Current controversies in tubal disease, endometriosis, and pelvic adhesion

Factors related to clearance of the small pelvic cavity during gynecologic laparoscopic surgery

AIM

To identify factors influencing the Trendelenburg angle required during laparoscopic gynecological surgery.

METHODS

Patients who underwent laparoscopic surgery at a single university hospital between May 1, 2019, and March 31, 2021 were enrolled. Data were extracted from the medical records, while magnetic resonance imaging scans and all laparoscopic surgery videos were retrospectively reviewed to assess the presence of the small intestine in the pelvic cavity as well as the adhesions at each site. Groups with and without the small intestine in the pelvic cavity, and those requiring a Trendelenburg angle above or below 13° were compared.

RESULTS

In total, 219 patients were examined. The Trendelenburg angle was significantly higher (p = 0.004), while a significant increase in ovarian adhesions was observed (p = 0.033; odds ratio [OR], 2.30; 95% confidence interval [CI], 1.05-5.01) in the group without the presence of the small intestine in the pelvic cavity. Furthermore, the group requiring a Trendelenburg angle of ≥13° had significantly thicker subcutaneous fat (p = 0.044) and more ileal adhesions (p = 0.040, OR, 1.82; 95% CI, 1.03-3.23) than the group with an angle of <13°.

CONCLUSION

Cases of ileal adhesions or thick subcutaneous fat are more likely to require a Trendelenburg angle of ≥13°. Therefore, Trendelenburg complications should be considered in this group. In addition, ovarian adhesions make it more difficult to exclude the small intestine from the small pelvic cavity, and may be associated with endometriosis.

Study on diagnosis and management strategies on heterotopic pregnancy: a retrospective study

Heterotopic pregnancy (HP) is a rare but potentially life-threatening event with a high risk of maternal death, which also jeopardise the coexisting intrauterine pregnancy (IUP), thus an early accurate diagnosis and prompt treatment can decrease adverse complications. We aimed to explore the early predictors for pregnancy outcomes of HP. We reviewed patients with HP following assisted reproductive technology in our institution between January 2013 and December 2020. The relationships between pregnancy outcomes and clinical features were analysed by logistic regression. We found that 29 patients (72.5%) of HP were accurately diagnosed by transvaginal ultrasonography (TVS). Eighteen patients in the surgery group had live births, three of whom delivered preterm. Additionally, the miscarriage rate was lower for patients with IUP cardiac activity than those without (16.7% vs. 90.0%, p < .001). Further by logistic regression analysis, an IUP with cardiac activity at HP diagnosis was identified as favourable independent predictor of live birth (p < .001). Therefore, early diagnosis and prompt surgical intervention are recommended to prevent the development of HP.Impact of statementWhat is already known on this subject? Heterotopic pregnancy (HP) has long been thought to be a rare but potentially life-threatening event with a high risk of complications. The early diagnosis of HP is challenging due to the co-existence of a viable intrauterine pregnancy (IUP) and the absence of typical clinical symptoms.What do the results of this study add? This stduy showed that symptoms combined with routine transvaginal ultrasonography (TVS) scans reduce the rates of misdiagnosis of HP and prompt surgical intervention after diagnosis may minimise the incidence of miscarriage of the IUP.What are the implications of these findings for clinical practice and/or further research? An IUP with cardiac activity at HP diagnosis is a predictor of a favourable prognosis of HP, and laparoscopy under general anaesthesia is effective and safe during the first trimester of pregnancy. Awareness, assessment and early interventions in view of symptoms combined with routine TVS is recommended to reduce the risk of miscarriage and ensure a favourable live birth rate.

[Impact of Endometriosis on the Therapeutic Effect of Hysteroscopic Fallopian Tube Catheterization Combined With Laparoscopy in Infertile Patients With Proximal Tubal Obstruction]

Objective

To investigate the impact of endometriosis on the therapeutic effect of hysteroscopic fallopian tube catheterization combined with laparoscopy in infertile patients with proximal tubal obstruction.

Methods

We conducted a retrospective analysis of patients who underwent hysteroscopic fallopian tube catheterization combined with laparoscopy for infertility caused by proximal fallopian tube obstruction between January 19, 2016 and March 20, 2020 at the Department of Reproductive Endocrinology, West China Second Hospital, Sichuan University. During the operation, hydrotubation was performed to verify whether there was proximal tubal obstruction. Then, the patients were categorized into an endometriosis group and a non-endometriosis group according to whether their proximal tubal obstruction was combined with endometriosis. The baseline data were balanced by propensity score matching and the rate of successful surgical unblocking of proximal tubal obstruction in infertile patients by hysteroscopic fallopian tube catheterization combined with laparoscopy was calculated. Treating cases lost to follow-up in both groups as non-pregnant cases according to the principle of intention-to-treat analysis, we followed up the pregnancy outcomes after surgery. The primary indicators included overall successful surgical unblocking rate, clinical pregnancy rate, and spontaneous pregnancy rate, while the secondary indicators included live birth rate, miscarriage rate, ectopic pregnancy rate, and the mean time to spontaneous pregnancy after surgery. The primary indicators included overall successful surgical unblocking rate, clinical pregnancy rate, and spontaneous conception rate, while the secondary indicators included live birth rate, miscarriage rate, ectopic pregnancy rate, and the mean time to spontaneous pregnancy after surgery.

Results

After propensity score matching, 113 cases were included in each of the two groups, with the overall successful surgical unblocking rate being 72.6%. The successful surgical unblocking rate of patients in the endometriosis group was higher than that of the non-endometriosis group, with the difference being statistically significant (78.8% vs. 66.4%, P<0.05). A total of 38 patients were lost after follow-up matching. Postoperative follow-up was performed to date and, through intention-to-treat analysis, the spontaneous conception rate was found to be higher in the endometriosis group than that in the non-endometriosis group (44.2% vs. 30.1%, P<0.05), while the mean time to spontaneous pregnancy after surgery was shorter in the endometriosis group than that in the non-endometriosis group (46 months vs. 53 months, P<0.05). There was no significant difference in clinical pregnancy rate, live birth rate, miscarriage rate, and ectopic pregnancy rate between the endometriosis group and the non-endometriosis group ( P>0.05).

Conclusion

When infertility caused by proximal tubal obstruction is combined with endometriosis, performing hysteroscopic fallopian tube catheterization combined with laparoscopy contributes to the improvement of reproduction outcomes.

Reproductive surgery: revisiting its origins and role in the modern management of fertility

For years, reproductive surgery was the mainstay of reproductive care. With the evolution and ultimate success of in vitro fertilization (IVF), reproductive surgery became an adjuvant therapy, indicated mainly for severe symptoms or to enhance success rates with assisted reproductive technologies. As success rates for IVF have plateaued, and emerging data rekindles the enormous benefits of surgically correcting reproductive pathologies, there is renewed interest among reproductive surgeons in reviving research and surgical expertise in this area. In addition, new instrumentation and surgical techniques to preserve fertility have gained traction and will solidify the need to have skilled reproductive endocrinology and infertility surgeons in our practice.

A novel machine learning model for predicting clinical pregnancy after laparoscopic tubal anastomosis

BACKGROUND

Laparoscopic tubal anastomosis (LTA) is a treatment for women who require reproduction after ligation, and there are no reliable prediction models or clinically useful tools for predicting clinical pregnancy in women who receive this procedure. The prediction model we developed aims to predict the individual probability of clinical pregnancy in women after receiving LTA.

METHODS

Retrospective analysis of clinical data of patients undergoing LAT in the Second Hospital of Lanzhou University from July 2017 to December 2021. Least absolute shrinkage and selection operator (LASSO) regression was used for data dimension reduction and feature selection. We incorporated the patients' basic characteristics, preoperative laboratory tests and laparoscopic tubal anastomosis procedure signature and obtained a nomogram. The model performance was evaluated in terms of its calibration, discrimination, and clinical applicability. The prediction model was further internally validated using 200 bootstrap resamplings.

RESULTS

A total of 95 patients were selected to build the predictive model for clinical pregnancy after LTA. The LASSO method identified age, intrauterine polyps, pelvic adhesion and thyroid stimulating hormone(TSH) as independent predictors of the clinical pregnancy rate. The prediction nomogram included the abovementioned four predictive parameters. The model showed good discrimination with an area under the curve (AUC) value of 0.752. The Hosmer‒Lemeshow test of calibration showed that χ2 was 4.955 and the p value was 0.838, which indicates a satisfactory goodness-of-fit. Decision curve analysis demonstrated that the nomogram was clinically useful. Internal validation shows that the predictive model performs well.

CONCLUSION

This study presents a nomogram incorporating age, intrauterine polyps, pelvic adhesion and TSH based on the LASSO regression model, which can be conveniently used to facilitate the individualized prediction of clinical pregnancy in women after LTA.

An Overview of Postoperative Intraabdominal Adhesions and Their Role on Female Infertility: A Narrative Review

Postoperative intraabdominal adhesions can occur after more than 90% of gynecologic surgeries. They not only cause chronic pelvic pain and small bowel obstruction, but are also one of the main reasons for infertility. Adhesions are not only a burden for the affected patients, but are also a burden for the healthcare system, since the treatment of adhesion-associated complications costs a considerable amount of money. The gold standard for the diagnosis of adhesions is by laparoscopy, although other methods, such as transvaginal hydro-laparoscopy, are being discussed as better alternatives. Ideally, adhesions are avoided inherently, by operating carefully and by using microsurgical principles. If this is not possible, gel barriers have been shown to be successful in reducing postoperative adhesions.

Status and related factors of postoperative recurrence of ovarian endometriosis: a cross-sectional study of 874 cases

PURPOSE

Exploring the status and related factors of postoperative recurrence of ovarian endometriosis.

METHODS

This study analyzed the results of questionnaires conducted in 27 hospitals across the country from January 2019 to November 2021. All women were divided into recurrence group and non-recurrence group to analyze the recurrence rate and related factors after ovarian endometriosis surgery.

RESULTS

The recurrence rates of ovarian endometriosis within 1 year, 1-2 years, 2-3 years, 3-4 years, 4-5 years and more than 5 years were 6.27%, 35.85%, 55.38%, 65.00% and 56.82%, respectively. Significant differences were found between two groups in terms of age at surgery (OR: 0.342, 95%CI: 0.244-0.481, P < 0.001), presence of dysmenorrhea (OR: 1.758, 95%CI: 1.337-2.312, P < 0.001), presence of adenomyosis (OR: 1.948, 95%CI: 1.417-2.678, P < 0.001) and family history of endometriosis or adenomyosis (OR: 1.678, 95%CI: 1.035-2.721, P = 0.021). The age at surgery (OR: 0.358, 95%CI: 0.253-0.506, P < 0.001), presence of dysmenorrhea (OR: 1.379, 95%CI: 1.026-1.853, P = 0.033) and presence of adenomyosis (OR: 1.799, 95%CI: 1.275-2.537, P = 0.001) were significantly associated with endometrioma recurrence in multivariate analysis. No significant associations were found between the recurrence rate and body mass index (BMI), educational background, age of menarche, gravida, parity, uterine leiomyoma, endometrial polyps or postoperative use of gonadotropin-releasing hormone agonist (GnRH-a).

CONCLUSIONS

Dysmenorrhea and presence of adenomyosis are independent risk factors for postoperative recurrence of ovarian endometriosis, and older age is an independent protective factor for postoperative recurrence.

Evaluation and Management of Infertility for Patients Without Insurance Coverage

Infertility is a common condition which causes substantial patient distress and prompts patients to seek care in outpatient gynecologic offices. The evaluation and treatment of infertility can be costly and insurance coverage for these services varies widely. Obstetrician-gynecologists and other women's health care professionals often struggle with the approach for patients without insurance coverage for infertility care. This article reviews the status of insurance coverage for infertility services, reviews options for both the evaluation and management of infertility for patients who do not have infertility insurance coverage, and provides resources for ongoing advocacy and support for these patients.

Diagnosis and treatment of tubal endometriosis in women undergoing laparoscopy: A case series from a single hospital

BACKGROUND

Tubal endometriosis (TEM) is a category of pelvic endometriosis (EM) that is characterized by ectopic endometrial glands and/or stroma within any part of the fallopian tube. The fallopian tubes may be a partial source of ovarian endometriosis (OEM). TEM is difficult to diagnose during surgery and is usually detected by pathology after surgery.

AIM

To provide a clinical basis for the diagnosis and treatment of TEM.

METHODS

In this study, the data of 30 patients who underwent laparoscopic salpingectomy due to various gynecological diseases and had pathological confirmation of TEM at our hospital were retrospectively analyzed, and the clinical basis for the diagnosis and treatment of TEM was evaluated.

RESULTS

Among 1982 surgical patients, 30 met the study criteria. Among those, 6 patients had a history of infertility, 12 patients had a history of artificial abortion, 13 patients had a history of cesarean section, 1 patient had a history of tubal ligation, 4 patients had an intrauterine device, and 22 patients had hydrosalpinx. Sixteen patients (53.33%) conceived naturally and gave birth to healthy babies. Pathology showed that only 2 patients had TEM without any other gynecological diseases, while the others all had simultaneous diseases, including 26 patients with EM at other pelvic sites.

CONCLUSION

The final diagnosis of TEM depends on pathological examination since there are no specific clinical characteristics. The rate of TEM combined with EM (especially OEM) was higher than that of other gynecological diseases, which indicates that TEM is related to OEM.

Is There Still a Place for Reconstructive Surgery in Distal Tubal Disease?

Tubal diseases account for 25–40% of female factor infertility. Mainly, they involve the distal part of the fallopian tube, and hydrosalpinx is the most severe manifestation. Usually, the management decision is made between reconstructive surgery and ART, depending on the severity of the tubal damage, patient age, ovarian reserve, and seminogram, as well as financial, religious, ethical, and psychological factors. Estimated live-birth rates after corrective surgery range from 9% to 69%. The success rate of IVF is about 30% live-birth rate per cycle initiated in women across all ages with tubal factor infertility. Surgery offers a long-term cure and patients may attempt conception many times but are burdened with perioperative adverse events. IVF bypasses potential complications of operative treatment; however, this has its own unique risks. The effectiveness of reconstructive surgery versus ART has not been adequately evaluated. The success of fertility management depends on a thorough interpretation of existing data and careful patient selection. The presented review provides updates on the most recent progress in this area.

Increased serum LOXL2 concentration in pelvic inflammatory disease with pelvic adhesion

Background

Lysyl oxidase-like 2 (LOXL2) belongs to a family of the LOX secretory enzyme, which involves the cross-linkage of extracellular matrix (ECM) proteins. Here, we aimed to analyze the correlation between serum LOXL2 and pelvic adhesion in chronic pelvic inflammatory disease (PID).

Methods

A total of 143 patients with PID and 130 healthy controls were included in this study. The serum levels of LOXL2 were measured using enzyme-linked immunosorbent assay (ELISA) kits. The patients were divided into non-adhesion group (102 cases) and adhesion group (41 cases).

Results

It was found that the serum level of LOXL2 expression was elevated in PID patients compared with healthy controls, and was elevated in PID patients with pelvic adhesion compared to patients without adhesion. In all PID patients, serum LOXL2 level was positively correlated with matrix metalloproteinases-9 (MMP-9), transforming growth factor-β (TGF-β1), whole blood viscosity (WBV) at low shear rate (LSR), WBV at high shear rate (HSR), and hematocrit (HcT). Multivariate logistic regression analysis showed that serum LOXL2 level was an independent risk factor for pelvic adhesion in PID patients (OR = 1.058; 95% CI = 1.030–1.086, P < 0.001).

Conclusions

Serum LOXL2 level not only predicts the presence of PID, but serum LOXL2 concentration is also associated with the presence of pelvic adhesions.

The role of gut and genital microbiota and the estrobolome in endometriosis, infertility and chronic pelvic pain

BACKGROUND

Endometriosis is a chronic, burdensome condition that is historically understudied. Consequently, there is a lack of understanding of the etiology of the disease and its associated symptoms, including infertility and chronic pelvic pain (CPP). Endometriosis development is influenced by estrogen metabolism and inflammation, which are modulated by several factors including the microbiome and the estrobolome (the collection of genes encoding estrogen-metabolizing enzymes in the gut microbiome). Therefore, there is increasing interest in understanding the role of microbiota in endometriosis etiology.

OBJECTIVE AND RATIONALE

To date, there is no cure for endometriosis and treatment options often are ineffective. This manuscript will review the potential relationship between the microbiome and endometriosis, infertility and CPP and highlight the available data on the microbiome in relation to endometriosis and its related symptoms. The overarching goal of this manuscript is to inform future microbiome research that will lead to a deeper understanding of the etiology of the disease and possible diagnostic modalities and treatments. The potential impact of the microbiome on estrogen regulation modulated by the estrobolome, as well as inflammation and other endometriosis-promoting mechanisms within the genital tract, will be reviewed. The methodological limitations of microbiome-related studies will be critically assessed to provide improved guidelines for future microbiome and clinical studies.

SEARCH METHODS

PubMed databases were searched using the following keywords: endometriosis AND microbiome, infertility AND microbiome, pelvic pain AND microbiome, IVF (in-vitro fertilization) AND microbiome, endometriosis AND infertility. Clinical and preclinical animal trials that were eligible for review, and related to microbiome and endometriosis, infertility or CPP were included. All available manuscripts were published in 2002-2021.

OUTCOMES

In total, 28 clinical and 6 animal studies were included in the review. In both human and animal studies, bacteria were enriched in endometriosis groups, although there was no clear consensus on specific microbiota compositions that were associated with endometriosis, and no studies included infertility or CPP with endometriosis. However, bacterial vaginosis-associated bacteria and Lactobacillus depletion in the cervicovaginal microbiome were associated with endometriosis and infertility in the majority (23/28) of studies. Interpretation of endometrial studies is limited owing to a variety of methodological factors, discussed in this review. In addition, metadata outlining antibiotic usage, age, race/ethnicity, menopausal status and timing of sample collection in relation to diagnosis of endometriosis was not consistently reported. Animal studies (6/6) support a bidirectional relationship between the gut microbiota and endometriosis onset and progression.

WIDER IMPLICATIONS

There is evidence that a dysbiotic gut or genital microbiota is associated with multiple gynecologic conditions, with mounting data supporting an association between the microbiome and endometriosis and infertility. These microbiomes likely play a role in the gut-brain axis, which further supports a putative association with the spectrum of symptoms associated with endometriosis, including infertility and CPP. Collectively, this review highlights the demand for more rigorous and transparent methodology and controls, consistency across the field, and inclusion of key demographic and clinical characteristics of disease and comparison participants. Rigorous study designs will allow for a better understanding of the potential role of the microbiome in endometriosis etiology and the relationship to other disorders of the female reproductive tract.

Role of ultrasonographic parameters for predicting tubal involvement in infertile patients affected by endometriosis: A retrospective cohort study

INTRODUCTION

Transvaginal ultrasound is fundamental for the mapping of endometriosis, and the imaging criteria have been clearly described for different organs study. However, no specific ultrasonographic signs of tubal endometriosis have been reported, with the exception of hydrosalpinx, which is the expression of an extreme tubal damage and obstruction. The detection of tubal pathology in infertile patients is fundamental, therefore the aim of the study was to evaluate incidence of tubal endometriosis in infertile patients, and to analyze ultrasonographic signs useful for detection of this condition.

MATERIAL AND METHODS

It is a single-center, retrospective cohort study. All 500 consecutive infertile women who underwent laparoscopic surgery for endometriosis were included. The preoperative workup included transvaginal ultrasound and was compared to intraoperative findings and histologic study.

RESULTS

The incidence of tubal endometriosis in our study was 8%. Using hydrosalpinx as the ultrasonographic marker for tubal involvement the overall pooled, sensitivity and specificity of TVU were 12% (95%CI, 5-23%) and 99% (95%CI, 98-100%), respectively. If at least one ultrasonographic parameter like hydrosalpinx, periadnexal adhesions or ovarian cyst was considered as a sign of tubal endometriosis, a sensitivity, VPN and specificity were 94% (95% IC, 85-98%), 97% (95%IC, 93-99%) and 31% (95%CI, 27-36%), respectively.

DISCUSSION

Hydrosalpinx as ultrasonographic sign alone is characterized by a high specificity but low sensitivity for detection of tubal endometriosis; its sensitivity can be improved by the addition of other markers such as endometrioma and/or periadnexal adhesions.

Is Chronic Endometritis Associated with Tubal Infertility? A Prospective Cohort Study

STUDY OBJECTIVE

Chronic endometritis (CE), which often presents asymptomatically, is associated with recurrent pregnancy loss, recurrent implantation failure after in vitro fertilization, and endometriosis. Data connecting CE with fallopian tubal occlusion are limited. The aim was to assess a potential association of CE, defined by the presence of syndecan-1 (CD138)-positive plasma cells in endometrial tissue samples, with fallopian tube patency and other factors for infertility, including endometriosis, adenomyosis, and hydrosalpinges.

DESIGN

Prospective, monocentral pilot study.

SETTING

Tertiary care center.

PATIENTS

A cohort of 100 women who were infertile was enrolled from July 2019 to December 2020.

INTERVENTIONS

Hysteroscopy with endometrial biopsy and laparoscopy with chromopertubation.

MEASUREMENTS AND MAIN RESULTS

CE was found in 13 women (13.0%) and was associated with endometriosis (p = .034) and unilateral/bilateral fallopian tube blockage (p = .013). In women with endometriosis, the mean number of CD138-positive cells was positively correlated with the revised American Society for Reproductive Medicine score (r = .302, p = .028). In a binary regression model, the presence of a hydrosalpinx on one or both sides (odds ratio 15.308; 95% confidence interval, 1.637-143.189; p = .017) and the finding of CE in the endometrial tissue sample (odds ratio 5.273; 95% confidence interval, 1.257-22.116; p = .023) were significantly associated with fallopian tubal occlusion.

CONCLUSION

CE was significantly associated with blockage of the fallopian tubes and endometriosis. Endometriosis stage was associated with the number of CD138-positive cells in endometrial biopsies.

Bedeutung der Fertilitätschirurgie bei Kinderwunsch

Die Bedeutung der Fertilitätschirurgie bei Kinderwunsch kann vielfach aufgrund fehlender eigener Erfahrung während der Facharztweiterbildung nicht erfasst werden, da nur an wenigen Zentren eine spezifische operative Ausbildung erfolgt. Neben der Abklärung anatomischer Fehlbildungen mittels Hysteroskopie bzw. Laparoskopie gehört die operative Myom- und Endometriosebehandlung zu den Standardverfahren der Fertilitätschirurgie. Hier ist die Erfahrung der Reproduktionsmediziner gefragt, damit unter maximaler Schonung der Ovarreserve ein bestmöglichstes Ergebnis hinsichtlich Endometriosesanierung bzw. Myomenukleation erreicht wird. Die Abklärung der Tubendurchgängigkeit mit Chromopertubation ist nach wie vor Goldstandard, auch wenn im ambulanten Sektor vorwiegend nichtoperative Verfahren zum Einsatz kommen. Die diagnostische und gegebenenfalls operative Hysteroskopie dient der Beurteilung des Endometriums und erlaubt den Ausschluss von Entzündungsprozessen oder dem Vorliegen von Polypen.

Role of tubal surgery in the era of assisted reproductive technology: a committee opinion

This document reviews surgical options for reparative tubal surgery and the factors that must be considered when deciding between surgical repair and in vitro fertilization. This document replaces the document of the same name, last published in 2012 (Fertil Steril 2015;103:e37-43). This document reviews surgical options for reparative tubal surgery and the factors that must be considered when deciding between surgical repair and in vitro fertilization.

Tubal infertility and pelvic adhesion increase risk of heterotopic pregnancy after in vitro fertilization: A retrospective study

To analyze risk factors associated with heterotopic pregnancy and the uterine pregnant outcome of those patients after surgery.We retrospectively analyzed 22 patients diagnosed as HP after in vitro fertilization (IVF) between January 2015 and December 2018.HP was diagnosed at gestation age of 55.4 ± 11.8 days. HP were presented as irregular vaginal bleeding, abdominal pain, and sometimes no symptoms. 81.8% of ectopic lesion in HP occurred at fallopian tubes, especially ampullary; cornual pregnancy takes up 13.6%. Compared with clinical intrauterine pregnancy (IUP), IVF with tubal infertility factors had higher risks of HP (OR 4.185, 95% CI 1.080- 16.217); IVF with pelvic adhesion also had higher risks of HP (OR 5.552 95% CI 1.677-18.382); IVF with more than 2 embryos transferred increased risks of HP (OR 23.253, 95% CI 1.804-299.767). The abortion rates of surgery-treated HP and IUP after IVF were 27.8% versus 10.3% (P = .042).These results demonstrate IVF with tubal infertility, pelvic adhesion or multiembryos transfer are risk factors of HP. Furthermore, surgery could induce abortion.

Surgical simulation supplements reproductive endocrinology and infertility fellowship training

Objective

To assess if a surgical boot camp improves laparoscopic skill among reproduction endocrinology and infertility (REI) fellows and increases fellow desire to incorporate surgical skills into practice and to examine whether fellowship in vitro fertilization (IVF) volume correlates with surgical efficiency.

Design

Prospective evaluation.

Setting

Simulation Center.

Patients

Forty REI fellows.

Interventions

Fellows were timed before and after training in laparoscopic suturing and knot tying and while using virtual simulators. Fellows were surveyed before boot camp on prior experience with IVF and reproductive surgery, and immediately and 1 month after boot camp on their desire to incorporate surgical skills into practice.

Main Outcome Measures

Efficiency of laparoscopic suturing and knot tying before and after boot camp; likelihood and persistence of incorporating surgical skills into practice immediately and 1 month after boot camp; and correlation between fellowship IVF volume and fellow surgical efficiency.

Results

Fellows experienced significant improvement in laparoscopic suturing (44 sec), intracorporeal knot tying (82 sec), and extracorporeal knot tying (71 sec). Fellows reported being more likely to incorporate operative hysteroscopy (89%), operative laparoscopy (87%), and laparoscopic suturing (84%) into practice immediately following boot camp with no difference 1 month later. Fifty-four percent of fellows reported being more likely to perform robotic surgery after the boot camp, increasing to 70% 1 month later. There were weak correlations between IVF case volume and efficiency in laparoscopic suturing or hysteroscopic polypectomy (Spearman correlation coefficients, -0.14 and -0.03).

Conclusions

An intensive surgical boot camp enhances surgical skill among REI fellows.