KEY POINTS Polycystic ovarian syndrome (PCOS) causes irregular menstrual cycles and symptoms of hyperandrogenism and affects 10% of females ([Figure 1][1]).[1][2] Symptoms most often begin between the ages of 18 and 39 years, but diagnosis and treatment of PCOS are often delayed or patients remain

ImportancePhysicians, especially surgeons, delay family building, and face age-related complications of pregnancy.ObjectiveTo explore factors that are associated with family building decisions among residents and fellows and to understand their thoughts on accessing family building supports, workplace culture, and attitudes toward family planning.Design, Setting, and ParticipantsThis qualitative study was conducted from May to August 2022 at postgraduate training sites across Ontario, Canada. Participants included 29 postgraduate learners. Purposive sampling from 80 eligible trainees was used to ensure diverse demographics, including sex, specialty, and institution. Semi-structured individual interviews lasting 30 to 90 minutes were conducted over a virtual platform. Participants were asked to share their thoughts and experiences on family planning in a medical career, family building goals, the role of mentorship, and knowledge of current family planning supports.Main Outcomes and MeasuresThemes associated with residents’ perception of family planning within the context of a medical career.ResultsTwenty-nine trainees, ages 25 to 37 years old (22 [75.9%] were female, 26 [89.7%] were heterosexual; median [range] age, 30 [25-37] years) from various institutions took part in this study. The participants included both 24 residents (82.8%) and 5 fellows (17.2%) and 8 (27.6%) were from surgical specialties, 3 (10.3%) from pediatrics and subspecialties, 4 (13.8%) from internal medicine and subspecialties, 2 (6.9%) from obstetrics and gynecology, 3 (10.3%) family medicine, 2 (6.9%) from anesthesia, and 7 (24.1%) other medical specialties. Four themes were identified: (1) tension between role as a physician and role as a parent; (2) impact of role models and mentorship on family planning choices; (3) family building is discouraged during training, especially in surgical specialties; and (4) need for tangible family planning supports in training.Conclusions and RelevanceIn this qualitative study of residents’ and fellows’ perspectives on family building, trainees did not perceive residency and fellowship programs as supportive for individuals who want to family build during training leading to personal and professional dissonance. Trainees identified that more tangible supports, transparent information, and mentorship may improve a trainees’ feeling of support.

[Voir la version anglaise de l'article ici: www.cmaj.ca/lookup/doi/10.1503/cmaj.231251][1] Points clés Le syndrome des ovaires polykystiques (SOPK) s'accompagne d'une irrégularité des cycles menstruels et de symptômes d'hyperandrogénie; il affecte 10 % des femmes ([figure 1][2])[1][3

Importance Physicians are known to delay childbearing compared with nonphysicians and to experience higher rates of age-related pregnancy complications. Delay of childbearing is more pronounced in surgical specialties, and family planning and building goals may influence specialty choice. Objective To assess medical students’ perspectives on the development of family planning goals and the timing of family building within a medical career to elucidate how these perceptions impact their choice of specialty. Design, Setting, and Participants This qualitative study included fourth-year medical students at the University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada, and was conducted between May and August 2021. Participants were purposively sampled to maximize diversity of gender and specialty choice. Interviews were conducted via videoconferencing software that were recorded, transcribed verbatim, and verified for accuracy. Thematic analysis was completed independently by 2 researchers and consensus on final themes was reached through discussion among study investigators. Data were analyzed between September and December 2021. Main Outcomes and Measures Participants were asked to share their perceptions of personal family planning goals, support currently in place, family planning education in medicine and factors contributing to their choice of specialty and program. Thematic analysis was completed. Results A total of 34 fourth-year medical students (median [range] age, 26 [24-33] years; 23 females [67.6%]) were interviewed. Four main themes were identified: (1) there is no ideal time to family build in a medical career, (2) family planning is a taboo topic, (3) surgical specialties offer less support for family building, and (4) residents who have children are perceived to place a burden on their colleagues. Medical students considered their family planning while deliberating among specialty choices and their experiences were highly influential in shaping their specialty selection. Conclusions and Relevance Results of this qualitative study suggest that medical students perceive that family building during training may have unfavorable implications for team dynamics and relationships with colleagues, and these perceptions may affect specialty choice and family planning goals. Integration of family planning discussions and support for family building into medical curricula is needed along with efforts to improve culture by supporting team dynamics and workload when students take parental leave.

Poistcoital bleeding is nonmenstrual bleeding that occurs after penetrative intercourse and often coexists with intermenstrual bleeding.[1][1],[3][2] Cervical ectropion (19%–34%), cervical or endometrial polyps (5%–18%), infection (e.g., vaginitis, cervicitis), pregnancy and trauma are common

[Voir la version anglaise de l’article ici: www.cmaj.ca/lookup/doi/10.1503/cmaj.230143][1] Le saignement postcoïtal est un saignement non menstruel qui survient après un rapport sexuel avec pénétration et il s’observe souvent avec des saignements intermenstruels[1][2],[3][3]. L’ectropion

(Abstracted from Fertil Steril 2023;119(3):484–489) Adenomyosis is a benign gynecologic condition that causes endometrial glands and stroma to be found in the myometrium. Although the criterion-standard diagnosis of adenomyosis remains histology after hysterectomy, ultrasound diagnosis has allowed earlier detection, but no standard definition of imaging-based diagnosis exists.

OBJECTIF:Décrire les pratiques actuelles fondées sur des données probantes pour le diagnostic et la prise en charge de l'adénomyose.POPULATION CIBLE:Toutes les patientes en âge de procréer qui ont un utérus.OPTIONS:Les options diagnostiques sont l'échographie endovaginale et l'imagerie par résonance magnétique. Les options thérapeutiques doivent être adaptées aux symptômes (saignements menstruels abondants, douleur et/ou infertilité) et comprendre des options médicamenteuses (anti-inflammatoires non stéroïdiens, acide tranexamique, contraceptifs oraux combinés, système intra-utérin à libération de lévonorgestrel, diénogest, autres progestatifs, analogues de la gonadotrophine), des options interventionnelles (embolisation de l'artère utérine) et des options chirurgicales (ablation de l'endomètre, excision de l'adénomyose, hystérectomie). RéSULTATS: Les critères de jugement sont la réduction des saignements menstruels abondants, l'atténuation de la douleur pelvienne (dysménorrhée, dyspareunie, douleur pelvienne chronique) et l'amélioration du devenir reproductif (fertilité, avortement spontané, issues de grossesse défavorables). BéNéFICES, RISQUES ET COûTS: Par la présentation des méthodes de diagnostic et des options de prise en charge, cette directive sera bénéfique pour les patientes qui expriment des plaintes de nature gynécologique potentiellement causées par l'adénomyose, en particulier celles qui souhaitent préserver leur fertilité. La directive sera également utile aux praticiens qui pourront améliorer leurs connaissances sur les différentes options. DONNéES PROBANTES: Des recherches ont été effectuées dans les bases de données MEDLINE Reviews, MEDLINE ALL, Cochrane, PubMed et Embase. La recherche initiale a été réalisée en 2021 et mise à jour avec les articles pertinents en 2022. Les termes de recherche utilisés sont les suivants : adenomyosis, adenomyoses, endometritis (utilisés ou indexés sous adenomyosis avant 2012), (endometrium AND myometrium) uterine adenomyosis/es, symptom/s/matic adenomyosis ET [diagnosis, symptoms, treatment, guideline, outcome, management, imaging, sonography, pathogenesis, fertility, infertility, therapy, histology, ultrasound, review, meta-analysis, evaluation]. Les articles retenus sont des essais cliniques randomisés, des méta-analyses, des revues systématiques, des études observationnelles et des études de cas. Des articles dans toutes les langues ont été répertoriés et examinés. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations Assessment, Development and Evaluation). Voir l'annexe A en ligne (Tableau A1 pour les définitions et Tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). PROFESSIONNELS CONCERNéS: Obstétriciens-gynécologues, radiologistes, médecins de famille, urgentologues, sages-femmes, infirmières autorisées, infirmières praticiennes, étudiants en médecine, résidents et moniteurs cliniques (fellows). RéSUMé POUR TWITTER: L'adénomyose est fréquemment observée chez les femmes en âge de procréer. Il existe des options de diagnostic et de prise en charge qui préservent la fertilité. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Objective: To describe the current evidence-based diagnosis and management of adenomyosis.Target Population: All patients with a uterus of reproductive age. Options: Diagnostic options include transvaginal sonography and magnetic resonance imaging. Treatment options should be tailored to symptoms (heavy menstrual bleeding, pain, and/or infertility) and include medical options (non-steroidal anti-inflammatory drugs, tranexamic acid, combined oral contraceptives, levonorgestrel intrauterine system, dienogest, other progestins, gonadotropin-releasing analogues), interventional options (uterine artery embolization), and surgical options (endometrial ablation, excision of adenomyosis, hysterectomy).Outcomes: Outcomes of interest include reduction in heavy menstrual bleeding, reduction in pelvic pain (dysmenorrhea, dyspareunia, chronic pelvic pain), and improvement in reproductive outcomes (fertility, miscarriage, adverse pregnancy outcomes). Benefits, Harms, and Costs: This guideline will benefit patients with gynaecological complaints that may be caused by adenomyosis, especially those patients who wish to preserve their fertility, by presenting diagnostic methods and management options. It will also benefit practitioners by improving their knowledge of various options.Evidence: Databases searched were MEDLINE Reviews, MEDLINE ALL, Cochrane, PubMed, EMBASE. The initial search was completed in 2021 and updated with relevant articles in 2022. Search terms included adenomyosis, adenomyoses, endometritis (used/indexed as adenomyosis before 2012), (endometrium AND myometrium) uterine adenomyosis/es, symptom/s/matic adenomyosis] AND [diagnosis, symptoms, treatment, guideline, outcome, management, imaging, sonography, pathogenesis, fertility, infertility, therapy, histology, ultrasound, review, meta -analysis, evaluation]. Articles included randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Articles in all languages were searched and reviewed.Validation Methods: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Table A1 for definitions and Table A2 for interpretations of strong and conditional [weak] recommendations).Intended Audience: Obstetrician-gynaecologists, radiologists, family physicians, emergency physicians, midwives, registered nurses, nurse practitioners, medical students, residents, and fellows.Tweetable Abstract: Adenomyosis is common in reproductive-aged women. There are diagnostic and management options that preserve fertility available.

Background Previous research has demonstrated that patients have difficulty with the decision to undergo non-urgent egg freezing (EF). This study aimed to investigate the decisional difficulties and possible decisional support mechanisms for patients considering EF, and for their providers. Methods This qualitative study involved a needs assessment via individual interviews. Participants included patients considering EF at one academic fertility clinic and providers from across Canada who counsel patients considering EF. 25 participants were included (13 providers and 12 patients). The interview guide was developed according to the Ottawa Decision Support Framework. Interviews were transcribed, and transcripts analyzed for themes and concepts using NVIVO 12. Findings Multiple factors contributing to decisional difficulty were identified, including: (1) multiple reproductive options available with differing views from patients/providers regarding their importance; (2) a decision typically made under the pressure of reproductive aging; (3) uncertainty surrounding the technology/inadequate outcome data; (4) the financial burden of EF; (5) inherent uncertainty relating to potential decision regret; and (6) differing perceptions between patients/providers regarding the role providers should play in the decision. Additionally, potential sources of decisional support were identified, including provision of basic information before and/or during initial consultation, followed by an opportunity during or after initial consultation for clarifying information and helping with value judgements. Individualized counselling based on patient values, adequate follow-up, psychosocial counselling, and peer support were also emphasized. Conclusions More decisional support for women considering EF is needed. Suggestions include a patient decision aid in conjunction with modified healthcare provider counselling, support and follow up.

Background The decision to undergo non-urgent egg freezing (EF) is complex for patients and providers supporting them. Though prior studies have explored patient perspectives, no study has also included the separate perspectives of providers. Methods This qualitative study involved semi-structured individual interviews exploring the decision to undergo EF. Participants included patients considering EF at one academic fertility clinic and providers who counsel patients about EF from across Canada. Data analysis was accomplished using thematic analysis. Data saturation was met after interviewing 13 providers and 12 patients. Findings Four themes were identified and explored, illuminating ways in which patients and providers navigate decision-making around EF: (1) patients viewed EF as a ‘back-up plan’ for delaying the decision about whether to have children, while providers were hesitant to present EF in this way given the uncertainty of success; (2) providers viewed ovarian reserve testing as essential while patients believed it unnecessarily complicated the decision; (3) patients and providers cited a need for change in broader societal attitudes regarding EF since social stigma was a significant barrier to decision-making; and (4) commonality and peer support were desired by patients to assist in their decision, although some providers were hesitant to recommend this to patients. Conclusions In conclusion, the decision to undergo EF is complex and individual patient values play a significant role. In some areas, there is disconnect between providers and patients in their views on how to navigate EF decision-making, and these should be addressed in discussions between providers and patients to improve shared decision-making.

A 34-year-old patient with a history of myomas and adenomyosis was referred with a 3-year history of primary infertility. She underwent laparoscopic and hysteroscopic myomectomies before presentation. Initial transvaginal ultrasound reported myometrial cysts with the largest measuring 2.0 × 2.0 × 1.4 cm (Fig. 1). Follow-up saline infusion sonohysterography reported a normal uterine cavity. She underwent in vitro fertilization, which yielded one cryopreserved blastocyst. Before embryo transfer, she received 3 months of leuprolide to shrink the cysts; however, there was no change in cyst size on subsequent ultrasound. Hysteroscopy was performed revealing that the ultrasonographic myometrial cysts were in fact an artifact of a significant intrauterine adhesion (Fig. 2). Fig. 2Hysteroscopic image showing a thick central uterine adhesion. View Large Image Figure Viewer Download Hi-res image

Objective: The purpose of this study was to understand how Canadian Obstetricians/Gynaecologists (OBGYNs) diagnose and manage adenomyosis. Methods: This cross-sectional study was performed via an online survey distributed to 262 OBGYNs at three Canadian universities (University of Toronto, University of Calgary, and McMaster University). Results: A total of 137 responses were obtained out of 262 OBGYNs (52.3%) with a completion rate of 98%. Adenomyosis was a diagnosis in 6%–10% of patients seen by OBGYNs. The most common clinical symptoms included heavy menstrual bleeding (HMB) (82.8%) and dysmenorrhea (91.0%). Most participants (83%) used transvaginal ultrasound (TVUS) as first-line imaging for diagnosis of adenomyosis. Many respondents (35.8%) indicated that adenomyosis was not associated with infertility or recurrent miscarriage. Treatment considerations for all patients with adenomyosis included levonorgestrel intra-uterine system (LNG-IUS) (91.8%), hysterectomy (88.8%), expectant management (85.1%), combined hormonal contraceptives (CHC) (83.6%), tranexamic acid (81.3%), gonadotropin releasing hormone (GnRH) agonists (64.2%), depo-provera (64.2%), dienogest (57.5%), and norethisterone acetate (NETA) (40.3%). Treatments for adenomyosis in patients wishing to conceive included expectant management (85.1%), tranexamic acid (79.1%), CHC (44.8%), LNG-IUS (32.8%), and GnRH agonists (35.8%). Excision of adenomyosis would only be offered by 24% of respondents. Uterine artery embolization (UAE) would not be used in the treatment of adenomyosis by 44% of respondents. Finally, 82.8% of respondents would use improvement of clinical symptoms to follow treatment success. Conclusion: Practice varies across Canada despite recent emerging evidence in the diagnosis and management of adenomyosis, highlighting the need for a clinical practice guideline on adenomyosis.

BACKGROUND:Reproductive decision-making is difficult for BRCA-positive women. Our objective was to assess the complexities of decision-making and identify decisional supports for patients and providers when discussing reproductive options prior to risk-reducing salpingo-oophorectomy (RRSO).METHODS:This study was of qualitive design, using data collection via semi-structured interviews conducted from November 2018 to October 2020. Individuals were included if they were identified to provide care to BRCA-positive women. In total, 19 providers were approached and 15 consented to participate. Providers were recruited from three clinics in Toronto, Ontario located at academic centers: [1] A familial ovarian cancer clinic, [2] A familial breast cancer clinic and [3] A fertility clinic, all of which treat carriers of the BRCA1/BRCA2 genetic mutation. The interview guide was developed according to the Ottawa Decision Support Framework and included questions regarding reproductive options available to patients, factors that impact the decision-making process and the role of decisional support. Interviews were transcribed and transcripts were analyzed thematically using NVIVO 12.RESULTS:Providers identified three major decisions that reproductive-aged women face when a BRCA mutation is discovered: [1] "Do I want children?"; [2] "Do I want to take the chance of passing on this the mutation?"; and [3] "Do I want to carry a child?" Inherent decision challenges that are faced by both providers and patients included difficult decision type, competing options, scientifically uncertain outcomes, and challenging decision timing. Modifiable decisional needs included: inadequate knowledge, unrealistic expectations, unclear values and inadequate support or resources. Identified clinical gaps included counselling time constraints, lack of reliable sources of background information for patients or providers and need for time-sensitive, geographically accessible, and centralized care.CONCLUSION:Our study identified a need for a patient information resource that can be immediately provided to patients who carry a BRCA genetic mutation. Other suggestions for clinical practice include more time during consultation appointments, adequate follow-up, value-centric counseling, access to psychosocial support, and a specialized decisional coach.

OBJECTIVE:To comprehensively describe current preimplantation genetic testing for aneuploidy (PGT-A) practices and management of non-euploid embryos in Canada. METHODS:This was a cross-sectional study utilizing an online survey distributed by email to all medical directors of fertility clinics with independent in vitro fertilization (IVF) embryology laboratories. The survey was designed to determine practice patterns regarding PGT-A usage; PGT-A reference laboratory, platform, and thresholds for classifying embryos; and management of embryos classified as mosaic, inconclusive, or aneuploid. RESULTS:Twenty-five medical directors (69%) participated in the survey. The majority of clinics (91%) offered PGT-A screening, with 45% of clinics offering PGT-A as routine screening. The majority of clinics (90%) that offered PGT-A received mosaicism data; 61% of these clinics had transferred mosaic embryos, and 94% would transfer mosaic embryos. Clinics that performed ≥1000 IVF cycles annually were more likely to have transferred mosaic embryos (100% vs. 45.5%; P = 0.043). The mean percentage of IVF cycles using PGT-A was lower in clinics that had transferred mosaic embryos (12.3% vs. 30.4%; P = 0.033). Only 1 clinic had transferred an aneuploid embryo, but 2 other clinics would consider this option. The majority of clinics (61%) that receive mosaicism data would recommend noninvasive prenatal testing (NIPT) following mosaic embryo transfer, with 22% of clinics indicating that this would be the only genetic test offered. CONCLUSION:We report significant practice variation in PGT-A and management of non-euploid embryos across Canada and highlight areas where consensus should be encouraged.

[Voir la version anglaise de l’article ici: www.cmaj.ca/lookup/doi/10.1503/cmaj.220686][1] Mon père avait coutume de dire qu’un chirurgien peut se raser le visage à l’eau froide. Maintenant que je suis sur le point de devenir professionnelle, je réalise que j’ai fermé les yeux pendant

My father used to say that a surgeon could shave his face in cold water. As I stand on the brink of staffdom, I realize that for years I’ve turned a blind eye to my own suffering. I would work all night, skip meals, twist my back until my muscles spasmed in pain and then chug an espresso, put on

Objectives To assess the decision making needs of providers when discussing egg freezing prior to risk-reducing salpingo-oopherectomy (RRSO) BRCA-positive women. Methods This qualitative study involved a needs assessment via semi-structured individual interviews guided by Ottawa Decision Support Framework. Participants included providers at a specialized ovarian/breast cancer or fertility clinic who treat patients carrying the BRCA1/BRCA2 mutation. Data analysis was guided by grounded theory. Interim analysis was performed after 10 providers, at which point 5 additional providers were recruited until data saturation was felt to be met. Results Three major decisions that reproductive-aged women face when a BRCA mutation is discovered were identified and included: (1) “Do I want children?”; (2) “Do I want to potentially pass on the mutation to my child?”; and (3) “Do I want to carry a pregnancy?” Inherent decisional needs included difficult decision type, competing options, scientifically uncertain outcomes, personal value judgements, and difficult decision timing. Modifiable decisional needs included: inadequate knowledge, unrealistic expectations, unclear values and inadequate support or resources. Identified clinical gaps included counselling time constraints, lack of reliable sources of background information for patients and need for time-sensitive, geographically-accessible and centralized care. Conclusions Our study identified a need for a patient information sheet specific to this population that can be immediately provided to patients carrying the BRCA mutation. Other suggestions for clinical practice include more time during consultation appointments, follow-up, access to psychosocial support, and a specialized decisional coach. To assess the decision making needs of providers when discussing egg freezing prior to risk-reducing salpingo-oopherectomy (RRSO) BRCA-positive women. This qualitative study involved a needs assessment via semi-structured individual interviews guided by Ottawa Decision Support Framework. Participants included providers at a specialized ovarian/breast cancer or fertility clinic who treat patients carrying the BRCA1/BRCA2 mutation. Data analysis was guided by grounded theory. Interim analysis was performed after 10 providers, at which point 5 additional providers were recruited until data saturation was felt to be met. Three major decisions that reproductive-aged women face when a BRCA mutation is discovered were identified and included: (1) “Do I want children?”; (2) “Do I want to potentially pass on the mutation to my child?”; and (3) “Do I want to carry a pregnancy?” Inherent decisional needs included difficult decision type, competing options, scientifically uncertain outcomes, personal value judgements, and difficult decision timing. Modifiable decisional needs included: inadequate knowledge, unrealistic expectations, unclear values and inadequate support or resources. Identified clinical gaps included counselling time constraints, lack of reliable sources of background information for patients and need for time-sensitive, geographically-accessible and centralized care. Our study identified a need for a patient information sheet specific to this population that can be immediately provided to patients carrying the BRCA mutation. Other suggestions for clinical practice include more time during consultation appointments, follow-up, access to psychosocial support, and a specialized decisional coach.