Sponsored by
AAGLAdvancing Minimally Invasive Gynecology Worldwide
Plenary 7: Reproductive Issues
MODERATOR
David L. Olive, MD
CO-MODERATORS
Stephen L. Corson, MD & Michael Lewis, MD
Munire Erman Akar, MDBenoit Rabischong, MD
Linda D. Bradley, MD Tycho van Meer, MD
Mark W. Dassel, MD
Professional Education Information Target Audience Educational activities are developed to meet the needs of surgical gynecologists in practice and in training, as well as, other allied healthcare professionals 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.
Table of Contents
Course Description ........................................................................................................................................ 1 Disclosure ...................................................................................................................................................... 2 Short Term Follow‐Up Results of the First Human Uterus Transplantation from Cadaver M. Ermine Akar ............................................................................................................................................ 4 Removal of Essure Device T. van Meer ................................................................................................................................................ 11 Investigating the Needs and Preferences of US Women with Fibroids E.A. Stewart ................................................................................................................................................ 14 Fertility Following Tubal Ectopic Pregnancy: Results of a Population‐Based Study B. Rabischong .............................................................................................................................................. 18 Utility of Site‐Specific Peritoneal Biopsies in the Benign‐Appearing Pelvis on Laparoscopy for the Diagnosis of Endometriosis in Chronic Pelvic Pain M.W. Dassel ............................................................................................................................................... 21 Cultural and Linguistics Competency ......................................................................................................... 24
Plenary 7: Reproductive Issues
Moderator: David L. Olive Co-Moderators: Stephen L. Corson, Michael Lewis
Faculty: Munire Erman Akar, Linda D. Bradley, Mark W. Dassel, Benoit Rabischong, Tycho van Meer
Course Description
This session provides investigative results on a variety of topics inherent to successful reproduction. These include the feasibility of uterine transplantation, endometriosis, uterine fibroids, the effects of ectopic pregnancy on reproductive outcomes, and the reversibility of hysteroscopic contraception. The description you develop is the most effective method we have of promoting your session. The description should be written to promote interest in your topic as it relates to minimally invasive gynecology. Please write a short description (no more than 150 words) that will be used for marketing your session. Please note descriptions are subject to editorial review/change by AAGL.
Course Objectives At the conclusion of this session, the participant will be able to: 1) Describe the methods of hysteroscopic sterilization; 2) Recognize the needs and preferences of women with uterine fibroids; and 3) assess fertility potential in women after ectopic pregnancy.
Course Outline 2:15 Short Term Follow Up Results of the First Human Uterus Transplantation from Cadaver
M. Erman Akar
2:25 Removal of Essure Device T. van Meer
2:35 Investigating the Needs and Preferences of US Women with Fibroids E.A. Stewart
2:45 Fertility Following Tubal Ectopic Pregnancy: Results of a Population-Based Study B. Rabischong
2:55 Utility of Site-Specific Peritoneal Biopsies in the Benign-Appearing Pelvis on Laparoscopy for the Diagnosis of Endometriosis in Chronic Pelvic Pain M.W. Dassel
3:05 Discussion
3:15 Adjourn
1
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* Viviane F. Connor Consultant: Conceptus Incorporated Frank D. Loffer, Executive Vice President/Medical Director, AAGL* Linda Michels, Executive Director, AAGL* Jonathan Solnik Other: Lecturer - Olympus, Lecturer - Karl Storz Endoscopy-America SCIENTIFIC PROGRAM COMMITTEE Arnold P. Advincula Consultant: CooperSurgical, Ethicon Women's Health & Urology, Intuitve Surgical Other: Royalties - CooperSurgical Linda Bradley Grants/Research Support: Elsevier Consultant: Bayer Healthcare Corp., Conceptus Incorporated, Ferring Pharmaceuticals Speaker's Bureau: Bayer Healthcare Corp., Conceptus Incorporated, Ferring Pharm Keith Isaacson Consultant: Karl Storz Endoscopy Rosanne M. Kho Other: Honorarium - Ethicon Endo-Surgery C.Y. Liu* Javier Magrina* Ceana H. Nezhat Consultant: Intuitve Surgical, Lumenis, Karl Storz Endoscopy-America Speaker's Bureau: Conceptus Incorporated, Ethicon Women's Health & Urology William H. Parker Grants/Research Support: Ethicon Women's Health & Urology Consultant: Ethicon Women's Health & Urology Craig J. Sobolewski Consultant: Covidien, CareFusion, TransEnterix Stock Shareholder: TransEnterix Speaker's Bureau: Covidien, Abbott Laboratories Other: Proctor - Intuitve Surgical 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). Munire Erman Akar* Tycho van Meer* Linda D. Bradley Grants/Research Support: Elsevier Consultant: Bayer Healthcare Corp., Conceptus Incorporated, Ferring Pharmaceuticals Speaker's Bureau: Bayer Healthcare Corp., Conceptus Incorporated, Ferring Pharm
2
Benoit Rabischong* Mark W. Dassel* David L. Olive Consultant: Ferring Pharmaceuticals, Bayer Healthcare Corp., Bayer-Sherring, Abbott Laboratories Michael L. Lewis* Stephen L. Corson Other: Royalties - Olympus Asterisk (*) denotes no financial relationships to disclose.
3
Prof Dr Munire ERMAN AKARAkdeniz University
Antalya, TURKEY
I have no financial relationships to disclose.
Objective: To describe the short term follow-up results of the first human uterus transplantation from multiorgan donor
Ref species Vascsupply
Transp Immunosupp.
No ofanimals
Viable grafts
Pregnancy/delivery
Knauer1896
Rabbit(a) - ovaries - 1 yes
Zhordonia1964
Sheep(a) omentopexy
Uterus&ovaries
- yes 20/12
Eraslan1966
Dog(a) anastomosis
Uterus&ovaries
- 18 10 normal function
Not tested
functionYonemoto1969
Dog(h) anastomosis
Uterus&ovaries
Azat&pred 14 7 rejby17-45days
Oleary1969
Dog(a) omentopexy
Uterus&Ovaries
- 32
Mattingly1970
Dog(a/h)
anastomosis
Uterus&ovaries
Azathioprin
7 autot50 homot
6 normalf13 rej by 6-21 days
2(autot)/1
Scott 1970
Dog(a/h)
omentopexy
segmenteduterus
Azat&pred(5 homot)
10 autot 7autot normal f
Not tested
Scott Primate omentopex Uterus - 10 10hom Normal menst and
Ref species Vascsupply
Transpl Immunosupp.
No ofanimals
Viable grafts
Pregnancy/delivery
Barzilai1973
Dog(a) omentopexyanastomoses
Uterus&ovaries
- 13 oment12 anast
9 totnecros10an Nby40days
1(anast)/1
Confino1986
Rabbit(a/h)
Sutured to the broad lig
Unilatuterus &ovary
Cyclosporine
8autot10 homot
3autot3homot preserved by30 days
Not tested
Lee1995
Rat(h) anastomosis
Uterus&ovaries
- 24 syngnic
Syn normalFrom1-180
Not tested
Ozkan&Akar et al 2011 Uterus from multiple organ donor
Brannstrom et al 2012 Uterus from mother to daughter
El-Akouri2002
Mouse(h)
anastomosis
Unilateral uterus
- 20 allo42 syn
Allorejbyd522 viable gr
1 by embryo transfer/1
Diaz Garcia2010
Rat(a) anastomosis
Uterus cyclosporine
allo 1
Mihara M2012
Monkey(h)
anastomoses
uterus - 2 syn 2 viable graft
1spontan preg
In 2000 in Saudia Arabia from a 46 year old live donor
Removed after 3 months as a result of massive necrosis of uterus due to a vascular problem(Twisting of the uterus andproblem(Twisting of the uterus and subsequent blood flow cessation)
poor fixation of the graft led to uterine prolapsus
4
5
Psychological stability Having no children Congenital uterine agenesis Trauma, benign causes or hysterectomy
history due to a benign reason Being able to sacrifice 2-4 years
posttransplantationposttransplantation 18-45 years Normal urinary system anatomy No accompanying disease history that
would risk surgery immunosuppresivetherapy and pregnancy
Informed consent giving detailed information about all of the risks
Insidence:1/5000 Autosomal recessive Congenital agenesis of uterus and vagina Secondary sexual characters normal Bilateral ovaries normal
A i i t li Accompanying urinary system anomalies 30-40%
Hearing problems 10-25% Vertebral anomalies 10%
67 MRKH patients since 2003
21 yr vaginal reconstruction in 2009 MRKH syndrome 46XX BMI:21kg/m2g/ Healthy Normal localization of kidneys Good ovarian reserve Psychologically stable 8 Frozen embryos
22 yr Blood group and HLA match (3/6 match) CMV(-) HPV 16,18,31,33 and 45(-)
N i l l i No cervical lesion No myoma or congenital uterine anomaly on
usg
6
Antithymosit globulin 2mg/kg(first 10 days) Prednisolone 1000mg till 7. day then 20g(started intraoperatively) Tacrolimus (started on 7.day)
Prednisolone 20mg/day Tacrolimus 0.2mg/day Mycophenolat mofetil 2g/day(after 10. day)
Wide spectrum antibiotics(first 10 days) Sulfadoxin pirimetamin Oral nistatin drops Oral valasiklovir (CMV prophylaxis)
A i h b i h l i ( i i d Antithrombotic prophylaxis(aspirin and subcutan heparin)
100% graft survival Petruzzo et al, 2010, Transplantation
7
Infection Diabetes Hiperlipidemia Nefrotoxic
M li Malignancy
Vaginal biopsy◦ Every 2 weeks in the first 3 months◦ Once a month in the following 6 months
endometrial biopsy every 3 months◦ StasisStasis, ◦ hemoragia, ◦ edema and glandular epithelial vacuolization, ◦ Presence of necrotic cells◦ Presence of apoptosis and lymphocytes
First menstruation 3 weeks after the surgery
0
5
10
15
20
25
30
-34
-19
*20
*65 77 *93
*121
*149
*175
*203
*229 243
*256 270
*284 298
*312
337.
00*3
51
LH(mIU/L)
FSH(mIU/L)
0
50
100
150
200
250
300
350
400
450
-34
-19
*20
*65 77 *93
*121
*149
*175
*203
*229 243
*256 270
*284 298
*312 337
*351
E2(pg/mL)
E2(pg/mL)
8
8 menstruasyon
Author Year Age Period betw.TXand IVF(year)
Protocol Gonadot
E2 at hCGday
IVForICSI
NoTE
LB
Immunosupr.
Lockwood
1995
36 10 long rFSH na IVF 2 1 cyclosporin
Furmann 1999
31 na na na na na na 2 cyclosporin
Case 2000
22 4 long rFSH 3712pg/ml ICSI 3 2 cyclosporin+coumadin/cyclo.+heparin
Khalaf 2000
28 10 long rFSH 4086pg/ml
ICSI 2 2 cyclosporin
Tamaki 2003
32 1 na na na ICSI 3 1 Cyclosporine+MMF+pred/cyclo+azath+pred
Fichez 2008
39 10 long rFSH 5605pg/ml
IVF 2 1 Azath+tacro+pred
Nouri 2010
31 10 antagon rFSH 3726pg/ml
IVF 1 1 Azath/cyclosp
Iugr Hypertension Proteinuria Preeclampsia
L bi h i h Low birth weight Prematurity PROM Graft rejection rate 6%
Delivery of a healthy near term baby
9
Thanks Diaz-Garcia C, Akhi SN, Wallin A, Pellicer A, Brannstrom M. First report on fertility:after allogenic uterus transplantation.Acta Obstet Gynecol Scand 2010;89:1491-4.
Brannstrom M, Diaz-Garcia C, Hanafy A, Olausson M, Tzakis A. Uterus transplantation: animal research and human possibilities. Fertil Steril 2012;97:1269-76.
Del Priore G, Stega J, Sieunarine K, Ungar L, Smith JR. Human uterus retrieval from a multi-organ donor. Obstet Gynecol 2007;109:101-4.
Egarter C, Huber J. Succesful stimulation and retrieval of oocytes in a patient with Mayer RokitanskyKuster syndrome. Lancet. 1988 ;1:1283-5.
Damario MA. Transabdominal-transperitoneal ultrasound guided oocyte retrieval in a patient with M llerian agenesis Fertil Steril 2002 78 189 91Mullerian agenesis. Fertil Steril. 2002 ;78:189-91.
Deshpande NA, James NT, Kucirka LM, Boyarsky BJ, Garonzik-Wang JM, Montgomery RA et al. Pregnancy outcomes in kidney transplant recipients: a systematic review and meta-analysis. Am J Transplant. 2011 Nov;11:2388-404.
Ramirez ER, Ramirez Nessetti DK, Nessetti MB, Khatamee M, Wolfson MR, Shaffer TH et al. Pregnancy and outcome of uterine allotransplantation and assisted reproduction in sheep. J Minim Invasive Gynecol 2011;18:238-45.
Wranning CA, Akhi SN, Diaz- Garcia C, Brannstrom M. Pregnancy after syngenic uterus transplantation and spontaneous mating in the rat.Hum Reprod 2011;26:553-8.
Diaz-Garcia C, Akhi SN, Wallin A, Pellicer A, Brannstrom M. First report on fertility:after allogenic uterus transplantation.Acta Obstet Gynecol Scand 2010;89:1491-4.
FIGO Committee Report. Uterine transplantation. Int J Gynecol Obstet 2009;106:270
10
Removal of Essure deviceAAGL nov 2012
T. van MeerS. Veersema
Department gynaecology
I have no financial relatianships to disclose.
Evidence literature only case reports
• Tubal perforation by Essure: three different clinical presentations. Langenveld J, Veersema S, Bongers MY, Koks CA. Fertil Steril. 2008 Nov
• Techniques for removal of the Essure hysteroscopic tubal occlusion d i L BM L SY F ti l St il 2007 Adevice. Lannon BM, Lee SY. Fertiel Steril. 2007 Aug
• Subserosal misplacement of Essure device manifested by late-onset acute pelvic pain. Mahmoud MS, Fridman D, Merhi ZO. Fertil Steril. 2009 Dec
• Removal of Essure device 4 years post-procedure: A rare case Jain P, Clark T.J. J. Obstet gynaecol, 2011,31
case series 24 patients
Retrospective review:
• Essure devices were removed between 2004 2011 i A t i H it l2004 – 2011 in Antonius Hospital (Nieuwegein, the Netherlands)
• 11 patients referred from other clinics
Why operate?
Fertil Steril. May 2011 Small bowel obstruction subsequent to Essure microinsert sterilization: a case report. Belotte J, Shavell VI, Awonuga AO, Diamond MP, Berman JM, Yancy AF
small bowel obstruction four weeks after Essure
Medisch Contact nr 35, 2 sept 2011
11
Results
• 20 x laparoscopic
• 12x hysteroscopy
• Mean operation time 42 min (15-70 min)
• No late or short term complications
• Day care setting
• Interval between placement and removal between 10 days and 3 years
Results
Reasons forremoval
Perforation 8
Expulsion/dislocation 7
Abdominal pain 7
Nickel allergy 1
Adnectomy 1
Conclusion
• Save and feasible to remove Essuredevices either laparoscopically or hysteroscopically
• No complications• No complications
• Possible beyond 12 weeks afterplacement
• Removal indicated in total perforation andpartial expulsion
Laparoscopic removal
Essure in omentum Tips and Tricks
• Locate device before table in Trendelenburg
• Locate device by ultrasound, X-ray, HSG before laparoscopy
• make sure you the whole device is removed
• Complete perforation: radiologic guidance (C-arm)
• Sterilization:Filshie clips or tubectomie
!!!pull essure in small steps !!!
12
LiteratureHurskainen R, Hovi SL, Gissler M, Grahn R, Kukkonen-Harjula K,Nord-Saari M, et al. Fertil Steril. Published online April 29, 2009.
Thoma V, Chua I, Garbin O, Hummel M,Wattiez A. Tubal perforation byEssure microinsert. J Minim Invasive Gynecol 2006
Hur H, Mansuria SM, Chen BA, Lee TT. Laparoscopic management ofhysteroscopic Essure sterilization complications: report of 3 cases.J Minim Invasive Gynecol 2008
Gerritse M, Veersema S, Timmermans A, Brolmann HA. Incorrect positionof Essure microinserts 3 months after successful bilateral placement.Fertil Steril 2009
Beckwith AW. Persistent pain after hysteroscopic sterilization withmicroinserts. Obstet Gynecol 2008
Lannon BM, Lee SY. Techniques for removal of the Essure hysteroscopictubal occlusion device. Fertil Steril 2007
Small bowel obstruction subsequent to Essure microinsert sterilization: a case report.Belotte J, Shavell VI, Awonuga AO, Diamond MP, Berman JM, Yancy AF. Fertil Steril 2011
Use of intraoperative fluoroscopy during laparotomy to identifyfragments of retained essure microinserts: case report. Howard DL, Christenson PJ, StricklandJL. J Minim Invasive Gynecol. 2012 Sep;19
13
Impact of Uterine Fibroids: National Survey of Symptoms, Quality
©2012 MFMER | slide-1
National Survey of Symptoms, Quality of Life, and Treatment Needs
Elizabeth A Stewart, MDWanda K Nicholson, MD MPH MBALinda Bradley, MDBijan J Borah, PhD
Disclosure
• Grant/Research: InSightec
• Consultant: Abbott Laboratories, Gynesonics
• Other: Royalties: UpToDate
©2012 MFMER | slide-2
Objectives
To conduct a nationwide survey of racially-diverse women with symptomatic fibroids assessing:
• Diagnosis and symptoms
©2012 MFMER | slide-3
• Information seeking
• Attitudes about fertility
• Impact on work
• Treatment preferences
Methodology
• Online Survey through Harris Interactive panel from 12/1/2011-1/16/2012
• 968 U.S. women, age 29-59* with symptomatic uterine fibroids without having had a hysterectomy
©2012 MFMER | slide-4
hysterectomy • Oversample of African-American women • Data weighted by age, education, region, and
income to reflect a nationally representative sample
* Due to the initially low incidence, the age range was shifted from 21-50 to 29-59 when no women under the age of 29 screened into the study.
DemographicsRace/Ethnicity %
White 59
African-American 28
Other 13
Age
29-39 26
40-49 46Education %
Marital Status %
Never married 16
Married or civil union
61
Divorced 11
Separated 1
Widow/Widower 2
Income
<$35K 23
$35-<50k 16
$50-<75K 19
$75K or more 38
©2012 MFMER | slide-5
40 49 46
50-59 28
Number of Children
None 31
1-2 46
3 or more 23
High School or less 28
Completed some college
35
College graduate 24
Completed at least some graduate school
14
Living with partner 9
Employment %
Employed full-time 51
Employed part-time
15
Not employed/stay at home partner
30
Retired/Student 4
Diagnosis:
On average, women experience fibroid symptoms for about 3.6 years before seeking treatment.
28% 35% 26%
26%
13% 7% 11%23%
60%
80%
100%
©2012 MFMER | slide-6
59% 58% 63%51%
0%
20%
40%
Total(a)
50-59 (g)
40-49(f)
29-39(e)
Saw 3 or more providers
Saw 2 providers
Saw 1 provider
Number of Providers Seen Prior to Diagnosis
BASE: ALL QUALIFIED RESPONDENTS (n=968)Q715 How many healthcare providers did you see for your uterine fibroid symptoms before you were diagnosed?
14
14%
19%
26%
30%
29%
36%
44%
39%
26%
29%
29%
Passing clots during period
Menstrual pain/Cramps
Heavy/Prolonged bleeding
Total (a)
% responding Very severe/Severe
gg
g
fg
Younger women are more likely than older women to rate fibroid symptoms as severe
g
©2012 MFMER | slide-7
16%
12%
17%
17%
22%
27%
25%
26%
23%
33%
37%
21%
24%
26%
Abdominal bloating
Abdominal pain/Cramping/Tightness
Fatigue
Passing clots during period29-39 (e)
40-49(f)
50-59 (g)fg
g
g
BASE: ALL QUALIFIED RESPONDENTS (n=968)Q740 How would you rate the fibroid symptoms/conditions you experienced in the past 3 months?
Fibroids negatively impact the work performance and potential for younger women.
% responding Strongly/Somewhat agree
16%
27%
30%
35%
37%
26%
28%
Prevented me from carrying out normal work-l t d f i l ibiliti
Caused me to miss days of workg
In the previous 3 months, having fibroids has……
g
g
g
©2012 MFMER | slide-8
5%
8%
15%
13%
10%
15%
24%
27%
21%
19%
32%
12%
15%
24%
Made me afraid I'll lose my job
Prevented me from traveling for work
Prevented me from reaching my true potential at work or in my professional life
related or professional responsibilities
Total (a)
29-39 (e)
40-49 (f)
50-59 (g)
BASE: EMPLOYED (n=675),Q815 Please indicate how much you agree or disagree with the following statements about your current work‐related experiences.
g
g
g
gg
fg
Younger women have more fears about their fibroids, particularly risk of depression and the ability to have a successful pregnancy.
% responding Strongly/Somewhat agree
40%
51%
54%
62%
59%
65%
72%
85%
65%
74%
81%
87%
55%
63%
69%
79%
I am going to need a hysterectomy
Of other possible health complications
There is something inside me that doesn't belong there
The fibroids will grow
Total (a)
g
I’m afraid…
g
gg
gg
gg
©2012 MFMER | slide-9
8%
23%
26%
30%
34%
40%
22%
38%
45%
49%
55%
55%
49%
53%
49%
60%
65%
66%
25%
38%
40%
46%
52%
54%
Fibroids will affect my ability to have a successful and healthy pregnancy
Fibroids will make me depressed
Fibroids will affect my relationship with husband/significant other
My body will never be normal again
Fibroids will affect my sex life
The fibroids might turn into cancer
Total (a)
29-39 (e)
40-49 (f)
50-59 (g)
BASE: ALL QUALIFIED RESPONDENTS (n=968)Q810 How do you feel about the following statements related to uterine fibroids?
gg
gg
gg
gg
gfg
fgg
Two out of three women in child-bearing years say it is important to have a treatment option that allows a women to keep her uterus.
17%
19%
16% 18%
34%46%
31% 29%
60%
80%
100%
Very important
Important
fg
©2012 MFMER | slide-10
23%14%
26% 27%
25%
22%
27% 26%19%
0%
20%
40%
Total(a)
29-39(e)
40-49(f)
50-59(g)
Somewhat important
Not at all important
BASE: ALL QUALIFIED RESPONDENTS (n=968)Q925 Regardless of fibroid treatment options, how important is it for you to keep your uterus?
e e
76% say it is important to have a treatment option not involving invasive surgery and enabling potential for future children.
24%
52% 46%
66%
48%
60%
80%
100%
Very important
Important
b
©2012 MFMER | slide-11
9% 12% 6%
15%18%
8% 16%
24%24%
19%
36%
0%
20%
40%
Total(a)
White (b)
African-American(c)
Other(d)
Somewhat important
Not at all important
BASE: ALL QUALIFIED RESPONDENTS (n=968)Q930 How important is it that a woman has a fibroid treatment option that does not involve invasive surgery and enables the potential for her to have children in the future?
c
Less than half of women report their physician has discussed all treatment options with them and that they take part in
decision-making
46%
27%
39%
40%
34%
35%
32%
40%
43%
%
35%
38%
41%
Doctor discussed all possible treatment options with me
Doctor invited me to take part in treatment decision-making
process
Doctor provided all information needed to understand treatment
options
©2012 MFMER | slide-12
20%
22%
26%
31%
26%
23%
26%
28%
22%
22%
30%
34%
23%
22%
28%
32%
None of these
Discussed treatment information found on the Internet/other
sources with my doctor
I researched treatment options on my own and discussed with doctor
my treatment preference
I expressed personal preferences for treatment to my doctor
Total (a)
White (b)
African-American (c)
Other (d)
BASE: ALL QUALIFIED RESPONDENTS (n=968)Q945 Which of the following describes your experience as it relates to fibroid treatment?
15
Despite the discussions, needs remain for information. Younger women have the greatest need.
17%
21%
21%
16%
35%
35%
36%
35%
35%
35%
36%
48%
30%
31%
32%
33%
Need information about consequences of treatment options
Need information about consequences of not having fibroids treated
Wants information about alternative treatments
Need information about treatment optionsfg
g
g
g
©2012 MFMER | slide-13
47%
4%
25%
19%
17%
25%
5%
21%
30%
22%
16%
29%
30%
30%
7%
24%
27%
None of these
Needs peer support
Found enough useful information on Internet
Need information about fibroids in general
treatment options
Total (a) 29-39 (e)
40-49 (f) 50-59 (g)
BASE: ALL QUALIFIED RESPONDENTS (n=968)Q950 Which of the following statements reflect your need for fibroid information?
c
g
fg
ef
Invasiveness is biggest treatment concern. Younger women are more concerned.
% responding Very/Somewhat concerned
29%
37%
35%
35%
41%
53%
39%
44%
48%
51%
49%
58%
56%
51%
60%
58%
64%
64%
40%
44%
47%
48%
50%
58%
Effects on sexuality
Number work days missed for recovery
Permanence of treatment
Potential pain during procedure
Undergoing the actual treatment
Invasiveness of procedure/Having surgery
g
fg
fgg
gg
gfg
©2012 MFMER | slide-14
6%
7%
15%
21%
24%
25%
24%
34%
14%
17%
21%
30%
35%
33%
38%
35%
37%
44%
31%
46%
42%
46%
52%
48%
17%
21%
22%
32%
34%
34%
37%
38%
Effect on ability to have a healthy pregnancy
Effects on fertility
How husband/partner will view me
Effects on sense of femininity
Potential for scaring
Inability to do household chores
Inability to take care of family
Potential loss of income Total (a)
29-39 (e)
40-49 (f)
50-59 (g)
BASE: ALL QUALIFIED RESPONDENTS (n=968),Q955 When trying to decide what treatment option is right for you, how concerned are you with the following?
g
fgg
fg
gg
fgg
g
fgg
fgg
Assessing Treatment Choice
• Traditional Hysterectomy, the surgical removal of the entire uterus, through an incision in the abdomen, eliminating any possibility of fibroid recurrence, ongoing menstrual discomfort or future pregnancy….Recovery time can be significant, taking up to 6 weeks. Women may experience pain during recovery.
• Less Invasive Hysterectomy, the surgical removal of the entire uterus through less invasive techniques, such as with small incisions and a scope, or through the vagina, eliminating any possibility of fibroid recurrence, ongoing menstrual discomfortor future pregnancy…Recovery time can take from 2 to 4 weeks, depending on the approach. Women may experience pain during recovery.
• Traditional Myomectomy, the surgical removal of fibroids from the uterine wall through an incision in the abdomen, opening up the possibility for future fertility, although there may be complications with pregnancy….Recovery time can range from 4 to 6 weeks. Women may experience abdominal discomfort and pain during recovery.
• Less Invasive Myomectomy, the surgical removal of fibroids from the uterine wall through small incisions and a scope or
©2012 MFMER | slide-15
y y, g g pthrough the vagina, opening up the possibility for future fertility, although there may be complications with pregnancy... Patients may require additional procedures if fibroids return or new fibroids grow. Recovery time can range from 1 to 4 weeks, depending upon approach. Women may experience abdominal discomfort and pain during recovery.
• Uterine Fibroid Embolization, a minimally invasive treatment that involves inserting a small catheter through an artery in the groin to arteries that supply the uterus. There have been successful pregnancies after this treatment, although UFE may pose risks to a woman’s ability to become pregnant and carry a pregnancy after treatment….Recovery time typically ranges between 3 to 10 days. Women may experience pain for a few weeks as the fibroid’s blood flow is restricted.
• Focused Ultrasound, a treatment that uses high intensity sound waves to heat and destroy uterine fibroid cells while leaving surrounding tissue intact. This is the first non-invasive option available for uterine fibroid patients, with no incisions made in the body. There have been successful pregnancies after this treatment and medical evidence is building that there may be fewer complications in pregnancies compared to other fibroid treatments. Patients can resume normal activities the day after treatment, with symptoms usually improving within several weeks. Women may experience transient leg pain
Focused ultrasound is the clear treatment option of choice for women with fibroids.
% rating treatment their top choice
9%
63%
17%
50%
8%
9%
64%
9%
11%
60%
L i i t
UFE or UAE
Focused ultrasound
Total (a)
b
c
©2012 MFMER | slide-16
0%
0%
6%
22%
6%
10%
7%
10%
3%
7%
10%
8%
3%
7%
9%
Traditional myomectomy
Traditional hysterectomy
Less invasive hysterectomy
Less invasive myomectomy Total (a)
White (b)
African-American (c)
Other (d)
BASE: ALL QUALIFIED RESPONDENTS (n*=968) *base varies slightlyQ960 Please rank the following treatment options where “1” = your top choice and “6” = your bottom choice.
Summary
• Fibroids cause significant morbidity for women, particularly those of child-bearing age
• Fibroids can negatively impact the workplace and career potential for women
• Women wait several years before seeking treatment and often see 2 or more healthcare providers for diagnosis
W d t i ll i f ti d d t d t d
©2012 MFMER | slide-17
• Women do not receive all information needed to understand treatment options and do not feel they participate in making treatment decisions
• Women want treatment procedures that preserve fertility, preserve the uterus, do not involve invasive surgery, decrease loss of work and allow quick return to daily life
• Women overwhelmingly prefer noninvasive and minimally invasive therapies
Acknowledgements
• Survey questions from the UFS-QOL were used with permission from the Society of Interventional Radiology (SIR) Foundation (Fairfax, Virginia)
©2012 MFMER | slide-18
(Fairfax, Virginia)
• The authors thank Jill W. Roberts, M.S. and Susan Kleese for assistance in preparation of the slides
16
References
Walker CL, Stewart EA. Science. 2005;308:1589-92.
Stewart EA. Uterine Fibroids: The Complete Guide. Johns Hopkins University Press, 2007
Laughlin SK, Stewart EA. Obstet Gynecol. Feb 2011;117:396-403.
Zimmermann A, Bernuit D, Gerlinger C, Schaefers M, Geppert K. BMC women's health. 2012;12:6.
©2012 MFMER | slide-19
Taran FA, Brown HL, Stewart EA. Fertil Steril. Sep 2010;94(4):1500-1503.
Gliklich RE, Leavy MB, Velentgas P, et al. 2011. Agency for Healthcare Research and Quality Effective Health Care Research Report No.31.
Spies JB, Coyne K, Guaou Guaou N, Boyle D, Skyrnarz-Murphy K, Gonzalves SM. Obstet Gynecol. 2002;99(2):290-300.
17
FertilityFertility FollowingFollowing TubalTubalEctopic Pregnancy: Ectopic Pregnancy:
Results of a PopulationResults of a Population--Based Study Based Study
41st AAGL Global Congress, Las Vegas, Nevada
Benoit Rabischong, MD,PhD, Marianne de Bennetot, MD, Bruno Aublet-Cuvelier, MD, PhD, Fabien Belard, D. Larrain, MD,
Hervé Fernandez, MD, Jean Bouyer, MD,PhDMichel Canis, MD, PhD, Jean-Luc Pouly, MD
Disclosure
• I have no financial relationships to disclose.
Epidemiologic Register for Ectopic Pregnancy in Auvergne
Created in 1992 (J.L Pouly, H. Fernandez, N. Job Spira)
General population basisGeneral population basis (non biased information, the « real life »)
3 departments of Auvergne’s region (Allier, Cantal, Puy de Dôme)
To study EP incidence on a long period, old and new risk factors, different To study EP incidence on a long period, old and new risk factors, different treatment’s results, costtreatment’s results, cost--effectiveness and consequences effectiveness and consequences
on fertility and quality of lifeon fertility and quality of life
p g g
20 medical centers, public and private
All women, 15-45 years old, treated for EP
1992-2008: 3193 patients (200 cases / year)
Epidemiologic Register Epidemiologic Register for Ectopic Pregnancy in Auvergnefor Ectopic Pregnancy in Auvergne
A A trainedtrained investigatorinvestigator / / medicalmedical center in charge of:center in charge of:Case identification, follow-up and data collection
PrePre--establishedestablished questionaryquestionary basis / patient:basis / patient:• Sociodemographic characteristics
• Sexual, gynaecological, reproductive and smoking habits
• Surgical histories and conditions of conception (contraception, IVF)
• Serological tests and β-HCG levels
• Characteristics of the EP (site, tubal rupture, haemoperitoneum…)
• Characteristics of treatment procedures
Interview by phone Interview by phone everyevery 6 6 monthsmonths / / fertilityfertility
ExhaustivenessExhaustiveness ratio ~ 90 %ratio ~ 90 % (capture-recapture technique)
Fertility Following Tubal Ectopic Pregnancy
Rate of Rate of sspontaneouspontaneous IUP IUP accordingaccording to the type of to the type of treatmenttreatment ??
highly controversial issue
RiskRisk factorsfactors ofof repeatedrepeated ectopicectopic pregnancypregnancy??RiskRisk factorsfactors of of repeatedrepeated ectopicectopic pregnancypregnancy??
Prospective Prospective followfollow--up of up of eacheach patient patient untiluntil 45 y 45 y oldoldin the in the Auvergne’sAuvergne’s registerregister to to studystudy the reproductive the reproductive
outcomeoutcome afterafter a a tubaltubal EP EP
Fertility Following Ectopic PregnancyResults of Auvergne’s Register, Patients
De Bennetot, Rabischong et Al. Fertil Steril 2012
18
Factors influencing Fertility Following EPRate of IUP, Univariable analysis, 1064 patients
TreatmentTreatment, p=0.007, p=0.007in favour of a conservative treatment (medical or surgical)
HistoryHistory ofof infertiliyinfertiliy, p<0.0001, p<0.0001HistoryHistory of of infertiliyinfertiliy, p 0.0001, p 0.0001
HistoryHistory of live of live birthbirth, p=0.007, p=0.007
TubalTubal diseasedisease, p<0.0001, p<0.0001
EP EP withwith IUD, p<0.0001IUD, p<0.0001
Age Age atat baselinebaseline, p<0.0001, p<0.0001
Fertility Following Ectopic Pregnancy24-months cumulative rates of spontaneous IUP/ treatmentKaplan-Meier, 1064 patients
100%100%90%
100%90%
100%80% 90%
100%80% 90%80% 90%80% 90%80% 90%70% 80% 90%% )70% 80%% )60% 70% 80%e ( % )60% 70%e ( % )60% 70%r a t e ( % )60% 70%r a t e ( %50% 60% 70%i v e r a t e ( %50% 60%i v e r a t e40% 50% 60%l a t i v e r a t e40% 50%l a t i v e 40% 50%m u l a t i v e 40%m u l a t i40%m u l a t i30% 40%C u m u l a t i30% 40%C u m u20% 30% 40%C u m u20% 30%C u10% 20% 30%C u10% 20%10% 20%10% 20%0% 10% 20%0% 10%0% 10%0% 10%02
46
810
0%02
46
810
0%02
46
810
Timetopregnanc
0%02
46
810
Timetopregnanc
0%02
46
810
Time to pregnanc0
24
68
10Time to pregnanc
02
46
810
Time to pregnancTime to pregnanc
RadicalRadicalRadical
C Radical
C Radical
C Radical
Conservative il
Conservative il
Conservative surgicalMedical
Conservative surgicalMedical
Conservative surgicalMedicalsurgicalMedicalsurgicalMedicalMedicalMedical
1214
1618
2022
2412
1416
1820
2224
1214
1618
2022
24cy(months)12
1416
1820
2224
cy(months)12
1416
1820
2224
cy (months)12
1416
1820
2224
cy (months)12
1416
1820
2224
cy (months)cy (months)
24-months cumulative rate:•• SalpingectomySalpingectomy: 67.4 %: 67.4 %•• SalpingostomySalpingostomy: 76.4 % : 76.4 %
•• MethtrexateMethtrexate: 75.6 %: 75.6 %De Bennetot, Rabischong et Al. Fertil Steril 2012
Fertility Following Ectopic PregnancyMultivariable analysis of factors influencing fertility: Cox model
AfterAfter adjustementadjustement for for confoundersconfounders, , therethere waswas onlyonly a a statisticallystatisticallynot not significantsignificant trend in trend in favourfavour of the conservative of the conservative strategystrategy..
Fertility Following Ectopic PregnancyMultivariable analysis for the two subgroup of women depending of history of infertility, tubal patency or age at the time of EP
De Bennetot, Rabischong et Al. Fertil Steril 2012
Fertility Following Ectopic PregnancyMultivariable analysis for the two subgroup of women depending of history of infertility, tubal patency or age at the time of EP
For patients For patients withwith atat least one of least one of thesethese threethree riskriskfactorsfactors ((subgroupsubgroup 1), the IUP rate 1), the IUP rate waswas
significantlysignificantly higherhigher afterafter conservative conservative treatmenttreatmentdd i hi h l il icomparedcompared withwith salpingectomysalpingectomy
(HR 0.67; 95% CI 0.50(HR 0.67; 95% CI 0.50--0.91)0.91)
In In thisthis subgroupsubgroup, no , no differencedifference in in fertilityfertility waswasfoundfound accordingaccording to the type of conservative to the type of conservative
treatmenttreatment, , medicalmedical or or surgicalsurgical..
Recurrence Following Ectopic PregnancyCumulative rates of repeat EP depending of the treatment
% % % % % % %% % % %
03
69
1215
Time to pregnancy (mon
Radical
Conservative-surgical
Medical
518
2124
nths)
22--year cumulative rate of year cumulative rate of repeatrepeat EPEP•• 19 % for 19 % for salpingostomysalpingostomy•• 18.5 % for 18.5 % for salpingectomysalpingectomy•• 25.5 % for 25.5 % for methotrexatemethotrexate•• No No differencedifference accordingaccording to the type of to the type of treatmenttreatment, p=0.86, p=0.86
De Bennetot, Rabischong et Al. J Gynecol Obstet Biol Reprod 2012
19
Recurrence Following Ectopic PregnancyMultivariable analysis of factors influencing the risk of recurrence (Cox model)
PreviousPrevious voluntaryvoluntary terminationtermination of of pregnancypregnancy waswas a a riskrisk factor of factor of recurrencerecurrence (HR 1.8; 95% CI 1.1(HR 1.8; 95% CI 1.1--3.0)3.0)
InterestInterest in in secondarysecondary preventionprevention
Effectiveness of Methotrexate1992-2008, Auvergne’s register, 3193 patients
419 419 patients patients treatedtreated by MTXby MTX Asymptomatic, β-HCG < 5000 IU
Mean pre-therapeutic HCG level = 1675 IU
Single dose regimen: one inramuscular injection of 50 mg/m2
Failure= need of a second line surgical treatment
MeanMean FailureFailure rate: 24.6 %rate: 24.6 %50% en 1992, 13% en 2008 ( p<0.0001)
Mean HCG level• Success: 1274,8 IU (95% CI 962-1587), Failure: 2920,2 IU (95% CI 1242.4-4598), p=0.06
Univariate and multivariate analysis
Significant factors of failure in multivariate analysis: History of combined oral contraception, 18.4% vs 30.4%, p = 0,0001
HCG HCG levellevel:: < 1300 IU< 1300 IU Failure rate Failure rate = 16.5 % = 16.5 % > 1300 IU> 1300 IU Failure rate Failure rate = 39.9 % = 39.9 % p < 0,0001p < 0,0001
OR 3.6, 95% CI 2.1OR 3.6, 95% CI 2.1--5.95.9Rabischong et Al. Fertil Steril 2011
Effectiveness of Laparoscopic Salpingostomy1992-2008, Auvergne’s Register, 3193 patients
1306 patients, Indication:1306 patients, Indication:• Whenever possible / Fertility, Pouly score (Fertil Steril 1989)
Mean HCG level•• Success: 2900.5 Success: 2900.5 +/+/-- 7156.1, 7156.1, FailureFailure: 3745.7 : 3745.7 +/+/-- 5428.6 5428.6 (p=0.20)(p=0.20)
Failure =Failure = second line of medical or surgical treatment
MeanMean failure rate = 6 6failure rate = 6 6 %% (24 6 % i h MTX)(24 6 % i h MTX) MeanMean failure rate = 6.6 failure rate = 6.6 % % (24.6 % with MTX)(24.6 % with MTX)
•• Stable Stable throughthrough all the all the periodperiod
•• LowerLower thanthan the the literatureliterature ( ( ~ 15 ~ 15 %%) and / single dose MTX ) and / single dose MTX
Factor of failure in multivariate analysis:HCG HCG levellevel::
< 1960 IU, < 1960 IU, failurefailure rate = 5.1 %rate = 5.1 %
Si > 1960 UI, Si > 1960 UI, failurefailure rate = 8.6 % , rate = 8.6 % , p= 0.03p= 0.03
But But poorpoor predictivepredictive value and value and clinicalclinical releavancereleavance of of thisthis cutcut--off off
Rabischong, Larrain et Al. Obstet Gynecol 2010
(5.9 % in 1992 vs 6.4% in 2008, p=0,89)
ConclusionsConclusionsFertilityFertility followingfollowing EP EP
The main The main strenghtstrenght of of thesethese resultsresults isis thatthat theythey reflectreflect the the dailydaily gynecologicalgynecological practicepractice
The conservative The conservative strategystrategy seemsseems to to bebe preferredpreferred wheneverwheneverpossible to possible to preservepreserve patient’spatient’s fertilityfertility withoutwithout increasingincreasing
the the riskrisk of of recurrencerecurrencethethe iskisk ofof ecu enceecu ence The The choicechoice betweenbetween conservative conservative treatmentstreatments doesdoes not not relyrely
on on subsequentsubsequent fertilityfertility, but more , but more likelylikely on on theirtheir ownownindications and indications and therapeutictherapeutic effectivenesseffectiveness or the or the qualityquality of of
lifelife RiskRisk factorsfactors of of recurrencerecurrence couldcould bebe consideredconsidered for for
secondarysecondary preventionprevention
Thank You Very Much For Your Attention !
20
Utility of Site‐Specific Peritoneal Biopsies in the Benign‐Appearing Pelvis on Laparoscopy for the Diagnosis of Endometriosis in
Chronic Pelvic Pain
Dassel M and N Desai, D Atashroo, M HibnerSt. Joseph’s Hospital and Medical CenterCreighton University College of Medicine
Phoenix, AZ
Disclosure
I have no financial relationships to disclose.
Objectives
• Recognize the need for tissue sampling in patients with chronic pelvic pain and a benign‐appearing pelvis
• Counsel patients on the prevalence of• Counsel patients on the prevalence of endometriosis in a benign‐appearing pelvis
Background
• Chronic pelvic pain is a common gynecologic syndrome with significant psychosocial and economic impact.
• The differential is very broad and can be• The differential is very broad and can be difficult to evaluate.
• One common cause is endometriosis
• Diagnostic Laparoscopy can be useful in diagnosis, but can sometimes appear benign.
Clinical Question
• Should peritoneal biopsies be performed in the benign‐appearing pelvis when encountered during diagnostic laparoscopy for pelvic pain?
• Null Hypothesis: Peritoneal biopsies in the benign‐appearing pelvis during diagnostic laparoscopy for pelvic pain will not demonstrate microscopic evidence of endometriosis
Materials and Methods
• Retrospective analysis
• Biopsies taken at 4 pre‐specified pelvic sites in the benign‐appearing pelvis during laparoscopic evaluation of pelvic painlaparoscopic evaluation of pelvic pain
• Tissue sent for standard pathological review
• Statistics were purely descriptive
21
L
A
Standard Biopsy Sites
L
P
R
• Biopsies were taken in the (A) anterior cul‐de‐sac, (P) posterior cul‐de‐sac, and the (L) left and (R) right ovarian fossae.
• Biopsies were ovoid and 1‐2 cm in greatest diameter.
ResultsPatients with chronic pelvic pain undergoing diagnostic laparoscopy(n=304)
Pathology in the Pelvis
Benign‐Appearing PelvisPelvis
(n=194)Pelvis(n=110)
Biopsy NEGATIVE for endometriosis(n= 81)73.4%
Biopsy‐POSITIVE for endometriosis(n=29)26.6%
Results
Variable Mean Std Dev Range
Age (years) 31 7.9 18‐56
Height (inches) 64” 3.0” 56”‐77”
Weight (lbs) 156 4.6 105‐329
BMI (kg/m2) 27.2 0.7 17.7‐54.9( g/ )
Self Reported Race Frequency Percent
White 105 91.30
Hispanic 6 5.22
Other 2 1.74
Unknown 2 1.74
Results
• Proportion of positive biopsy sites
36/401=8.98%
• Proportion of patients with at least one positive biopsy site
29/110=26.36%
• 23 with 1 positive, 5 with 2 positive, 1 with 3 positive
• In the 23 with 1 biopsy‐positive sight
Results Interpretation
• Of 110 patients with a benign‐appearing pelvis on laparoscopy, 29 (26%) had at least one biopsy‐site positive for endometriosis
• Approximately 1 in 4 patients were given a• Approximately 1 in 4 patients were given a diagnosis of endometriosis that would have otherwise gone unrecognized
Future Direction
• Future peritoneal biopsy studies should be performed prospectively comparing patients with and without chronic pelvic pain.
• Clinical outcome data regarding clinical utility g g yof endometriosis diagnosis by peritoneal should be sought
• Determine how many and at which location biopsies should be performed to establish the diagnosis
22
Clinical Correlation
• Peritoneal biopsies during diagnostic laparoscopy for pelvic pain are low morbidity
• Can establish a diagnosis of endometriosis in 26% of individuals with chronic pelvic pain and normal diagnostic laparoscopy
• Thereby we continue to perform peritoneal biopsies in patients with chronic pelvic pain with benign‐appearing laparoscopy with 2 caveats:
1. We need to establish pain outcomes in endometriosis‐positive patients treated with conventional therapy for endometriosis
2. A prospective controlled trial would yield better data as to the baseline level of endometriosis in a non‐ pelvic pain population.
References• 1. Jamieson DJ, Steege JF. The prevalence of dysmenorrhea, dyspareunia, pelvic pain, and irritable bowel syndrome in primary care practices. Obstetrics and gynecology 1996;87(1):55‐8.• 2. Mathias SD, Kuppermann M, Liberman RF, Lipschutz RC, Steege JF. Chronic pelvic pain: prevalence, health‐related quality of life, and economic correlates. Obstetrics and gynecology
1996;87(3):321‐7.• 3. Gao X, Outley J, BottemanM, Spalding J, Simon JA, Pashos CL. Economic burden of endometriosis. Fertility and sterility 2006;86(6):1561‐72.• 4. Tripoli TM, Sato H, Sartori MG, de Araujo FF, Girao MJ, Schor E. Evaluation of quality of life and sexual satisfaction in women suffering from chronic pelvic pain with or without
endometriosis. The journal of sexual medicine 2011;8(2):497‐503.• 5. Howard F. Chronic Pelvic Pain. ACOG Practice Bulletin 2004;51:1‐17.• 6. Howard FM. Chronic pelvic pain. Obstetrics and gynecology 2003;101(3):594‐611.• 7. Kresch AJ, Seifer DB, Sachs LB, Barrese I. Laparoscopy in 100 women with chronic pelvic pain. Obstetrics and gynecology 1984;64(5):672‐4.• 8. Mahmood TA, Templeton AA, Thomson L, Fraser C. Menstrual symptoms in women with pelvic endometriosis. British journal of obstetrics and gynaecology 1991;98(6):558‐63.• 9. Eltabbakh GH, Bower NA. Laparoscopic surgery in endometriosis. Minerva ginecologica 2008;60(4):323‐30.• 10. Lamvu G, Williams R, Zolnoun D, Wechter ME, Shortliffe A, Fulton G, et al. Long‐term outcomes after surgical and nonsurgical management of chronic pelvic pain: one year after
evaluation in a pelvic pain specialty clinic. American journal of obstetrics and gynecology 2006;195(2):591‐8; discussion 98‐600.• 11. Leng JH, Lang JH, Zhao XY, Li HJ, Guo LN, Cui QC. [Visual and histologic analysis of laparoscopic diagnosis of endometriosis]. Zhonghua fu chan ke za zhi 2006;41(2):111‐3.• 12. Walter AJ, Hentz JG, Magtibay PM, Cornella JL, Magrina JF. Endometriosis: correlation between histologic and visual findings at laparoscopy. American journal of obstetrics and
gynecology 2001;184(7):1407‐11;discussion 11‐3gynecology 2001;184(7):1407‐11; discussion 11‐3.• 13. Howard FM. The role of laparoscopy in the evaluation of chronic pelvic pain: pitfalls with a negative laparoscopy. The Journal of the American Association of Gynecologic
Laparoscopists 1996;4(1):85‐94.• 14. Redwine DB. 'Invisible' microscopic endometriosis: a review. Gynecologic and obstetric investigation 2003;55(2):63‐7.• 15. Redwine DB, Yocom LB. A serial section study of visually normal pelvic peritoneum in patients with endometriosis. Fertility and sterility 1990;54(4):648‐51.• 16. Balasch J, Creus M, Fabregues F, Carmona F, Ordi J, Martinez‐Roman S, et al. Visible and non‐visible endometriosis at laparoscopy in fertile and infertile women and in patients with
chronic pelvic pain: a prospective study. Hum Reprod 1996;11(2):387‐91.• 17. Murphy AA, Green WR, Bobbie D, dela Cruz ZC, Rock JA. Unsuspected endometriosis documented by scanning electron microscopy in visually normal peritoneum. Fertility and sterility
1986;46(3):522‐4.• 18. Nascu PC, Vilos GA, Ettler HC, Abu‐Rafea B, Hollet‐Caines J, Ahmad R. Histopathologic findings on uterosacral ligaments in women with chronic pelvic pain and visually normal pelvis at
laparoscopy. Journal of minimally invasive gynecology 2006;13(3):201‐4.• 19. Nisolle M, Paindaveine B, Bourdon A, Berliere M, Casanas‐Roux F, Donnez J. Histologic study of peritoneal endometriosis in infertile women. Fertility and sterility 1990;53(6):984‐8.• 20. Ogden CL, Fryar CD, Carroll MD, Flegal KM. Mean body weight, height, and body mass index, United States 1960‐2002. Advance data 2004(347):1‐17.• 21. Arumugam K, Templeton AA. Endometriosis and race. The Australian & New Zealand journal of obstetrics & gynaecology 1992;32(2):164‐5.• 22. Stegmann BJ, Sinaii N, Liu S, Segars J, Merino M, Nieman LK, et al. Using location, color, size, and depth to characterize and identify endometriosis lesions in a cohort of 133 women.
Fertility and sterility 2008;89(6):1632‐6.• 23. Vasquez G, Cornillie F, Brosens IA. Peritoneal endometriosis: scanning electron microscopy and histology of minimal pelvic endometriotic lesions. Fertility and sterility 1984;42(5):696‐
703.• 24. Sampson JA. Peritoneal Endometriosis due to the menstrual dissemination of endometrial tissue into the peritoneal cavity. American journal of obstetrics and gynecology
1927;14:422‐69.
Thank you for your attention.
23
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 13166 (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).
California Business & Professions Code §2190.1(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 http://www.imq.org
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 1964 http://www.usdoj.gov/crt/cor/pubs.htm.
Executive Order 13166,”Improving Access to Services for Persons with Limited English
Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm 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. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.
US Population
Language Spoken at Home
English
Spanish
AsianOther
Indo-Euro
California
Language Spoken at Home
Spanish
English
OtherAsianIndo-Euro
19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%
24
