OB and GYN update: highlights and practice changing articles from 2025 (Lund & Bacon, 3/11/2026)

A recording of this presentation is available HERE.

(late entry)

Many thanks to Drs. Allison Bacon and Erin Lund for an excellent review of important practice-changing literature from the fields of OB and Gyn in 2025. It's obviously important for us to keep track of practice-changing advances, but the task can be overwhelming and burdensome, particularly if it's an area you are not using on a daily basis. 

Dr. Bacon started us off with 3 practice-changing OB papers:

1) Quality-Improvement (QI) Strategies for the Safe Prevention of Preterm Birth, ACOG Committee Statement 17, May 2025

Key take homes:

• current US NTSVD (normal term spontaneous vaginal delivery) rate is 25.6% but ranges 18.5-84.6%, and the WHO goal is 23.6%>> the variability represents opportunity for improvement through local QI projects
• in fact the CMQCC initiative in California reduced rates from 26% to 22.8% (from 2014 to 2019)
• suggested strategies to improve vaginal delivery:
• local policies and procedures to support vaginal birth
• labor support huddles
• team trainings for interpretation of fetal heart rate monitoring
• unit based policies for oxytocin and management of labor dystocia

2) FIGO good practice recommendations on preconception care: A strategy to prevent preterm birth, Int'l Journal of Gynecology/Obs 2025

• preterm delivery is responsible for most neonatal and infant deaths
• many risk factors for preterm birth can be targeted outside of pregnancy
• baby-centered assessment as a part of preconception care
• examples risk factors and interventions
• teen pregnancies>> preconception counseling 
• optimize screening/treatment of chronic conditions (e.g. hypertension, DM, thyroid)
• mental health>> screen for mental health and eating disorders
• infectious disease>> HPV vaccination, screen for STIs, preserve oral health
• nurtitional status>> discuss BMI, dx/tx iron-deficiency

 

3) Air Pollution Linked to Risk of Spontaneous Preterm Birth, Celeste Krewson, 2025, Contemporary Ob/gyn

• talk to patients about PM2.5 as mechanism for for social drivers of health, use of air filters?
• solutions driven by housing, community, city planning

Dr. Lund presented the second half on the important gyn literature:

1) ACOG Clinical Consensus #9: Pain Management for in-Office uterine and cervical procedures

• healthcare professionals tend to underestimate the pain people with uterus may feel during a procedure, providers may deem pain management not needed and therefore not offer to patients
• despite discrepancy between level of pain between patients and providers, patients still do report high degree of satisfaction with in-office gyn procedures
• higher pre-procedural anxiety and anticipated pain are 
• associated with higher pain scores
• THEREFORE options for pain management should be offered to all patients for in-office procedures
• IUD: topical anesthetic is more effective over placebo or misoprostol
• lidocaine spray>> lidocaine injection (?2017 RCT)
• no evidence to support pre-procedure NSAID, though may help for post-procedure pain
• use of ultrasound has been shown to decrease pain of IUD insertion

• EMB: 10% lidocaine spray (3 puffs before), naproxen 30 minutes prior reduced pain in one study, performing EMB with full bladder may reduce pain
• Uterine aspiration: paracervical block, NSAIDs pre-procedure (for post-procedure pain), oral benzos do not reduce pain but do reduce anxiety
• Colpo: topical/intracervical lidocaine recommended for biopsies and LEEP

• Trauma-informed care: universal trauma precautions, given patients control over procedure, ask permission to begin/continue procedure, careful with words used (e.g. not bed, table)

2) Management of Recurrent Bacterial Vaginosis, ACOG Clinical Practice Guideline Update 12/2025

• Recurrence is common! 66% of patients experience recurrence of BV within 12 months of initial diagnosis
• Recent RCT comparing partner therapy for recurrent BV (treating partner with oral and topical) showed marked decrease in recurrence (35% vs. 65% at 12 weeks), absolute risk was BIG -2.6 recurrences per person per year
• Increasing evidence that BV should be considered an STI: predominantly occurring in sexually active populations, associated with new/multiple sexual partners, there is microbiological evidence that sexual partners exchange bacteria
• Ideal people to partner treat: monogamous male/female partners (shared decision making for other scenarios)
• Coverage may vary-- CA extended partner therapy applies to STIs (GC/CT), MAY be applied to BV (pharmacy dependent)
• Note clindamycin gel can weaken latex condoms
• Also note, recent evidence based guidelines say it's okay to drink alcohol and take metronidazole!! 

Practicing Changing OB Updates in 2024-25 (Watson, 4/23/2025)

 A recording of this presentation is available HERE.

***

Thanks to Dr. Hannah Watson, our interim Maternity Care Director at the Santa Rosa Family Medicine Residency, for an excellent talk on 2024-2025 OB Updates. She covered five studies recently published, which suggested some practice changes in the care of OB/Gyn patients. I love looking at recent literature to either reinforce our current practice or to update in real time what we do clinically. 

She also toured us through some beautiful wildflowers!

Here are my take home pearls:

1) VTE prophylaxis in patients after c-section (while hospitalized) may not change outcomes. 

In this retrospective cohort study of patients who received VTE ppx vs. those who didn't, 0.31% vs 0.08% (not statistically significant) developed VTE; 6.7% vs. 1.7% were readmitted, 3% vs 1% wound complications.

Bruno AM, Sandoval GJ, et al Postpartum pharmacologic thromboprophylaxis and complications in a US cohort. Am J Obstet Gynecol. 2024 Jul;231(1):128.e1-128.e11. doi: 10.1016/j.ajog.2023.11.013. Epub 2024 Feb 12. PMID: 38346912; PMCID: PMC11194157.

2) While antepartum betamethasone (for fetal lung maturity) has excellent evidence prior to 34 weeks EGS, in patients who deliver at 34-36 weeks, the positive impact of maternal steroids varies based on gestational age AND mode of delivery (LTCS vs. vaginal). 

In this secondary analysis of the 2017 Antenatal Later Preterm Steroids (ALPS) Trial, 7ounger gestational age and surgical delivery confer greater benefit of steroids. Of note, GDM patients were excluded from the ALPS trial.

Clapp MA, Li S, Cohen JL, Gyamfi-Bannerman C,  et al Betamethasone Exposure and Neonatal Respiratory Morbidity Among Late Preterm Births by Planned Mode of Delivery and Gestational Age. Obstet Gynecol. 2024 Dec 1;144(6):747-754. doi 10.1097/AOG.0000000000005756. Epub 2024 Oct 10. PMID: 39388700.

3) Pregnant patient with GDM may benefit with improved glucose control from split dosing their long acting (i.e. glargine) insulin when using over 20-30 units per day. Also injecting prandial insulin 20-30 minutes BEFORE eating improves glycemic control. 

Valent AM, Barbour LA. Insulin Management for Gestational and Type 2 Diabetes in Pregnancy. Obstet Gynecol. 2024 Nov 1;144(5):633-647. doi: 10.1097/AOG.0000000000005640. Epub 2024 Jun 13. PMID: 38870526.

4) Concurrent partner treatment (oral metronidazole and topical clindamycin) for patients with bacterial vaginosis (BV) reduces risk of recurrence of BV by 50% at 12 weeks. 

Recurrence rates of BV were still high: 63% at 12 weeks in the control group (no partner treatment) and 35% in the partner treatment group.

https://www.nejm.org/doi/full/10.1056/NEJMoa2405404

5) The Jada (aspiration system) demonstrates equivalent outcomes to the Bakri (balloon system) for post partum hemorrhage management.

Of note, Dr. Watson says that both she and patients generally prefer the Jada system, which generally stays in for one hour; whereas the Bakri requires traction for up to 12 hours. Evidence shows either system is better the sooner it is placed.

Shields, Laurence E. MD; Klein, Catherine MSN, RN et al Effectiveness of the Intrauterine Balloon Tamponade Compared With an Intrauterine, Vacuum-Induced, Hemorrhage-Control Device for Postpartum Hemorrhage. Obstetrics & Gynecology 145(1):p 65-71, January 2025. | DOI: 10.1097/AOG.0000000000005770

Options for Menstrual Suppression (Mak, 4/16/25)

 A recording of this presentation is available HERE.  

Thanks to Dr. Ray Mak for a good refresher on menstrual suppression. A reminder from Dr. Mak up front that there are varied reasons that people with a uterus prefer to suppress their menstruation -- from personal preference to medical indications, and we can and should know how to counsel them on how to safely do so.

Check out this table that outlines some of the reasons for menstrual suppression. Not included in the table are financial reasons (people spend $6000-$18,000 over their lifetime for menstrual products) or cancer risk reduction. 

Patient preference		Challenges with menstrual hygiene	Intellectual or developmental delay Limited dexterity or mobility
Gynecologic	Dysmenorrhea Endometriosis-related pain and bleeding Menorrhagia PMS Abnormal uterine bleeding	Work or social indications	Military deployment or space travel Athletes Camping or wilderness experience
Hematologic	Anemia Coagulation disorder Malignancy Chemotherapy	Other conditions worsened by menses	Irritable bowel syndrome Asthma Postural tachycardia syndrome Migraines

Combined oral contraceptives

The most commonly accepted and practices way to ensure menstrual suppression comes via continuous Combined oral contraceptives (COCPS)

-efficacy is 49%, 68% and 88% are 2, 6 and 12 cycles respectively

-monophasic OCPs are preferred 

-breakthrough bleeding (BTB) is the most common side effect and decreases with time

-lower estrogen levels in OCPs is associated with more BTB

-a hormone free break of 3-4 days is usually sufficient to manage BTB

-see two images below from the AAFP with guidelines on management of BTB

 

Additionally, menstrual suppression can occur using alternative contraceptive modes, including:

• vaginal ring (skipping ring-free week)>> amenorrhea 89% at 6 months, BTB more common early and diminishes with time (NSAIDs may help, no studies on adding estrogen)
• contraceptive patch (skipping patch-free week), not as well studied, no long term data, higher estrogen exposure, similar issues with BTB
• hormonal IUD (Mirena, Liletta)>> amenorrhea 50% at 1 year, 60% at 5 years; lower dose IUD not effective at attaining amenorrhea, can uses NSAID/estrogen or OCPs for BTB
• depo provera injections>> amenorrhea 50-75% at 1 year, increases with prolonged use; concerns about decreased bone density over time, also weight gain/mood changes. For BTB: NSAID, estrogen, cOCPs, decreasing injection interval (e.g. 2 months)
• etonogestrel implant>> 22% amenorrhea at 1 year, improved with prolonged use, irregular BTB is common

Aside from using contraceptive methods to induce menstrual suppression, other medications can be used, including:

• norethindrone acetate 5mg daily, not approved for contraception>> 76% amenorrhea at 2 years, can titrate up to 15mg daily (for BTB), different than norethindrone mini-pill (0.35)
• testosterone therapy for trans and gender diverse patients >> testosterone therapy usually suppresses by 3-6 months, transmen generally prefer to avoid estrogen  (because of desire for masculinization)
• GnRH agonists (puberty blockers), fast onset 4-6 weeks, high efficacy 96%, no increased prothrombotic use (often used in oncologic patients)
• Danazol

Menstrual suppression considerations for people with disabilities:

• can they swallow pills?
• can they tolerate invasive procedure?
• caution: bone density, weight gain, VTE risk in pts with decrease mobility at baseline
• scheduled withdrawal bleeding may be preferred over random BTB

Don't forget this chart:

The Pelvic Exam through a Trauma Informed Lens (Goldberg-Boltz, 1/22/25)

A recording of the presentation is available HERE. 

Many thanks to Dr. Nicole Boltz for an excellent presentation this week on The Pelvic Exam through a Trauma-Informed Lens. This was both a practical and meaningful presentation -- one which will stick wit you as you move quickly through your clinic day.

Here are my notes:

• If you do intimate/pelvic exams, consider reading this letter: Dear Doctor: A letter from a survivor or sexual trauma to all medical professionals, by Carol Chandler

• We should all be doing universal sexual assault screening for ALL patients (do not leg bias guide you). There are many ways to do this screening that are patient-centered, but there is no one right way. Remember it may take many visits (or many years) for a patient to feel comfortable enough to disclose. Meet the patient where they are.

• The four Rs of a trauma-informed approach (SAMHSA)
• Realize: Understand the impact of trauma on people and communities
• Recognize: Identify the signs and symptoms of trauma
• Respond: Integrate knowledge about trauma into policies, procedures, and practices
• Resist re-traumatization: Take action to prevent re-traumatizing individuals

• Find humor even in the hard things we do: https://www.instagram.com/reel/C7kbKUpsuAD/?igsh=NTc4MTIwNjQ2YQ%3D%3 (this is super funny!!!!!!)

Okay, onto the Pelvic Exam:

• Prepare a safe and non-judgmental space
• ideally meet the patient prior to the exam or procedure (when dressed!)
• set the ground for empowerment: they are in charge, we go at their pace, they can stop whenever
• explain the procedure and purpose
• ask if they want to see/touch/listen to the instruments
• ask of they want a support person in the room
• ask if they want you to know anything before the exam
• ask what can be done to make the exam more comfortable
• ask for any questions
• Language, language, language
• the goal is to use non-triggering language
• empower the patient with your language (they are in charge)
• framing matters: "when/if you are able" and "you MIGHT feel" and "would you like me to proceed or shall I pause?" and "tell me when you're ready"
• consider these substitutions: exam table (instead of bed), drape (rather than sheet), foot rests (rather than stirrups), instruments (rather than device names)
• Body positions matter: for some, certain positions can be triggering. Ask which position is most comfortable for them
• in/out footrests, frog legged, on exam table
• never force legs open
• ask permission to move/touch body, considering tapping knee to get legs to drop
  
  
  
  
• During exam
• Consider distractions: toe wiggling, tapping on knees in a pattern, tapping on chest, deep breathing
• Getting dressed: After the exam, allow patient to get dressed before you discuss findings/assessment/plans. Then explain what you did, what you saw, what are the next steps.

Barriers to Fertility Care (Orozco-Llamas, 9/18/2024)

Many thanks to Dr. Orozco-Llamas for an excellent, thought-provoking presentation this week on Barriers to Fertility Care. A recording of her presentation is available HERE.

My notes:

2020 American Society for Reproductive Medicine definition for infertility:

• Inability to achieve a successful pregnancy based on a patient’s medical, sexual, and reproductive history, age, physical findings, diagnostic testing or any combination of those factors.

• Need for medical intervention to achieve a successful pregnancy either as an individual or with a partner

In patients having regular, unprotected vaginal-penile intercourse, evaluation should be initiated at 

• 12 months when the female is under 35 years of age
• 6 months when female is 35 - 40 years
• Immediate evaluation may be warranted in female >40 years

Infertility affects 15% of heterosexual couples in the US

Male factor accounts for 40-50%

Female factor accounts for 35-50%

Unexplained fertility accounts for ~30%

This talk did not cover the usual fertility evaluation, but a typical plan for infertility includes diagnostic services (serum lab tests, semen analysis, imaging and diagnostic procedures, e.g. laparoscopy or hysteroscopy) and treatment services, including medications (clomiphene/letrozole), surgery (laparoscopy or hysteroscopy), intrauterine inseminations (IUI) and in vitro fertilization (IVF)

Each of these components has an associated cost:

For patients who need fertility specialty care, costs are generally self pay. At our local fertility clinic-- Advanced Fertility Associates, Inc, here are some current out of pocket costs:

• Consult $280 

• US done in-house $275  (even if done already at outside facility)

• Blood work $350 (often needs repeating)

• IUI $400 per cycle

• IVF $10,000-$15,000 per cycle

It is important to note that fertility treatments do not every guarantee a successful pregnancy and many of these costs need to be multiplied to achieve success. If you look at the graph below from KFF, you can see that whereas a single cycle of IUI may cost about $3500 dollars, the average cost per successful pregnancy is over $10,000 dollars. 

Ovulation stimulating medication is relatively low-cost for our Medi-Cal and uninsured patients (~$18 for a course of clomiphene and/or letrozole), but there is currently no in clinic IUI offered at our community health centers. Patients can be counseled on doing home insemination, which has a lower success rate.

We know that IVF has been in the national political conversations lately. It is important to note that there is wide variability in states regarding private insurance mandates around fertility care. 

As of June 2024, 23 states have mandates requiring insurance companies to include some coverage for infertility diagnosis and treatment. Of these, 15 states specifically require coverage for IVF. Most require a clinical diagnosis of infertility, often requiring all people seeking coverage, including single people and people in same sex partnerships, to demonstrate clinical infertility (sometimes requiring a rounds of IUI before covering IVF).

Where policies cover IVF, coverage is limited by either a dollar limit or a maximum number of IVF cycles.  Several of the states that mandate insurance coverage of infertility treatment do not require religious organizations, small businesses, or employers who self-insure to offer coverage. Several states require that the patient be married. Many states place an age limit on infertility treatment.

No state Medicaid (in California, MediCal) currently covers IUI or IVF.

***

All this being said, patients of color and patients with low SES have higher rates of infertility! In fact

• All non-white racial and ethnic groups (black, other race, and Hispanic) are significantly more likely to experience infertility than whites.

• Both high school dropouts and high school graduates are significantly more likely to experience infertility than four-year college graduates. 

• Women who are not white and women who are of lower SES are significantly less likely to report ever having received infertility treatment.

This is an equity issue. It shouldn't be surprising that women seeking fertility treatments tend to be older, white, of higher income and privately insured. 

Also of note, there is evidence that women who work with pesticides have higher rates of infertility. See image below for details on two studies that are highlighted. This is particularly relevant to many of our local SoCo patients who work in vineyards and local farming industry. 

What can primary care docs working in the safety net do with patients who need fertility services?

• Talk to your  patients about fertility!

• Refer to WHPC or GYN clinic at Vista SRCH

• Education on infertility and ovulation cycle

• Mental health resources

• Diet and lifestyle modifications

• Guidance on when to refer and providing financial information

References:

• Bill Status - SB-729 Health Care Coverage: Treatment for Infertility and Fertility Services. leginfo.legislature.ca.gov/faces/billStatusClient.xhtml?bill_id=202320240SB729.
• Figà-Talamanca, Irene. “Occupational risk factors and reproductive health of women.” Occupational medicine (Oxford, England) vol. 56,8 (2006): 521-31. doi:10.1093/occmed/kql114
• Fuortes, L et al. “Association between female infertility and agricultural work history.” American journal of industrial medicine vol. 31,4 (1997): 445-51.
• Gaskins, Audrey J, and Jorge E Chavarro. “Diet and fertility: a review.” American journal of obstetrics and gynecology vol. 218,4 (2018): 379-389. doi:10.1016/j.ajog.2017.08.010
• “Infertility: An Overview Patient Education Booklet.” Infertility: An Overview Patient Education Booklet | ReproductiveFacts.Org, American Society for Reproductive Medicine, www.reproductivefacts.org/news-and-publications/fact-sheets-and-infographics/infertility-an-overview-booklet/.
• Infertility Workup for the Women’s Health Specialist: ACOG Committee Opinion, Number 781. Obstetrics & Gynecology 133(6):p e377-e384, June 2019. | DOI: 10.1097/AOG.0000000000003271
• Katz, Patricia et al. “Costs of infertility treatment: results from an 18-month prospective cohort study.” Fertility and sterility vol. 95,3 (2011): 915-21.
• Mays, Mackenzie. “A Bay Area Cancer Patient Froze Her Eggs in Hopes of Having Children. She Can’t Afford to Finish IVF - Los Angeles Times.” Los Angeles Times, 9 Apr. 2024, www.latimes.com/california/story/2024-03-31/ivf-isnt-covered-by-insurance-in-california-hopeful-parents-are-struggling-to-afford-fertility-care.
• Phillips, Kiwita, et al. “Infertility: Evaluation and Management.” AAFP, 15 June 2023, www.aafp.org/pubs/afp/issues/2023/0600/infertility.html.
• Practice Committee of the American Society for Reproductive Medicine. Electronic address: asrm@asrm.org. “Definitions of infertility and recurrent pregnancy loss: a committee opinion.” Fertility and sterility vol. 113,3 (2020): 533-535. doi:10.1016/j.fertnstert.2019.11.025
• Weigel, Gabriela, et al. “Coverage and Use of Fertility Services in the U.S. | KFF.” KFF, 15 Sept. 2020, www.kff.org/womens-health-policy/issue-brief/coverage-and-use-of-fertility-services-in-the-u-s.

Endometrial Cancer (Delic 11/8/2023)

A link to a recording of this presentation is available HERE. 

***

Many, many thanks to our speaker this week, Dr. Lejla Delic, a local gynecologist-oncologist, who works with our local oncologists and gynecologists to care for patients in our community with gyn cancers. Her presentation was excellent -- so good, in fact, that we we want her back for a Part 2, on ovarian cancer. Stay tuned. We will get her scheduled in the winter/spring.

In the meantime, my notes:

Gynecological cancers occur in the uterus (most common, aka endometrial cancer), cervix, fallopian tubes, ovaries, peritoneal cavity, vulva and vagina.

In the US, there are ~65,000 new cases of uterine cancer  per year --> 12,000 deaths

In the US, there are ~19,000 new cases of ovarian cancer per year--> 12,000 deaths

Unfortunately, mortality from uterine/endometrial cancer is on the rise

Endometrial cancer, the most common type of gyn cancers, has a lifetime prevalence of 3%. Women are average age 60 years old at the time of diagnosis and, because endometrial cancer typically presents with post-menopausal bleeding, 75% are diagnosed in the early stage (stage I and II). When it does metastasize, endometrial cancer typically spreads via local lymphatics to the pelvic nodes and then to the aortic lymph nodes. 

Unfortunately, black women in this country are dying at disproportionate rates of endometrial cancer and are diagnosed with more aggressive cancers, younger than white women. 

Risk factors for endometrial cancer:

• Obesity (endogenous unopposed estrogen). In fact, every 5 points of BMI increases your risk of being diagnosed with endometrial cancer by 50%. 
• Chronic anovulation (obesity, PCOS)
• Nulliparity, infertility, early menarche, late menopause
• Exogenous unopposed estrogen (e.g. HRT without progesterone)
• Tamoxifen (2x risk of uterine cancer)
• Hereditary: these present earlier than sporadic cancers, more typically in non-obese younger women (<50 years old), including genetic syndromes like Lynch Syndrome and MLH1, 2, 6, etc. 

Risk reduction for endometrial cancer:

• OCPs (combined)
• Weight loss
• Hysterectomy (offered to women with Lynch syndrome after age 45 or when fertility is accomplished)

NEJM: Association with race and BMI and endometrial cancer

Historically, endometrial cancers have been divided in two groups: Type 1-- or non-aggressive, more excess estrogen type--  and Type 2, more aggressive, poorly differentiated, frequently metastasize (40% of women with Type 2 have +LN at time of diagnosis. Increasingly, however, new molecular characterization studies are changing the way we think about and treat endometrial cancer and are being integrated into the categorization. This is because prognosis is variable depending on these molecular characteristics.

90% of women with endometrial cancer present with post-menopausal (PMP) uterine bleeding. All cases of PMP bleeding should be investigated but it is important to note that only 9-14% of women with PMP bleeding have cancer.  Abnormal uterine bleeding (AUB) in premenopausal women may present more like "intermenstrual" bleeding.

Evaluation of AUB:

1) Pelvic ultrasound: in PMP women, >4mm endometrial stripe necessitates and EMB. Of note, endometrial stripe thickness in premenopausal women is totally useless. Also, in someone with repeated bleeds, even a thin stripe should not prevent you from getting an EMB.

2) Endometrial biopsy (EMB)

Of note, Type 2 Endometrial cancers, an EMB has a 25% false negative rate.

If the patient has recurrent bleeding, even if they have a normal EMB, refer for hysteroscopy and D&C

Treatment of endometrial cancer:

1) Surgery

All gyn cancers (except for cervical, trophoblastic and vaginal) need surgery to be staged.

Surgery includes hysterectomy, bilateral salpingectomy, and lymph node assessment (sential LN mapping).

Stage I: cancer confined to uterus

Stage II: cancer extends to cervix

Stage III: LN involvement/ovaries/tubes

Stage IV: distant mets (omentum, lungs)

Robotic/minimal invasive surgery has best outcomes (but NOT in cervical cancer). With robot, conversion to open only happens 3% of the time (whereas its 20% of the time with typical surgery). This is really important for patients with elevated BMI who have a much better/easier recovery with minimally invasive surgery and way less bad outcomes.

2) Immunotherapy may be indicated for Stage III or IV or recurrent endometrial cancer 

Historically, chemo was used (Carboplatin and paclitaxil) but with new molecular studies, immunotherapy is showing increasing promise.

Fertility preservation in young women with endometrial cancer is important to many women! 14% are pre-menopausal at diagnosis and may not be done building their families. Low Grade (1) and non-invasive cancers (as determined by MRI) can sometimes be treated temporarily with high dose progesterone (either oral Megace 80mg BID or Mirena IUD). Informed consent is important. About 50% respond, but 20-30% will either progress or return. Some women hate the side effects of high dose progesterone, which include increased appetite, weight gain, and blood clots. 

***

On a final note, Dr. Delic recommends TWO passes with your EMB pipelle when doing an EMB to ensure you get a good amount of tissue. And without a tenaculum whenever possible. 

Stay tuned for the spring for Part 2: Ovarian cancers

LGBTQ+ Fertility and Preconception Counseling (Lopez 4/5/2022)

Many thanks to Dr. Julissa Lopez for her important Grand Rounds presentation on LGBQT+ Fertility and Preconception Counseling. Key take home message up front: primary care physicians SHOULD be helping LGBQT+ patients pursue the families they desire. It's definitely within our scope.

If you would like to watch, the presentation is available HERE. 

Dr. Lopez started with a reminder of the wide range of gender and gender identities that we may encounter. Refer to the Flying Gender Unicorn graphic below as often as you need to to remind you of the range of gender identity, gender expression, gender expression at birth, sexual identity, etc (and to help your patients and you better understand themselves). 

Dr. Lopez' 3-part framework for gender identity considerations

• Biology>>sex>>chromosomes and anatomy
• Psyche>>gender>> identity and expression
• Interpersonal>>sexuality, sexual orientation, attraction

Important reminder for all of us who care for childbearing age patients of all genders and gender identities: Do NOT assume that LGBQT+ do not desire pregnancy. 

In fact, since the early 2000s, there has been a "Gayby Boom"

• 2002: 41% of Lesbians and 52% of gay men expressed an interest in having children
• 2013: 51% of LGBT are parents or want to be
• 2017: 49% of lesbians and bisexual women have had a child (through previous relationship, reproductive technology, adoption, etc)

There is growing consensus that LGBTQ+ community have a right to pathways to parenthood. This includes an increasing number of state laws that protect fostering and adoptive parents. Information on state laws and protections are available HERE via the Movement Advancement Project, where maps like this live:

https://www.lgbtmap.org/equality-maps/foster_and_adoption_laws

The remainder of Dr. Lopez' presentation focused on ways in which primary care clinicians care for persons with ovaries not on gender affirming hormone therapy (GAHT) and persons with testicles not on GAHT achieve biologic parenthood.

1) Preconception care: this is similar to care for any patient who desires children. Goal is to plan for family building: optimize fertility and minimize pregnancy complications

• Risk assessment and counseling
• Cost: home insemination w/fresh semen (cheapest), genetic and STI testing can cost updwards of $3-4K, sperm is $700-$1500/vial
• Optimize health: routine screening, alcohol and substance use screening, prenatal vitamins, medical conditions (DM, BMI, stress)
• Social and legal considerations (depending on state of residence)
• Outcomes counseling: typically families achieve pregnancy with 3 cycles of IUI (this is much higher than other IUI populations because you are not dealing with someone with fertility challenges), increased rates when both (vs. one) partner attempt pregnancy

2) Deciding origin of sperm

• known vs. anonymous donor
• frozen vs. fresh (more effective)
• sperm banks provide STI and genetic testing (could be more desirable but more expensive)
• washed vs. unwashed (i.e. processed-- removing prostaglandins for IUI)
• West Cost sperm banks have online donor searches vs. direct contact
• differences in $$
• Local sperm banks: California Cryobank (LA), The Sperm Bank of California (Berkeley), California Sperm Bank (SF), Seattle Sperm Bank (Seattle, Tempe, San Diego)

3) Preparation for insemination: mapping out reproductive cycle (we definitely know how to do this)

• 28 day cycle: ovulation occurs 14 days before first day of menses
• educate on use of home ovulation kit: LH surge, cycles day 10-12
• frozen sperm has a short life span, so should be inserted 24 ours after LH surge (right before ovulation); there is no benefit to repeated insemination

4) Assisted Reproductive technology i.e. intrauterine insemination (IUI) in the office

IUI is more effective than transvaginal (home syringe method) and can (and should) be done by PCP in the office. Using the reproductive cycle above.

• 1cc syringe
• 18cm polyethylene catheter (available online)
• Speculum
• No other medications needed
• Patient lies down for 10-15 minutes after insemination

https://www.obgynofatlanta.com/iui

***

In contrast with above, for persons contributing sperm (i.e. men), the needs are different and always require a fertility clinic/specialist (i.e. cannot be managed by PCP alone) because they must involve an ovum donor and a surrogate (or both in one)

Things to consider in discussions as you refer folks to fertility centers:

• intentional unknowing (mixing sperm to fertilize ovum)
• genetic fatherhood in turns
• genetic vs. gestational surrogacy (different ovum donor from who carries the pregnancy)

Local Fertility Centers: Southern California Reproductive Center, CCRM Fertility (SF and Orange County)

Abortion in the US in 2022: What is at Stake? (Wallace 2/2/2022)

Many thanks to Dr. Robin Wallace for a really poignant and timely Grand Rounds this week on Abortion in the US: What is at stake in 2022. As we await the Supreme Court decision regarding Dobbs vs. Jackson in Mississippi-- decision expected in June 2022-- it is tremendously important for the medical community to know what is at stake if Roe is overturned.

Dr. Wallace graduated from the Santa Rosa Family Medicine Residency in 2007 and completed the to UCSF Family Planning Fellowship after residency. She worked for 8 years at a family planning clinic in Dallas, Texas and now lives and works in North Carolina. 

A link to a recording of her presentation is available HERE. 

With increased access to effective contraception, abortions have decreased steadily since the early 1980s

• However, abortions are still common-- in 2017 in the US, 862,320 abortions were performed 
• Most abortions occur at less than 8 weeks, 89% occur in the first 12 weeks
• 10% happen in 2nd and 3rd trimesters: this is a critical and important health care service 

The US unintended pregnancy rates has also been going down, dropping below the intended pregnancy rate (since the ACA went into effect and required coverage of contraception)

There is evolving literature on "pregnancy ambivalence". It is not easy to classify intentions. There are plenty of nuances that exist on a spectrum

Abortion restriction disproportionately impacts low income women of color

While overall abortion numbers of declined, the proportion of medication abortions (MAB) have increased, generally up through 11 weeks. 

In some settings well over 50% are MAB.

2018 Comprehensive Review of Abortion Safety and Quality

There was a clear and dramatic drop in abortion related deaths after Roe vs. Wade (1973) 

This 2018 Comprehensive Review of Abortion Safety and Quality concluded withat abortion is a safe procedure.

It also refuted any association between abortion and breast cancer, future infertility, and depression/mental illness.

Abortions have a mortality rate of 0.7/100K-- this compared to a shot of penicillin which has a mortality rate of 2/100K, and giving birth a mortality rate of 8.8/100K.

increased mortality as gestational age increases, as the physiology gets more complex 

20% of abortion related deaths are among those for whom pregnancy threatens their life 

abortion mortality rate higher in black women (1.1/100K)

"Legal abortions in the US are safe, but the likelihood that women will receive the type of abortion services that best meet their needs varies considerably depending on where they live."

Legal restrictions impact abortion care

Many states have created barriers to safe, effective, patient centered, timely, efficient, and equitable abortion services.

• Targeted restrictions of abortion providers (TRAP laws): specifically target the practice of medicine related to abortion care
• "undue burden" standard established (Casey, 1994)
• Example of TRAP laws (in North Carolina) include: mandatory ultrasound, mandatory waiting periods, telemedicine ban on abortion care, "physician only" procedure (no midwives, nurse practitioners), Medicaid restriction on coverage, State health plan restriction

Texas Senate Bill 8 (went into effect 9/2021)

• Restricts abortion after 6 weeks 
• Enforcement intentionally crafted to circumvent the usual pathways of enforcement (the state) through private civil actions
• Anyone can file lawsuit against someone who has violated the law (including those performing abortions, as well as those who aid and abet those procedures)
• This has created enormous fear in counselors, medical assistants, uber drivers
• If a person who sues is found in court to be in the right, they are awarded &10K for each abortion in violation
• In a study from Texas in 2018, even though 58% of people <6 weeks, only 16% were <6 weeks when they had their actual abortion appointment

• Texas SB8 has faced many challenges (abortion providers, ACLU, etc)
• in the past federal district court has consistently blocked these laws from going into effect, but the 5th circuit court of appeals
• Supreme Court denied emergency request to block the law
• DOJ filed separate lawsuit (US vs. Texas), US Supreme Court heard these arguments 11/1, have not blocked enforcement despite having had several opportunities to do so (e.g. 1/20, denied plaintiff's request to return to be heard)
• Sonia Sotomayor, "This case is a total disaster for the rule of law."

We know from prior attempts by Texas legislators to restrict abortion what TRAP laws do to abortion access

• HB2 (2013): Governor Rick Perry, admitting privileges law requiring any abortion provider have hospital admitting privileges within 30 miles of where they are providing abortions
• Shut down >1/2 of abortion clinics, severely reducing access to Texans
• Disproportionate effect on Latinx patients, rural patients, and those traveling for care
• Increase in 2nd trimester abortions (therefore increasing complication rates)
• especially black patients, low income, patients who had to travel far
• Though the US Supreme Court nullified HB2 in 2016, having been enforced for 3 years had lasting impact
• clinics, once closed, were not reopened

The Turnaway Study is a really elegant longitudinal UCSF study examining the effects of unwanted pregnancy on women's lives in 1000 women who were denied abortions compared to women who were granted abortions. When patients are denied the abortions they want, families are significantly affected

• financial instability, poverty
• staying in violent relationships
• resulting children not meeting developmental milestones

Dobbs vs. Jackson (Mississippi), currently being considered at US Supreme Court

• bans abortion in Mississippi after 15 weeks
• decision expected June 2022
• many experts are expecting the Supreme Court to uphold this law, which would essentially nullify Roe and permit states to limit abortion access based on gestational age
• What would happen if Roe falls?
• there are few states (blue, e/g/ CA, WA, OR, NY) with expanded access to abortion
• other states (e.g. Florida) with protections that are currently in place but can be revoked easily by politicians
• lots of states where abortion will not be protected in any way

https://reproductiverights.org/maps/what-if-roe-fell/

Dr. Wallace's Recommended Resources:

https://liberalarts.utexas.edu/txpep/

https://reproductiverights.org/

https://txabortionaccessnetwork.org/

https://www.guttmacher.org/

https://prh.org/

https://rhedi.org/

https://www.reproductiveaccess.org/

Practical Reproductive Medicine for the Primary Care Provider (Uzelac, 5/12/2021)

Many thanks to Dr. Peter Uzelac, medical director of the Marin Fertility Center, who gave a really great presentation this week on reproductive medicine  for primary care providers. He covered a lot of important topics that are not bread and butter for us, but that are definitely important to understand and consider in caring for patients of reproductive age. Dr. Uzelac also gave us some great insight as to what patients can/are doing themselves and what we can/might recommend.

For those of you who want to see the presentation, a video recording is available HERE.

For my notes, keep reading. . . 

Optimizing Natural Conception: 

• the "fertile window" is a 6 day interval when conception is possible, ending on the day of ovulation
• frequency of intercourse recommended for optimal fertility success: q1-2 days in the fertile window (though 2-3 times/week nearly equivalent)
• there is no substantial evidence that monitoring increases success
• it turns out that changes in cervical mucus performs as well or better than basal body temperature (BBT) or urinary LH
• no timing, position, resting around sexual intercourse have any impact on fertility
• moderate alcohol (1/day) or moderate caffeine (1 cup coffee/day) is probably okay
• smoking, recreational drugs (including marijuana) are not good

Causes of infertility: 

• male factor 30% 
• diminished ovarian reserve 30%
• ovulatory dysfunction 10%
• tubal/peritoneal 20%
• unexplained 10%

When should someone be evaluated for infertility?

In the absence of a remarkable history or physical findings, treatment should be started if no pregnancy results after active attempt for pregnancy within:

• 12 months for women <35 (85% of couples trying to get pregnant will be successful after 12 months)
• 6 months for women >35
• Immediate evaluation and tx for women >40

3 "Tiers" of Diagnosis and Treatment of Infertility

• Tier 1: for all couples; focus on the basics: eggs, uterus/tubs, sperm
• Tier 2: ~15% of people; more focused, newer diagnostics, less validates (endometriosis, chronic endometritis, molecular sperm assessment, things only seen during ovarian stimulation or embryo culture)
• Tier 3: difficult/rare cases, after multiple treatment failures (immunomodulation, uterine microbiome) 

What historical clues can help?  

• Menstrual history:
• Intervals: 28 days +/- 7 is considered normal
• abnormal uterine bleeding (structural, hormonal, endometriosis)
• pain/dysmenorrhea (endometriosis)
• Duration of infertility: unsurprisingly, the longer the problem, the harder to solve
• Gs and Ps
• How many children desired? (start planning with first child--> embryo banking)

What physical clues can help?

• ultrasound (cysts, polyps, fibroids, adenomyosis)
• BMI (extremes, upper and lower)
• androgen excess (especially in oligomenorrhea)
• Thyroid

How do you know a woman is ovulating? There are many ways to detect, none are perfect

• Of note, 1-12% of normal women's cycles are anovulatory (more likely in extremes of reproductive age)
• You can detect ovulation through a variety of methods:
• mid cycle symptoms: discharge, mittelschmerz
• moliminal symptoms (fluid, breast tenderness, craving, mood)
• hormones: LH surge, mid-luteal progesterone (normal is >3ng/ml, drawn one week prior to expected menses rather than on a specific cycle day; levels may vary 7-fold even within hours)
• Ultrasound: dominant follicle, corpus luteum cysts

What patients may be doing to detect ovulation? Tracking w/apps, diary good start but women get too focused on these, urine ovulation kits (detect both LH surge and estrogen surge as well), wearables, post-ovulatory progesterone kit. All can be used to demonstrate ovulation and time intercourse. 

Pearl: Eumenorrheic patients with sporadic anovulation doesn't impact fertility. They will eventually get pregnant over the 12 month interval! Many women get very focused on this step. Try to have patient focus less on ovulation if they are generally ovulating.

What about ovarian reserve? This is often the most important factor in fertility; age is so impactful on chances for successful pregnancy. Plus, fertility doctors can fix almost anything EXCEPT ovarian reserve

• all eggs a woman will ever have are present at birth
• apoptosis occurs through a woman's lifetime
• egg survival falls more around age 35/37, fertility ends early 40s, but menopause doesn't happen until closer to 50
• for a woman's last 10 years, she often has  regular periods but not able to get pregnant
• last child statistically  is age 42, pregnancy is possible but not probable after 43

Ovarian reserve testing: REI no longer use FSH/E2 (not sensitive enough), or provocative tests, really test of choice is anti Mullerian hormone (AMH)

• AMH is more sensitive than FSH (can be done on OCPs, needs to be adjusted by 30%). 
• A follow-up test: antral follicle count (on ultrasound)

Of note, these markers are poor predictors of fecundability , they mostlyt help to characterize where a patient is on their fertility timeline, not really a great test to predict pregnancy. REI uses them to predict response to stimulation in IVF

What patients are doing? At home "hormone testing" not well validated, often include hormones not assessed at the same time as other hormones, so not great. Would NOT recommend.

Fertility ultrasound (Antral follicle):

What you are looking for on ultrasound:

• early resting follicles 2-10mm
• dominant follicle 20-28mm prior to ovulation
• corpus luteum cyst left behind right after ovulation

Uterus/tubes:

• For tubes: hysterosalpingogram (HSG): proximal and distal tube occlusion, adhesions, etc
• not great for uterine cavity visualization, cannot differentiate septate from bicornuate uterus
• bilateral FILL and SPILL, delays in fill/spill, obstruction (proximal vs. distal), hydrosalpinx
• For uterus: saline sonogram (hysterosonography) defines size and shape of uterine cavity (91% sensitivity, 84% spec for intrauterine pathology: polyps, myomas, synechiae)
• hysteroscopy is not typically done unless plan for intervention (e.g. ablate septum, polypectomy)

Male factor:

• history: prior fertility, erectile or ejaculatory dysfunction, anabolic steroid use (testosterone, previous abdominal or scrotal surgery, STD
• semen analysis: concentration, motility, morphology
• see WHO guidelines below for normal values
• results are a SPECTRUM: more abnormal parameters, the higher increase in fertility problems
• only a spot check, lots of fluctuations (should be repeated if abnormal)

What are patients doing? Home semen analysis is available: 

• Yo test ($50)
• Fellow: send in kit, conventional semen analysis  ($170)

Tier 2 conditions to consider:

• Endometriosis, underdiagnosed, classically a surgical diagnosis, now fertility doctors using specialty markers
• Chronic endometritis
• Microbiome

Reproductive Therapeutics 

"Simple fixes"

•  Polypectomy, ovulation induction in PCOS, IUI for mild male factor, etc

Superovulation and Intrauterine insemination (IUI) for women <37

• Clomid or letrozole x 5 days
• IUI (with sperm washing)

*NEW guidelines 2020: Immediate IVF should be offered in women >38 years of age