Objective: To evaluate the efficacy of surgical management for isthmoceles in patients presenting with secondary infertility. Data Sources: A systematic search was performed in MEDLINE, EMBASE, and Cochrane Library databases from inception to May 2020. The search was limited to studies published in English. Methods of Study Selection: After the removal of duplicates, 3380 articles were screened for inclusion independently by 2 authors. These 2 authors assessed for studies which focused on women of reproductive age with a diagnosed isthmocele and secondary infertility who underwent any surgical intervention for defect repair with at least 1 of the goals being fertility restoration. Tabulation, Integration, and Results: A total of 13 studies, comprising of 1 randomized controlled trial, 6 prospective case series, and 6 retrospective case series describing 234 patients who underwent surgical management for an isthmocele and secondary infertility were included. The methodologic quality of the included studies was assessed independently by both reviewers. Next, the data extraction was performed independently and then compared to ensure no discrepancies. A total of 188 patients were treated by hysteroscopy, 36 by laparoscopy, 7 by laparotomy, and 3 through a vaginal approach. In total, 153 of the 234 patients (65.4%) achieved pregnancy across all studies within their respective study periods. Pregnancy rates in the randomized controlled trial were 21 of 28 (75%) for those treated by hysteroscopy compared with 9 of 28 (32%) for those untreated. Among the studies reporting pregnancy outcomes, 101 of 116 (87.1%) pregnancies resulted in a live birth. The incidence of adverse events was 2%, including the risk of reoperation.
Conclusion:The results of this systematic review suggest that the surgical treatment of an isthmocele, particularly through hysteroscopy, in patients with residual myometrial thickness of at least 2.5 mm, may be effective in treating isthmoceleassociated secondary infertility with a relatively low complication rate. Further high-quality studies are needed because of the small sample sizes and observational nature of most available data.
Objective: To study the feasibility of fertility preservation in a transgender man without an extended period of androgen cessation. Design: Report of a foundational case of oocyte cryopreservation in a transgender man without stopping testosterone therapy before controlled ovarian stimulation. We performed a literature review, identifying five publications on oocyte cryopreservation outcomes in transgender men on testosterone. Setting: A university-affiliated fertility clinic in Canada. Patient(s): A 28-year-old transgender man taking testosterone for 3 years requesting oocyte cryopreservation before gender-affirming surgery. He desired to proceed without stopping testosterone. Pretreatment antim€ ullerian hormone level was 1.89 ng/mL. The patient's consent was obtained for written publication. Intervention(s): Testosterone was stopped for only three doses (immediately before and during ovarian stimulation). A standard antagonist protocol was used with letrozole to minimize estrogenic side effects. Main Outcome Measure(s): Number of oocytes retrieved and days off testosterone. Result(s): Thirteen oocytes were retrieved; 11 were mature and vitrified. The total time off testosterone was 24 days. In all prior publications, testosterone was stopped for 3-6 months.
Conclusion(s):Transgender men have traditionally discontinued exogenous testosterone until the resumption of menses (%6 months). This is known to be distressing. This is the first published case demonstrating the feasibility of ovarian stimulation without prolonged testosterone cessation in a transgender man. Future studies with a larger sample size should be performed to confirm these findings. The short duration off testosterone may improve patient's experiences, increase treatment acceptability, and decrease gender dysphoria for transgender men considering fertility preservation. (Fertil Steril Rep Ò 2020;1:43-7. Ó2020 by American Society for Reproductive Medicine.
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