Plenary 6: Reproductive Issues MODERATORS. Brian M. Cohen, MBChB, MD (Postdoctoral) Stephen L. Corson, MD Cihat Unlu, MD DISCUSSANTS

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1 Plenary 6: Reproductive Issues MODERATORS Brian M. Cohen, MBChB, MD (Postdoctoral) Stephen L. Corson, MD Cihat Unlu, MD Mario E. Castellanos, MD M. Jonathon Solnik, MD DISCUSSANTS Antonio R. Gargiulo, MD Serene Srouji, MD Motti Goldenberg, MD Anusch Yazdani, MBBS Miriam Hanstede, MD Neena Malhotra, MD Emad Mikhail, MD Arti M. Luthra, MS Adrienne Mandelberger, MD Chandra C. Shenoy, MD Sponsored by AAGL Advancing Minimally Invasive Gynecology Worldwide

2 Professional Education Information Target Audience This educational activity is developed to meet the needs of residents, fellows and new minimally invasive specialists in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s). Physicians should claim only the credit commensurate with the extent of their participation in the activity. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME.

3 Table of Contents Course Description... 1 Disclosure... 2 National Trends of Surgical Management of Ectopic Pregnancy. United States Emad Mikhail... 4 Reproductive Outcomes of 10 Years Asherman's Surgery Miriam Hanstede... 6 Genital Tuberculosis in Female Infertility: An Enigma Arti M. Luthra Does the Mode of Surgery for Hydrosalpinges Affect Outcome in In Vitro Fertilization (IVF) Cycles? A Randomized Trial Comparing Laparoscopic Salpingectomy and Proximal Tubal Occlusion (PTO) Neena Malhotra Laparoscopic Removal of Streak Gonads in Turner Syndrome Adrienne Mandelberger Treatment of Difficult Ectopic Pregnancies With Needle Aspiration and Local Infusion Chandra C. Shenoy Cultural and Linguistics Competency... 17

4 Plenary 6: Reproductive Issues Moderators: Brian M. Cohen, Stephen L. Corson, Cihat Unlu Discussants: Antonio R. Gargiulo, Motti Goldenberg, Mario E. Castellanos, M. Jonathon Solnik, Serene Srouji, Anusch Yazdani Faculty: Miriam Hanstede, Arti M. Luthra, Neena Malhotra, Adrienne Mandelberger, Emad Mikhail, Chandra C. Shenoy This section provides participants with insight regarding the management of the ectopic pregnancy; simple and complex surgery of hydrosalpinges before IVF, Asherman s syndrome, genital tuberculosis, and the surgical removal of streak gonads. Learning Objectives: At the conclusion of this course, the participant will be able to: 1) Discuss management of tubal pregnancy whether simple or highly complex (including injection therapy), 2) explain the manner in which hydrosalpinges should be managed surgically prior to in vitro fertilization; 3) describe the outcomes of Asherman s syndrome, endoscopic assesment of genital tuberculosis, and endoscopic removal of streak gonads. Course Outline 12:05 National Trends of Surgical Management of Ectopic Pregnancy. United States E. Mikhail 12:11 Discussant M. Goldenberg 12:15 Reproductive Outcomes of 10 years Asherman's Surgery M. Hanstede 12:21 Discussant M.J. Solnik 12:25 Genital Tuberculosis in Female Infertility : An Enigma A.M. Luthra 12:31 Discussant A.R. Gargiulo 12:35 Does the Mode of Surgery for Hydrosalpinges Affect Outcome in In- Vitro Fertilization (IVF) Cycles? A Randomized Trial Comparing Laparoscopic Salpingectomy and Proximal Tubal Occlusion (PTO) N. Malhotra 12:41 Discussant S. Srouji 12:45 Video: Laparoscopic Removal of Streak Gonads in Turner Syndrome A. Mandelberger 12:51 Discussant M.E. Castellanos 12:55 Video: Treatment of Difficult Ectopic Pregnancies With Needle Aspiration and Local Infusion C.C. Shenoy 1:01 Discussant A. Yazdani 1:05 Adjourn 1

5 PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop and have no conflict of interest to disclose (in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* Amber Bradshaw Speakers Bureau: Myriad Genetics Lab Other: Proctor: Intuitive Surgical Erica Dun* Frank D. Loffer, Medical Director, AAGL* Linda Michels, Executive Director, AAGL* Johnny Yi* SCIENTIFIC PROGRAM COMMITTEE Arnold P. Advincula Consultant: Intuitive Royalty: CooperSurgical Sarah L. Cohen* Jon I. Einarsson* Stuart Hart Consultant: Covidien Speakers Bureau: Boston Scientific, Covidien Kimberly A. Kho Contracted/Research: Applied Medical Other: Pivotal Protocol Advisor: Actamax Matthew T. Siedhoff Other: Payment for Training Sales Representatives: Teleflex M. Jonathon Solnik Consultant: Z Microsystems Other: Faculty for PACE Surgical Courses: Covidien FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the best available evidence from medical literature (in alphabetical order by last name). Mario E. Castellanos* Brian M. Cohen* Stephen L. Corson* Antonio R. Gargiulo Consultant: Kawasaki Robotics USA, Inc., OmniGuide Motti Goldenberg* Miriam Hanstede* Arti Luthra* Neena Malhotra* Adrienne Mandelberger* Emad Mikhail* Chandra C. Shenoy* M. Jonathon Solnik Consultant: Z Microsystems Other: Faculty for PACE Surgical Courses: Covidien Serene Srouji* Cihat Unlu* Anusch Yazdani* 2

6 Asterisk (*) denotes no financial relationships to disclose. 3

7 NATIONAL TRENDS OF SURGICAL MANAGEMENT OF ECTOPIC PREGNANCY. UNITED STATES DISCLOSURES I have no financial relationships to disclose. EMAD MIKHAIL, M.D. LEARNING OBJECTIVES To appraise the prevalence and temporal trends in surgical management of ectopic pregnancy in the U.S. To compare those trends based on presence of concomitant IUP. Background Ectopic pregnancies account for approximate to 2% of all pregnancies, with the great majority occurring in the fallopian tube. 1 Surgical options include Salpingectomy or salpingostomy. 2 The most common complication and the major reason for secondary intervention after conservative management is persistent ectopic pregnancy. 3 STUDY POPULATION Setting: All community hospitals in the U.S. participating in HCUP, excluding rehabilitation and long-term acute care hospitals. Participants: The study includes all inpatient hospitalizations for women receiving treatment for ectopic pregnancy as identified using ICD-9- CM codes. Study Design A cross-sectional analysis of Nationwide Inpatient Sample (HCUP- NIS) for all patients who underwent surgical management of ectopic pregnancy Joinpoint regression was used to estimate temporal trends [APC] in salpingectomy versus salpingostomy during the study period 4

8 National Trends of surgical management of tubal ectopic pregnancy National Trends of surgical management of tubal ectopic pregnancy based on presence of concomitant IUP APC for Salpingectomy versus Salpingostomy Subgroup All ectopic pregnancies Cost of Inpatient Care for Ectopic Pregnancy Direct costs of medical care Per Annual expenditures hospitalization (in millions) Mean (95% CI) Total (95% CI) 6,062 (5,958, 6,165) (156.5, 174.7) Surgical outcome* Salpingectomy Salpingotomy/salpingostomy Other adnexal procedure No procedure 6,393 (6,273, 6,513) (100.6, 113.7) 5,909 (5,738, 6,080) 13.5 (12.5, 14.5) 7,155 (6,977, 7,332) 11.3 (10.6, 12.0) 3,699 (3,515, 3,882) 5.3 (4.8, 5.7) REFERENCES 1 American College of O, Gynecologists. ACOG Practice Bulletin No. 94: Medical management of ectopic pregnancy. Obstetrics and gynecology 2008; 111(6): Stock L, Milad M. Surgical management of ectopic pregnancy. Clinical obstetrics and gynecology 2012; 55(2): Seifer DB. Persistent ectopic pregnancy: an argument for heightened vigilance and patient compliance. Fertility and sterility 1997; 68(3): CONCLUSION There is an increasing tendency to perform salpingectomy as oppose to salpingostomy as surgical management approach of ectopic pregnancy. There is no significant change in the trends for non-surgical management. 5

9 Disclosure slide I have no financial relationships to disclose Reproductive Outcomes of 10 years Asherman's Surgery Miriam Hanstede M.D. 2 Objective Between Fritsch and Asherman Identify the potential problems of a pregnant Asherman s patient List the risk factors of morbidity in the post partum periode of an Asherman patient H.Fritsch N= B.Bass N= S.Stamer N= J.Asherman N= Intra uterine adhesions 10 years retrospective cohort Trauma to the endometrium in a non gravid uterus Trauma to the endometrium caused by infections IUA Trauma to the endometrium in a gravid uterus Asherman Syndroom Trauma to the endometrium caused by hypoxia 707 patients 638 Asherman 770 procedures 69 excluded 6

10 Etiology of IUA Classification of IUA Grade ESGE 3 n % a Totaal Grade AFS 4 n % Score 1-4 (mild) Score 5-8 (moderate) Score 9-12 (severe) Totaal Outcome Spontaneous recurrence Outcome 1-3 attempts n % Complete Incomplete Drop out n % No recurrence Recurrence Total Dropouts and incomplete resection Year author n % recovery of uterine anatomy 1986 Fedele et al Capella-Allouc et al Pace et al Fernandez et al Recurrence and grade of adhesions Follow-up ( ) Grade ESGE % a Grade AFS % Milde 22.9 Moderate 22.7 Servere 36.5 n % Complete In-complete Dropout Subtotal Not yet contacted 107 Total 638 Response rate: 80.2% 7

11 Follow-up Take home babyrate 68.6% 14 IRB approval Follow up on 638 women Response rate 80.2% Complete data on 389 women 292 (75.1%) women at least got pregnant once 97 (24.9%) did not (yet) conceive EUG n=6 423 pregnacies Parity n=264 Miscarriage n=153 Life birth n=267 (10 twins) Perinatale death n=2 13 Multivariate analysis Multivariate analyse Pregnancies Multivariate analysis Age Miscarriage Gravidity Parity Causal procedure Graad adhesions ESGE Restore of uterine anatomy Spontaneous recurrence Life Birth Multivariate analysis Age Miscarriage Gravidity Parity Causal procedure Graad adhesions ESGE Restore of uterine anatomy Spontaneous recurrence Pregnancy complications Remarkable n % General population (%) IUGR premature/immature birth Abruptio placentae No complications Totaal Unknown 14 n % General population (%) Head Breach % Unknown Total

12 Placenta implantation problems 19 1st trimester procedure post partum procedure Placenta problems n % General populatie % Placenta praevia Placenta acreta Placenta increta Placenta percreta Placenta praevia en accreta, increta of percreta No placenta related problems Total Unknown 20 Post partum complications Reference Post partum complications n % Hemorragia post partum Manuel removal of placenta Combination of the above Post partum curettage for retained products No problems related to post partum period Subtotal Unknown Total % Post partum complications 1 Schenker JG, Margalioth EJ. Intrauterine adhesions: an updated appraisal. Fertil Steril. 1982;37: Hanstede MMF, van der Meij E, Goedemans L, Emanue MH. Centralized Asherman s surgery : accepted for publication Ferti Steril K. Wamsteker and S. De Block, Diagnostic hysteroscopy: technique and documentation, in Endoscopic Surgery for Gynecologists, C. Sutton and M. Diamond, Eds., pp , Saunders, London, UK, American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, mullerian anomalies and intrauterine adhesions. Fertil Steril.1988;49: Yu D, Wong Y, Cheong Y, Xia E, Li T. Asherman syndrome: one century later. Fertil Steril, 2008; Fedele L, Vercellini P, Viezzoli T, Ricciardiello O, Zamberletti D. Intrauterine adhaesions: current diagnostic and therapeutic trends. Acta Eur Fertil 1986;17: Capella-Allouc S, Morsad F, Rongieres-Bertrand C, Taylor S, Fernandez H. Hysteroscopic treatment of severe Asherman s syndrome and subsequent fertility. Hum Reprod 1999;14: Pace S, Stentella P, Catania R, Palazzetti PL, Frega A. Endoscopic treatment of intrauterine adheiosn. Clin Exp Obstet Gynecol 2003;30: Fernandez H, Al Najjar F, Chauvenaud-Lambling et al. (2006). "Fertility after treatment of Asherman's syndrome stage 3 and 4". J Minim Invasive Gynecol 13 (5):

13 Genital Tuberculosis In Female Infertility An Enigma DISCLOSURE I have no financial relationships to disclose. Dr Arti Luthra MS Director, Luthra maternity & Infertility Centre Objective Patients To diagnose Genital Tuberculosis, a frequent cause of infertility in developing countries To evaluate the Laparoscopic and Hysteroscopic appearances in Genital Tuberculosis Correlation of these endoscopic features with Endometrial polymerase chain reaction and BACTEC culture 100 infertile women in the reproductive age group (25-38 years) were studied between January Jan 2014 Patients with HSG positive findings like tubal block, Intrauterine synechiae were enrolled in the study and underwent diagnostic laparoscopy and hysteroscopy. The endometrial sample obtained by curettage were sent for analysis of PCR for mycobacterium complex and Bactec Culture. The PCR and Bactec culture results obtained were retrospectively correlated with the endoscopic features of the individual patient. Laparoscopic appearance Observations on Laparoscopy Perihepatic adhesions Periovarian adhesions Signs No. of Patients PCR Positive Bactec culture positive Normal findings Peritubal adhesions Peri-ovarian adhesions Bilateral T.O. masses None Beading of tubes 8 0 None Hydrosalpinx Miliary Tubercles 10

14 Signs No. of Patients PCR Positive Bactec culture positive Hysteroscopic appearance Cornual block Delayed spill Perihepatic adhesions Miliary Tubercles Rigid tubes 10 4 None Hydrosalpinx Fimbrial phimosis Bowel and omental adhesions None None Periosteal Fibrosis Intrauterine Synechiae Small uterine cavity Hysteroscopic Findings Results Signs No. of Patients PCR Positive Bactec culture positive Fibrosed ostia 4 1 None Intrauterine synechiae-mild Moderate Severe Asherman s syndrome Small uterine cavity Endoscopic evaluation is 85% sensitive, and 33% specific. In 48 cases with positive endoscopic findings, endometrial PCR was positive in 20% of cases, Bactec culture was positive in 15% of cases suspected of endometrial Tuberculosis. A negative evaluation of the endometrium does not rule out Genital tuberculosis because the disease can be present in fallopian tubes without Tubercular endometritis in 30-40% of cases. Endometrial bacteriological PCR assay plus bactec culture with clinical and endoscopic evaluation are the Gold standards in diagnosis of GTB. References 1. Kohli MD, Nambam B, Trivedi SS, Sherwal BL, Arora S, Jain A. PCR based evaluation of tubercular endometritis in infertile women of North India. J Reprod Infertil 2011;12: Mani R, Nayak S, Kagal A, Deshpande S, Dandge N, Bharadwaj R. Tubercular endometritis in infertility: A bacteriological and histopathological study. Indian J Tuberc 2003;50: Kumar P, Shah NP, Singhal A, Chauhan DS, Katoch VM, Mittal S, et al. Association of tuberculous endometritis with infertility and other gynecological complaints of women in India. J Clin Microbiol 2008;46: Khanna A, Agrawal A. Markers of genital tuberculosis in infertility. Singapore Med J 2011;52: Gupta N, Sharma JB, Mittal S, Singh N, Misra R, Kukreja M. Genital tuberculosis in Indian infertility patients. Int J Gynaecol Obstet 2007;97: Baxi A, Hansali N, Manila K, Priti S, Dhawal B. Genital tuberculosis in infertile women: Assessment of endometrial TB PCR results with laparoscopic and hysteroscopic features. J Obstet Gynaecol India 2011;61: Bhanu NV, Singh UB, Chakraborty M, Suresh N, Arora J, Rana T, et al. Improved diagnostic value of PCR in the diagnosis of female genital tuberculosis leading to infertility. J Med Microbiol 2005;54: Jindal UN, Verma S, Bala Y. Favorable infertility outcomes following anti-tubercular treatment prescribed on the sole basis of a positive polymerase chain reaction test for endometrial tuberculosis. Hum Reprod 2012;27: Malpani A, Malpani A. Anti-tubercular treatment, genital TB and infertility. Hum Reprod 2012;27: Thangappah RB, Paramasivan CN, Narayanan S. Evaluating PCR, culture and histopathology in the diagnosis of female genital tuberculosis. Indian J Med Res 2011;134:

15 DOES THE MODE OF SURGERY FOR HYDROSALPINGES AFFECT OUTCOME IN IN-VITRO-FERTILIZATION (IVF) CYCLES? - A RANDOMIZED TRIAL COMPARING LAPAROSCOPIC SALPINGECTOMY AND PROXIMAL TUBAL OCCLUSION (PTO) DISCLOSURES I HAVE NO FINANCIAL RELATIONSHIPS TO DISCLOSE Neena Malhotra MD, DNB, MRCOG ART Centre, Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India LEARNING OBJECTIVES Examine the mechanism of poor outcome at IVF in women with hydrosalpinx Discuss surgical options prior to in-vitrofertilization (IVF) cycles Compare two surgical techniques-salpingectomy and proximal tubal occlusion (PTO) as regards outcome in women undergoing IVF cycle Tubal disease Hydrosalpinx Manifestation of severe disease, associated with deleterious outcome at IVF 10 30% of IVF ET indicated for hydrosalpinx (Andersen AH, 1996 ) Genital TB is the leading cause of tubal damage and hydrosalpinx ( 46.5%) in India (Kulshreshta.V, 2011) Lower implantation and pregnancy rate in association with hydrosalpinx (Parikh.F, 1996) Impact of Hydrosalpinx Embryo toxic Mechanical effect affects receptivity Interference to apposition by bathing the endometrial lining Fluid rich in PG, IL,TNF α, Leukotriene Altered Expression Integrins (αvβ3), LIF HOXA 10, HOXA 11 Why this study? Surgery prior to IVF improves outcome Salpingectomy more invasive (Johnson.N, Cochrane Review, 2010) Reassuring ovarian function after salpingectomy ( Strandell 1999, 2001; Gelbaya 2006) Tubal occlusion less invasive, minimal compromise in ovarian functions Limited studies that compare salpingectomy to less invasive methods as tubal occlusion ) 12

16 Aims and Objectives To compare effects laparoscopic proximal tubal occlusion (PTO) or salpingectomy on ART outcome in women with hydrosalpinx undergoing IVF ET Materials and Methods Study design: Prospective randomized controlled trial Place of study: ARU, AIIMS, N. Delhi, India Subjects: Tubal factor with hydrosalpinx for intervention prior to IVF IRB approval Informed consent Materials and Methods Materials and Methods Pre-IVF evaluation-history, examination and infertility workup including Ovarian reserve - FSH, E 2, AMH and AFC Endometrial assessment with 2D/ 3D imaging in luteal phase Hysteroscopy and Mock ET Screened for Genital TB TVS to screen for hydrosalpinx INCLUSION Tubal factor with bilateral hydrosalpinx <40 years Exclusion of bias Women undergoing first IVF cycle Salpingectomy converted to PTO for severe adhesions EXCLUSION >40 years Endometriosis Prior surgery on the ovaries PCOS Poor ovarian reserves Abnormal uterine cavity Contraindication for laparoscopy Materials and Methods Sample size Seventy five subjects (From May, 2012 to June 2014) Randomized prior to IVF Group I- Salpingectomy (n=38) Group II-Proximal Tubal Occlusion (n=37) All surgeries by single surgeon (NM) Laparoscopy with three ports Salpingectomy -bi-polar electro cautery and scissors PTO - bi-polar electro cautery only 20 excluded 8 AMH <1.5ng/ml 4 endometriosis 3 previous ovarian surgery 2 FSH >12 miu/ml 1 Unwilling 2 convertedtopto Consort Diagram 38 allocated to salpingectomy (group I) 38 treated 95 patients assessed for eligibility 75 patients randomized 37 allocated to Proximal Tubal Occlusion (group II) 37 treated 38 analyzed 37analyzed 13

17 Outcome measures Results Demographic profile Primary outcomes Clinical pregnancy rate Ongoing pregnancy rate Live birth rate Secondary outcomes Response to COH Dose and duration of Gonadotropins Serum E 2 on day of hcg injection Number of oocytes retrieved Fertilization rate Cleavage rate Number of good quality embryos transferred Implantation rate Group I Salpingectomy (n=38) Group II PTO (n=37) P value Age (years) 30.7± ± BMI (kg/m 2) 24.2± ± Duration of infertility 7.0± ± (years) Type - Primary (%) - Secondary (%) 31 (88.5%) 4 (11.5%) 32 (86.4%) 5 (13.6%) Genital TB (%) 14 (40%) 15 (40.5%) 0.43 Protocol - Agonist (%) - Antagonist (%) 26 (74.2%) 9 (25.8%) 27 (72.9%) 10 (27.1%) Response to COH and IVF outcome Pregnancy outcome in both groups Group I Salpingectomy (n=38) Group II PTO (n=37) P value Dose of Gn ± ± Days of stimulation 11.1± ± E2 on day of hcg 3040± ± Follicles (15-20 mm) 10.0± ± Oocyte retrieved* 8.4 (2-18) 5.6 (2-21) 0.97 Fertilization rate 0.8± ± Cleavage rate 0.9± ± Implantation rate(%) 4.4% 7.2% 0.52 *values expressed as median Clinical pregnancy rate Ongoing pregnancy rate Miscarriage rate LBR Group I Salpingectomy (n=38) Group II PTO (n=37) P value 7 (18.4%) 9 (24.3%) (18.4%) 8 (21.6%) (0%) 1 (2.7%) (18.4%) 8 (21.6%) 0.56 Conclusions References Response to COH and pregnancy outcome similar with both surgical interventions Fertilization, cleavage and implantation rate were comparable in both groups Tubal occlusion is a preferred surgical intervention not just in terms of invasiveness but for little compromise in ovarian reserves Women with borderline reserves should be offered tubal occlusion over salpingectomy Further RCT with larger size are needed to confirm Andersen AN, Lindhard A, Loft A, Ziebe S, Andersen CY. The infertile patient with hydrosalpinges. IVF with or without salpingectomy? Hum Reprod 1996; 11: Kulshrestha V, Kriplani A, Agarwal N, Singh UB, Rana T. Genital tuberculosis among infertile women and fertility outcome after antitubercular therapy. Int J Gynaecol Obstet ; 113(3): Parikh FR, Nadkarni SG, Kamat SA, Naik N,Soonawala SB, Parikh RM: Genital tuberculosis:a major pelvic factor causing infertility in Indian women. Fertil Steril 1997; 67: Johnson N, van Voorst S, Sowter MC, Strandell A, Mol BWJ. Surgical treatment for tubal disease in women due to undergo in vitro fertilisation. Cochrane Database of Systematic Reviews 2010, Issue 1. Strandell A, Lindhard A, Waldenstro mu, et al. Hydrosalpinx and IVF outcome: a prospective, randomized multicentre trial in Scandinavia on salpingectomy prior to IVF. Hum Reprod 1999; 14: Strandell A, Lindhard A, Waldenstrom U, Thorburn J, Janson PO, Hamberger L. Hydrosalpinx and IVF outcome: cumulative results after salpingectomy in a randomized controlled trial. Human Reproduction 2001; 16: Gelbaya TA, Nardo LG, Fitzgerald CT, Horne G, Brison DR, Lieberman BA. Ovarian response to gonadotrophins after laparoscopic salpingectomy or the division of fallopian tubes for hydrosalpinges. Fertility and Sterility 2006; 85(5):

18 Laparoscopic Removal of Streak Gonads in Turner Syndrome Adrienne Mandelberger, MD Icahn School of Medicine at Mount Sinai, New York, New York Objective: To demonstrate the skills necessary for complete resection of bilateral streak gonads in Turner Syndrome. Design: Video case presentation with narration highlighting the key techniques utilized. Setting: Turner syndrome is a form of gonadal dysgenesis that affects 1/2500 live births. Patients often have streak gonads and may present with primary amenorrhea or premature ovarian failure. Patients with a mosaic karyotype that includes a Y chromosome are at increased risk for gonadoblastoma and subsequent transformation into malignancy. Gonadectomy is recommended for these patients, typically at adolescence. Streak gonads can be difficult to identify and tissue margins are often in close proximity to critical retroperitoneal structures. Resection can be technically challenging and requires a thorough understanding of retroperitoneal anatomy and precise dissection techniques to ensure complete removal. Interventions: Laparoscopic approach to bilateral salpingo-oopherectomy of streak gonads. Retroperitoneal dissection and ureterolysis are performed, with the aid of the Ethicon Harmonic Ace, to ensure complete gonadectomy. Conclusion: Careful and complete resection of gonadal tissue in the hands of a skilled laparoscopic surgeon is key for effective cancer risk reduction surgery in Turner syndrome mosaics. 15

19 Treatment of Difficult Ectopic Pregnancies with Needle Aspiration and Local Infusion Chandra C. Shenoy, MD Mayo Clinic, Rochester, Minnesota Objective: To show how ectopic and heterotopic pregnancies can be treated with ultrasound guided needle aspiration and local infusion. Design: Demonstration of technique with narrated video footage and two case presentations. Setting: Ectopic pregnancies occurs when a pregnancy implants outside of the uterus. Although the most common extrauterine location for implantation is the fallopian tube, other types of ectopic pregnancies can occur. Additionally, the incidence of heterotopic pregnancies an ectopic pregnancy concurrent with an intrauterine pregnancy is rising due to assisted reproductive technology. Case 1 is a patient with an unstable cervical ectopic pregnancy. Surgical resection and systemic methotrexate were not viable options. She is successfully treated with needle aspiration and intergestational infusion of methotrexate. Case 2 is a patient with a heterotopic pregnancy: an intrauterine pregnancy and an interstitial ectopic. The interstitial pregnancy is successfully treated with needle aspiration and intergestational infusion of hyperosmolar dextrose. Interventions: Needle aspiration and local infusion can be accomplished using a transvaginal ultrasound, needle guide, 16-gauge single lumen Chiba needle, empty syringe, and syringe with local infusion agent. The technique is similar to oocyte retrieval or an ultrasound guided cyst aspiration. Conclusion: When an alternative to expectant management, surgical resection, and systemic methotrexate is necessary for treatment of an ectopic pregnancy, needle aspiration and local infusion of methotrexate, potassium chloride, or hyperosmolar dextrose should be considered. 16

20 CULTURAL AND LINGUISTIC COMPETENCY Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as the AAGL, to assist in enhancing the cultural and linguistic competency of California s physicians (researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP). US Population Language Spoken at Home California Language Spoken at Home English Spanish Spanish Indo-Euro Asian Other English Indo-Euro Asian Other 19.7% of the US Population speaks a language other than English at home In California, this number is 42.5% California Business & Professions Code (c)(3) requires a review and explanation of the laws identified above so as to fulfill AAGL s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the program, the importance of the services, and the resources available to the recipient, including the mix of oral and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of Executive Order 13166, Improving Access to Services for Persons with Limited English Proficiency, signed by the President on August 11, was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies, including those which provide federal financial assistance, to examine the services they provide, identify any need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access. Dymally-Alatorre Bilingual Services Act (California Government Code 7290 et seq.) requires every California state agency which either provides information to, or has contact with, the public to provide bilingual interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population. If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills. A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. ~ 17