 human blastocysts that were vitrified and warmed with the Vit Kit Freeze/Thaw (Irvine Scientific, CA), or with two protocols using the Global Fast Freeze/Thaw Kits (LifeGlobal, Canada). Frozen/thawed Day 2–3 or discarded embryos were cultured to blastocyst (culture day 5–6). Group 1 blastocysts were vitrified with the Vit Kit (n = 29) and High Security Vitrification (HSV) devices. Group 2 (n = 47) and Group 3 (n = 48) blastocysts were cryopreserved with the Global Fast Freeze Kit and 0.25 ml straws, using a direct plunge or a −100 °C holding step, respectively. Group 4 (Controls, n = 30) were not vitrified. Blastocysts were subsequently cultured for 24 h, assessed for survival and expansion, and then stained individually with propidium iodide and Hoechst. Live and total cell number was assessed with ImageJ (NIH), and the percentage of live cells calculated for each blastocyst. The percentage of live cells was not different between vitrified and control (non-vitrified) blastocysts, thus vitrification did not affect cell survival. Survival (following thawing and after 24 h culture), re-expansion, and percentage of live cells were not different for blastocysts vitrified and warmed between the two vitrification/warming kits, or between the two protocols for the Global Fast Freeze/Thaw Kits. Blastocyst vitrification can be achieved with equal success using simplified protocols and cheaper and easy to load freezing straws, providing simultaneously increased safety, and efficiency with lower cost, when compared with vitrification using specialized embryo vitrification devices.

The incidence of endometriosis in the infertile female is estimated to be between 20 and 50 %. Although the causal relationship between endometriosis and infertility has not been proven, it is generally accepted that the disease impairs reproductive outcome. Indirect imaging techniques and transvaginal laparoscopy now offer the possibility of an early stage diagnosis. Although it remains debated whether the disease is progressive, treatment in an early stage is recommendable as it carries less risk for ovarian damage, hence premature ovarian failure. Under water, inspection with the technique of transvaginal hydrolaparoscopy (THL) accurately shows the invagination of the ovarian cortex as minimal superficial lesions but with the presence of well-differentiated endometrial like tissue at the base, the lateral walls and especially the inner edges of the small endometrioma. An inflammatory environment is responsible for the formation of connecting adhesions with the broad ligament and lateral wall with invasion of endometrial-like tissue and formation of adenomyotic lesions. In around 50 % of the small endometriomas, adhesiolysis is necessary at the site of invagination with opening of the cyst, to free the chocolate content and hereby recognize the underlying endometrioma. The detailed inspection of these early-stage endometriotic lesions at THL reunites the hypothesis of Sampson with the observation of Hughesdon.

STUDY QUESTION What classification system is more suitable for the accurate, clear, simple and related to the clinical management categorization of female genital anomalies? SUMMARY ANSWER The new ESHRE/ESGE classification system of female genital anomalies is presented. WHAT IS KNOWN ALREADY Congenital malformations of the female genital tract are common miscellaneous deviations from normal anatomy with health and reproductive consequences. Until now, three systems have been proposed for their categorization but all of them are associated with serious limitations. STUDY DESIGN, SIZE AND DURATION The European Society of Human Reproduction and Embryology (ESHRE) and the European Society for Gynaecological Endoscopy (ESGE) have established a common Working Group, under the name CONUTA (CONgenital UTerine Anomalies), with the goal of developing a new updated classification system. A scientific committee (SC) has been appointed to run the project, looking also for consensus within the scientists working in the field. PARTICIPANTS/MATERIALS, SETTING, METHODS The new system is designed and developed based on (i) scientific research through critical review of current proposals and preparation of an initial proposal for discussion between the experts, (ii) consensus measurement among the experts through the use of the DELPHI procedure and (iii) consensus development by the SC, taking into account the results of the DELPHI procedure and the comments of the experts. Almost 90 participants took part in the process of development of the ESHRE/ESGE classification system, contributing with their structured answers and comments. MAIN RESULTS AND THE ROLE OF CHANCE The ESHRE/ESGE classification system is based on anatomy. Anomalies are classified into the following main classes, expressing uterine anatomical deviations deriving from the same embryological origin: U0, normal uterus; U1, dysmorphic uterus; U2, septate uterus; U3, bicorporeal uterus; U4, hemi-uterus; U5, aplastic uterus; U6, for still unclassified cases. Main classes have been divided into sub-classes expressing anatomical varieties with clinical significance. Cervical and vaginal anomalies are classified independently into sub-classes having clinical significance. LIMITATIONS, REASONS FOR CAUTION The ESHRE/ESGE classification of female genital anomalies seems to fulfill the expectations and the needs of the experts in the field, but its clinical value needs to be proved in everyday practice. WIDER IMPLICATIONS OF THE FINDINGS The ESHRE/ESGE classification system of female genital anomalies could be used as a starting point for the development of guidelines for their diagnosis and treatment. STUDY FUNDING/COMPETING INTEREST(S) None.

Purpose: Evidence regarding distinguishing characteristics of women with symptomatic leiomyomas during pregnancy who undergo myomectomy during pregnancy and those who respond to conservative treatment is sparse because it mostly derives from case reports and small patient series. As the first of its type, the present study analyzed the characteristics of women with symptomatic leiomyomas treated with myomectomy during pregnancy and those treated conservatively. Methods: We performed a computer search of medical records from 1 January 2001 to 31 March 2011 using the International Classification of Diseases Codes for pregnancy, myomectomy and leiomyomas during pregnancy. Results: 27 patients were admitted during pregnancy directly related to leiomyomas; 17 of the 27 patients received conservative treatment for symptomatic leiomyomas, and 10 patients had surgery during pregnancy: 3 had undergone diagnostic surgical procedures and 7 myomectomy. Perioperative and postoperative morbidity was low in all women in our sample. Conclusion: In our pilot study, myomectomy during pregnancy was safely performed in carefully selected patients, with subserosal or pedunculated leiomyomas that failed to respond to conservative treatment, with low perioperative and postoperative morbidity.

Post-operative adhesions are frequent sequela of abdominal and gynaecological surgery. They are associated with a high level of morbidity. This “field guideline” was written by a panel of European experts (anti-adhesions in gynecology expert group (ANGEL) and the European Society of Gynaecological Endoscopy (ESGE), adhesion research special interest group. It aims to provide surgeons with a quick reference guide to adhesion prevention adapted to the conditions of their daily practice.

This follow-up RCT was conducted to evaluate laparoscopic psychomotor skills retention after finishing a structured training program. In a first study, 80 gynecologists were randomly allocated to four groups to follow different training programs for hand-eye coordination (task 1) with the dominant hand (task 1-a) and the non-dominant hand (task 1-b) and laparoscopic intra-corporeal knot tying (task 2) in the Laparoscopic Skills Testing and Training (LASTT) model. First, baseline skills were tested (T1). Then, participants trained task 1 (G1: 1-a and 1-b, G2: 1-a only, G3 and G4: none) and then task 2 (all groups but G4). After training all groups were tested again to evaluate skills acquisition (T2). For this study, 2 years after a resting period, 73 participants were recruited and tested again to evaluate skills retention (T3). All groups had comparable skills at T1 for all tasks. At T2, G1, G2, and G3 improved their skills, but the level of improvement was different (G1 = G2 > G3 > G4 for task 1; G1 = G2 = G3 > G4 for task 2). At T3, all groups retained their task 1 skills at the same level than at T2. For task 2, however, a skill decay was already noticed for G2 and G3, being G1 the only group that retained their skills at the post-training level. Training improves laparoscopic skills, which can be retained over time depending on the comprehensiveness of the training program and on the complexity of the task. For high complexity tasks, full training is advisable for both skills acquisition and retention.

Deep infiltrating endometriosis, which is frequently associated with pain, is diagnosed at clinical examination and with indirect imaging techniques like ultrasound and MRI. The aim of this study was to evaluate complications and recurrence rate after laparoscopic resection of deep infiltrating endometriosis by shaving technique. Between January 2004 and December 2010, 74 procedures for deep infiltrating endometriosis were performed in patients with pain and/or infertility. The endometriotic plaques were resected laparoscopically using scissors and bipolar and/or unipolar current. If rectosigmoidal invasion was present, a shaving was performed. Mean age was 31.7 years (SD ± 4.4). The vaginal nodule was a solitary lesion in 4 % of the patients without involvement of the ovaries, rectum or bladder. In 86 % of the cases, the rectosigmoid was involved as well. Mean follow-up was 776 days (SD = 465). One patient developed postoperatively a severe complication with intestinal perforation secondary to thermal necrosis (1.4 %). In four patients recurrence of symptoms was noted (8 %). Conservative surgery for deep infiltrating endometriosis resulted in the relief of pain, with a low postoperative complication rate (1.4 %). This shaving technique also resulted in a limited risk of recurrence of the symptoms (8 %).

In a press release in April 2014, the US Food and Drug Administration [1] discourages doctors from using laparoscopic power morcellators in removing fibroids or myomatotic uteri in order to reduce the risk of sarcomatous cell escape. The USbased company Johnson & Johnson, the largest manufacturer of the devices, halted global sales and distribution of power morcellators, while many hospitals in USA ban the use of morcellation under these circumstances. Patients’ safety and wellbeing especially after surgery is a common and primary concern of surgeons and hospitals; however, there is no reliable way to determine if a uterine fibroid contains a sarcoma prior to removal. Patients should know that the use of laparoscopic power morcellation for hysterectomy or myomectomy may deteriorate their survival rate in case of a sarcoma, and they should discuss the risks and benefits of the available treatment options with their health care professionals. The incidence of uterine sarcomas is extremely low, 0.23% [2], or according to FDA analysis of currently available data (1:350), 0.29 %. They are classified according to histological subtypes in order of decreasing incidence: leiomyosarcomas, endometrial stromal sarcomas (ESS) and ‘other’ sarcomas. The ESS are lesions within the endometrial cavity and diagnosis can be established prior to surgery by endometrial biopsy [3]. The rarity of these tumours has prevented the performance of large epidemiological studies to identify risk factors. Assuming an incidence of uterine sarcomas of 0.23 % by applying the ‘inverse rule of 3’, a surgeonwill need to perform 1304 laparoscopic interventions to observe at least one case of uterine sarcoma with 95 % confidence. Imaging characteristics, tumour markers and other parameters indicating the risk of sarcoma are not available or not specific. In addition, the lack of uniform histologic criteria for diagnosing uterine leiomyosarcoma (ULMS) makes interpretation of the older studies difficult [4]. As the Stanford study [5] was the first to appreciate that the type of necrosis in a uterine smooth muscle tumour was of crucial importance, studies that preceded it did not evaluate the presence or absence of tumour cell necrosis. A leiomyosarcoma usually exhibits diffuse moderate-tosevere atypia, a mitotic count of >10 MFs/10 HPFs and tumour cell necrosis. A tumour with any two of these features V. Tanos :H. Brolmann : R. L. DeWilde : P. O’Donovan :R. Campo Head IVF and Reproductive Surgery, Aretaeio Hospital, Nicosia, Cyprus

The effect of different structured training programs on basic laparoscopic psychomotor skills (LPS), as assessed by hand–eye coordination (HEC), and on advanced LPS, as assessed by laparoscopic intracorporeal knot tying (LICK), was evaluated. Sixty gynecologists without laparoscopic experience were randomly allocated to three groups for different HEC training and similar LICK training. During HEC training, group 1 (G1) trained the dominant hand (DH) and the nondominant hand, G2 trained the DH only, and G3 did not train at all. All groups then underwent LICK training. HEC and LICK training consisted of 60 repetitions of the relevant task. All participants were tested at the beginning of the study (T1), before LICK training (T2), and after LICK training (T3). The time to correctly performed exercise was scored. The groups had comparable scores at T1. At T2, G1 and G2 improved their relevant HEC scores (both hands in G1, DH in G2), and LICK scores improved according to the previous HEC training (G1 > G2 or G3 and G2 > G3). At T3, all groups further improved their LICK scores up to the same level. The LICK training did not provide any additional improvement in HEC for G1 and G2, but it further improved HEC for G3, though not up to the same level of the other groups. This study confirms that training improves laparoscopic skills and indicates that many repetitions are required for reaching proficiency. Full acquisition of LPS (e.g., HEC) facilitates the acquisition of more complex laparoscopic tasks (e.g., LICK). Mastering LICK is not sufficient for acquiring HEC skills, the clinical relevance of which still needs to be evaluated. Mastering both skills before starting a training program in the operating theater is advisable.

To evaluate pregnancy rates after tubal microsurgical anastomosis.Retrospective study.Private tertiary care center.Two hundred sixty-one women undergoing tubal microsurgical anastomosis.Tubal anastomoses were performed by minilaparotomy using microsurgical principles and approximating proximal and distal tubal ends in a two-layer technique with 8-0 ethylon.Pregnancy outcome was analyzed for the technique of sterilization, location of anastomosis, tubal length, age, and semen parameters.After exclusion of 89 patients lost to follow-up (34%) and 8 who did not attempt to conceive, 164 of the 261 patients were analyzed.The overall intrauterine pregnancy rate was 72.5%, with a miscarriage rate of 18% and a tubal pregnancy rate of 7.7%. Related to age, the cumulative intrauterine pregnancy rate was, respectively, 81%, 67%, 50%, and 12.5% for patients36, 36-40, 40-43, and43 years. Mean time to pregnancy was respectively 6.9, 6.2, and 12.7 months, respectively, for patients aged36, 36-39, and 40-43 years According to the type of sterilization, intrauterine pregnancies occurred in 72% after ring sterilization, 78% after clip sterilization, 68% after coagulation, and 67% after Pomeroy sterilization. Intrauterine pregnancies and ectopic pregnancies, respectively, occurred in 80% and 3.4% in the isthmo-isthmic, 63% and 18% in the isthmo-ampullar, 75% and 8.3% in the isthmo-cornual, 100% and 0% in the ampullo-ampullar, and 60% and 0% in the ampullo-cornual anastomosis groups. Tubal length after anastomosis did not influence the pregnancy rate. In case of fertile sperm, the pregnancy rate was found to be 80%, and it decreased to 50% in case of subfertile semen.Our results clearly demonstrate the validity of tubal microsurgical anastomosis, establishing a quasinormalization of the fertility potential and offering the opportunity for a spontaneous conception.

Infertility has been notorious for its time-consuming and prolonged explorations and the resultant delay in diagnosis. This delayed diagnosis adds to the burden of the patient and, in spite of the higher pregnancy rate and lower cost reported with traditional treatment algorithm as first-line therapy compared with liberal referral to assisted reproduction technologies (ART) (Karande et al., 1999), has stimulated physicians and specialized centres to promote the latest approach. This strategy has the additional problem, especially for developing countries, that ART carry a higher risk of neonatal and maternal morbidity than natural conception, even in the absence of multiple pregnancy (Helmerhorst et al., 2004; Ombelet et al., 2005, 2006). Recent observations demonstrate that exploration of the female reproductive tract is not only useful for diagnosis and treatment but also necessary for enhancing the in vitro fertilization—embryo transfer (IVF-ET) results. Indeed, a Cochrane review including three RCT shows that laparoscopic salpingectomy prior to IVF-ET in patients with hydrosalpinges improves pregnancy, ongoing pregnancy and live birth rates (Johnson et al., 2002). Furthermore, the incremental cost of the surgical intervention to achieve this higher live birth rate was reported to be beneficial (Strandell et al., 2005). Everybody agree on the value of an accurate exploration of the female reproductive tract for the management of infertility but opinions greatly differ as how and to which extent these investigations should be performed. In current practice hysterosalpingography (HSG) is still used as a first-line investigation, although it is not a pain-free (Tur-Kaspa et al., 1998) and riskfree procedure and even when its sensitivity, specificity and prognostic values for the management of the infertility are debatable (Glatstein et al., 1997; Swart et al., 1995; Mol et al., 1997, 1999). This option is largely based on the absence of alternatives since endoscopic procedures (e.g. conventional laparoscopy and hysteroscopy) demanding high skills and sophisticated equipments do not fulfil the criteria of being minimally invasive, affordable and accessible. Although conventional laparoscopy is considered the gold standard for the exploration of the female reproductive tract, it is for several reasons not suitable as a first-line investigational technique. Laparoscopy is an expensive procedure requiring hospitalization, operating room and general anaesthesia, as in open abdominal surgery. The procedure is invasive and not without morbidity and mortality. Indeed, even in experienced hands the blind transabdominal access can cause major blood vessel and bowel injury (Jansen et al., 1997; Brosens et al., 2003), whereas the distension medium (i.e. CO2 pneumoperitoneum) causes discomfort and additional hazards (Molinas and Koninckx, 2000; Molinas et al., 2001; Nguyen et al., 2002; Kissler et al., 2004). Furthermore, the see-and-treat possibility of laparoscopy requires the presence of a high skilled reproductive surgeon at the diagnostic screening procedure, which is not always feasible. The exploration of the female reproductive tract should be as easy as HSG and as accurate as standard laparoscopy. No conclusive answer has been given until now, but the transvaginal ultrasound and endoscopic procedures offer probably the most efficient and accurate solution to the problem. The challenge is for both developed as developing countries identical: to find a low cost and easily accessible diagnostic procedure with operative possibilities for offering the fastest and minimal invasive lane to pregnancy. In this article we outline a challenging concept for the management of infertility in both developed and developing countries: a model based on ambulatory endoscopic techniques (i.e. modern mini-hysteroscopy and transvaginal laparoscopy) for the exploration of the female reproductive tract, describing their diagnostic and operative possibilities and limitations.

It is generally accepted that intrauterine insemination (IUI) should be preferred to more invasive and expensive techniques of assisted reproduction and be offered as a first-choice treatment in cases of unexplained and moderate male factor subfertility. Scientific validation of this strategy is rather difficult because literature is rather confusing and not conclusive. IUI is proven easier to perform, less invasive and less expensive than other methods of assisted reproduction. Effectivity has been documented in controlled studies under the condition that the inseminating motile count exceeds more than 1 million motile spermatozoa. Risks are minimal, provided the multiple gestation incidence can be reduced to an acceptable level and provided at least one tube is patent. Therefore, in developing countries, reflection on the implementation and use of IUI as a first-line treatment for most cases of non-tubal infertility seems mandatory. The costs are minimal, training is easy, quality control possible and severe complications are almost non-existing. In cases of unexplained infertility or combined male subfertility and ovulatory dysfunction, correction and/or ovarian stimulation with clomiphene citrate (CC) is probably the best strategy from a cost-benefit point of view unless CC-resistancy has been proven in which the use of low-dose gonadotrophins is necessary.

The apprentice–tutor model was useful for training surgeons for many years, but the complexity of surgical technology in the 21st century, especially endoscopic surgery, has exponentially increased the demands for surgical education. Therefore, more and more people now accept that endoscopic surgery, demanding as it requires specific skills, should also be taught outside the operating theatre. Although many systems, including animal models and simulators, have been proposed, an in-house structured and validated method for testing and training laparoscopic skills is missing in gynaecology. We have developed a laparoscopic skills testing and training (LASTT) model and performed two studies evaluating its feasibility and the construct validity of three different exercises (camera navigation, camera navigation and forceps handling, and forceps handling and bi-manual coordination), specifically selected to test and train laparoscopic psychomotor skills (LPS). In the first study, ten experts and 14 novices repeated each exercise between 20 and 30 times. The results demonstrated that the model is useful for testing and training laparoscopic skills. Clear learning curves were observed for both experts and novices, with better scores for the former at the beginning and the end of the study, proving the construct validity of the model. In the second study, 42 experts and 241 novices repeated each exercise three times during skill evaluation workshops organised by the European Academy of Gynaecological Surgery. The results confirmed the construct validity of the model. In conclusion, the LASTT model seems a cost-effective tool for providing an in-house program for continuous training and evaluation of LPS in all surgical disciplines in which laparoscopic procedures are, or might be, performed.

Transvaginal laparoscopy offers an accurate and minimally invasive method for the exploration of the female pelvis in patients with infertility. Access to the pouch of Douglas is gained through a simple needle puncture technique of the posterior fornix using a pre-warmed watery solution as the distension medium. A review of recently published papers and our own experience illustrate the safety of the technique. Transvaginal laparoscopy can be considered as one of the first and safest examples of the recent developments in natural orifice transluminal endoscopic surgery (NOTES).

Objective The purpose of the present review is to provide a survey of the various measures of preventing adhesions used in hysteroscopic surgery. Study Design A systematic computerized literature search was conducted to provide a survey of the various measures used in hysteroscopic surgery to prevent adhesions. Finally, 29 studies were included in the analysis, showing a wide variety of methods and agents advocated in international literature. They are explained in various sections, based on the IUA prevention approach adopted (surgical technique, early second-look hysteroscopy, barrier method, pharmacological therapy). Results The results of our review show that (i) use of surgical techniques which reduce the use of electrosurgery should be preferred whenever possible (Level of evidence: 4); (ii) an early second-look hysteroscopy would appear to be an effective preventive, as well as therapeutic, strategy regarding IUA but studies on the topic are too few for relevant evidence; (iii) barriers methods are the most widely used and, among these, gel barriers have been proven to have a significant clinical effect on IUA prevention, because of higher adhesiveness and prolonged residence time on the injured surface (Level of evidence: 1b); (iv) the role of hormonal and antibiotic therapy in the prevention of post-operative IUA is difficult to evaluate as it has been used in association with other prevention strategies in most studies included in our review. Conclusions Robust and high quality randomized trials to assess the effectiveness of different anti-adhesion therapies are still needed before one or more of these strategies may be strongly recommended for improving clinical outcomes in women treated by operative hysteroscopy.

STUDY QUESTION: What is the recommended diagnostic work-up of female genital anomalies according to the European Society of Human Reproduction and Embryology (ESHRE)/European Society for Gynaecological Endoscopy (ESGE) system? SUMMARY ANSWER: The ESHRE/ESGE consensus for the diagnosis of female genital anomalies is presented. WHAT IS KNOWN ALREADY: Accurate diagnosis of congenital anomalies still remains a clinical challenge because of the drawbacks of the previous classification systems and the non-systematic use of diagnostic methods with varying accuracy, some of them quite inaccurate. Currently, a wide range of non-invasive diagnostic procedures are available enriching the opportunity to accurately detect the anatomical status of the female genital tract, as well as a new objective and comprehensive classification system with well-described classes and sub-classes. STUDY DESIGN, SIZE, DURATION: The ESHRE/ESGE CONgenital UTerine Anomalies (CONUTA) Working Group established an initiative with the goal of developing a consensus for the diagnosis of female genital anomalies. The CONUTA working group and imaging experts in the field have been appointed to run the project. PARTICIPANTS/MATERIALS, SETTING, METHODS: The consensus is developed based on: (i) evaluation of the currently available diagnostic methods and, more specifically, of their characteristics with the use of the experts panel consensus method and of their diagnostic accuracy by performing a systematic review of evidence and (ii) consensus for the definition of where and how to measure uterine wall thickness and the recommendations for the diagnostic work-up of female genital anomalies, based on the results of the previous evaluation procedure, with the use of the experts panel consensus method. MAIN RESULTS AND THE ROLE OF CHANCE: Uterine wall thickness is defined as the distance between the interostial line and external uterine profile at the midcoronal plane of the uterus; alternatively, if a coronal plane is not available, the mean anterior and posterior uterine wall thickness at the longitudinal plane could be used. Gynecological examination and two-dimensional ultrasound (2D US) are recommended for the evaluation of asymptomatic women. Three-dimensional (3D) US is recommended for the diagnosis of female genital anomalies in 'symptomatic' patients belonging to high risk groups for the presence of a female genital anomaly and in any asymptomatic woman suspected to have an anomaly from routine evaluation. Magnetic resonance imaging (MRI) and endoscopic evaluation are recommended for the subgroup of patients with suspected complex anomalies or in diagnostic dilemmas. Adolescents with symptoms suggestive for the presence of a female genital anomaly should be thoroughly evaluated with 2D US, 3D US, MRI and endoscopically. LIMITATIONS, REASONS FOR CAUTION: The various diagnostic methods should always be used in the proper way and evaluated by experts to avoid mis-, over- and underdiagnosis. WIDER IMPLICATIONS OF THE FINDINGS: The role of a combined US examination and outpatient hysteroscopy should be prospectively evaluated. It is a challenge for further research, based on diagnosis, to objectively evaluate the clinical consequences related to various degrees of uterine deformity. STUDY FUNDING/COMPETING INTERESTS: None.

There is molecular evidence that endometriosis has a negative impact on the ovaries, although the exact pathophysiology concerning endometriosis-associated subfertility is not known. The negative impact on the tubo-ovarian unit can be directly by distorting the anatomy, indirectly by invoking inflammation or by oxidative damage with poorer-quality oocytes. Endometriosis even seems to have a negative effect on pregnancy outcome after in vitro fertilization.